Documentation Motivation for Providers Using AHLTA 3.3.8

1. Documentation Motivation for Providers Using AHLTA 3.3.8 Defense Health Clinical Systems Electronic Health Record Core Program Management Office

2. Agenda • Purpose • Understand providers as people • Understand goals of patient care documentation from a provider perspective • Patient Medical Summary Documentation • Patient Encounter Note Documentation • ICD Coding • E&M Coding • Summary Defense Health Clinical Systems

3. Purpose • Educate audience on provider priorities and their impact on patient documentation • Educate audience on historical documentation capability and limitations of AHLTA • Educate audience on documentation enhancements in AHLTA 3.3.7 and 3.3.8 • Educate audience on capabilities and limitations of AHLTA for automatic billing coding Defense Health Clinical Systems

4. Providers as People Defense Health Clinical Systems

5. Providers as People • Providers… • Chose medicine to help people • Conditioned to be confident (Stubborn? Arrogant?) • Trained to put care above all else • Are still human with bias, concerns, and character flaws • Consequences…. • May stubbornly and pridefully resist suggestion of any importance of documentation beyond medical benefit • May not respond to billing pressure in socialized system • Will respond to consistent military leadership priorities Defense Health Clinical Systems

6. Goals of Patient Care Documentation Defense Health Clinical Systems

7. Medical Record Should be… • Efficiently understandable to future caretakers • A concise and understandable explanation of how conclusions and care plan decisions were reached • A concise and understandable explanation of future evaluation/treatment plans • A quick source of medical summary data as the foundation for evaluation and treatment • Statistically useful source of data for epidemiology • Low priority compared to the patient in front of you Defense Health Clinical Systems

8. Provider Non-Medical Goals • Balance thoroughness of documentation against need to finish note quickly (minimum standard) • Defense against lawsuits (All providers) • Stay off leadership “Bad Boy List” (All providers) • Justify need for adequate staffing (Some providers) • Make money for the MHS (Some providers) Defense Health Clinical Systems

9. NON-Goals of Military Providers • Code for billing to support personal salary (N/A) • Code to most specific level of detail possible • Increased detail will be sought IF the leadership has instilled in the provider a priority for billing AND if additional detail will add billing value to the encounter Defense Health Clinical Systems

10. Patient Summary Documentation Defense Health Clinical Systems

11. Patient Summary Documentation • Medication List • Medication Allergy List • Past Medical History • Past Surgical/Procedure History Defense Health Clinical Systems

12. Patient Summary Documentation • Brief – for quick review • Complete – All data necessary for safe treatment • Easily updated – during routine patient care Defense Health Clinical Systems

13. Patient Summary Documentation • Autocite Contents • Problem List • Surgical/Procedure History • Family History • Social History • Medications • Medication Allergies Defense Health Clinical Systems

14. Patient Summary Documentation • Autocite – historically rejected because… • Not brief • Overly complete – Details buried in the forest • Not easily updated in previous AHLTA versions • Not visible while editing note documentation • Navigation unacceptably slow for fast paced clinic Defense Health Clinical Systems

15. AutoCite “In the past”(Imagine long, duplicative lists below) Defense Health Clinical Systems

16. Patient Summary Work-Around • AIM (Alternate Input Method) form Textboxes • Brief • Complete • Easily updated during encounter • However…. • Dependent on manually copying note data forward • Data is NOT mineable for use by population health, 2766, data quality management, etc Defense Health Clinical Systems

17. Patient Summary Work Around Defense Health Clinical Systems

18. Autocite “Now” (Medications) • Medication Reconciliation • “Meds” module check box for current medications • AutoCite only prints current medications • “Meds” module print options • All Active Medications (in use and not in use) • Only Active Medications which are currently used • Admission/TX Medications • Discharge Medications • All Medications on record • Abbreviations are expanded for all medication lists • Ability to add to list, including homeopathic medications Defense Health Clinical Systems

19. “Meds” Module AHLTA 3.3.7+ Defense Health Clinical Systems

20. Medication Reconciliation Printout Defense Health Clinical Systems

21. AutoCite Medication List (3.3.7+) Defense Health Clinical Systems

22. Medical History Summary Lists • Edited within the “Problems” module • View ALL, or only ACTIVE entries • Autocite ONLY lists ACTIVE entries • Entries not repeated for multiple encounters • View encounters associated with a single Entries • No current ability to add clarifying comments Defense Health Clinical Systems

23. Problem List Update in A/P Module Defense Health Clinical Systems

24. Problem List Defense Health Clinical Systems

25. Autocite Problem List (3.3.7+) Defense Health Clinical Systems

26. Patient Encounter Documentation Defense Health Clinical Systems

27. Typical AHLTA Note Body Excerpt Hematologic: A tendency for easy bruising Neurologic: No lightheadedness. Memory Lapses or loss. Physical findings . . . Neck: Appearance:  Of the neck was normal. . . . Rectal: Rectum:  Normal.  Had no mass. Defense Health Clinical Systems

28. AHLTA note “Quality” • NOT efficiently understandable • Wording is mechanical and choppy. Doesn’t flow. • Bullet order determined by AHLTA hard-wired organization rather than by usefulness in reasoning • Overly verbose  slow reading and comprehension • Statistically mineable for epidemiology (low priority) Defense Health Clinical Systems

29. Desired note format • S.O.A.P. • Subjective • Objective • Assessment • Plan • Natural English language • Readable as phrases which flow together • Logical sequence leading to conclusions • Separated into paragraphs of related information, organized in a logical sequence to support conclusions Defense Health Clinical Systems

30. Sample “GOOD” Quality Excerpt HPI: Pt is a 19 y/o female, 1 week into army boot camp, healthy and active without medical complaint as of 3 hours ago. Two hours ago she began to c/o HA and stiff neck. She then developed photophobia, progressing to crying and irritability and a spreading rash, for which her drill sergeant brought her to sick call clinic. She shares quarters with 38 recruits. Room mates have no HA’s, back or neck pain, photophobia, or rash. Room mates have only minor c/o myalgias attributed to the rigors of basic training. Otherwise no illness in contacts other then URI sx’s. Pt Arrival time: 1440 IMM: No Meningococcal vaccine per record review. IMM O/W UTD. PMH: …. Defense Health Clinical Systems

31. AHLTA Note Documentation Options • “Paste” good quality note into AHLTA encounter • “S.O. Tree” bullet note creation • “AIM Form” note creation Defense Health Clinical Systems

32. “Paste” Note into AHLTA • Create “GOOD” note in Word Processor, and paste note into “Add Note”. Defense Health Clinical Systems

33. “Paste” Note into AHLTA • PRO’s • Note is clear and concise • Data flows logically from one data point to another, ultimately to final conclusion • “Templates” for different complaints can be easily created/stored by any word processor Defense Health Clinical Systems

34. “Paste” Note into AHLTA • CON’s • “In the past”, notes could only be “Pasted” after the A/P • This changed the S.O.A.P. note flow to A.P.S.O. • Now (AHLTA 3.3.7+), notes can also be pasted in SO or AP • Coding cannot be automated through AHLTA • Statistical data mining for epidemiology is not possible • “Templates” are not centralized: No standardization • “Copy Forward” accomplished by “shadow” folders -HIPAA Security risk Defense Health Clinical Systems

35. “S.O. Tree” Bullet Note Creation Defense Health Clinical Systems

36. “S.O. Tree” Bullet Note Creation • PRO’s • Built in “Copy Forward” facilitates continuity of care • Automatic coding by AHLTA (kind of) • Statistical mining for epidemiology can be accomplished • Personalized templates easily created • Centralized templates facilitate standardization of practice Defense Health Clinical Systems

37. “S.O. Tree” Bullet Note Creation • CON’s • Meaning of bullets often not clear and no logical narrative flow (not clear and easily understandable) • Tendency towards over-documentation (not concise) • Difficulty locating desired finding in tree with 1000’s of medical terms • Sometimes provider settles for “close enough” meaning • Sometime provider gives up and does not document finding Defense Health Clinical Systems

38. “Aim Form” Note Creation • Form based template • PRO’s • Text boxes facilitate “Free Text” for logical flow • Related “Bullets” logically grouped together • Balance between medically desirable free text format and data mineable bullet format • Centralized form creation facilitates standardization Defense Health Clinical Systems

39. “Aim Form” Note Creation • CON’s • Notes are not customizable • Embedded “Summary Data” not available outside of note • If desired bullet is not on form… • Spend extra time getting out of form to find bullet • Choose “close enough” bullet for time efficiency • Decide to not document bullet if not critical to note • Over-Documentation tendency if form is too complete Defense Health Clinical Systems

40. “AIM Form” note creation Defense Health Clinical Systems

41. “AIM Form” note creation Defense Health Clinical Systems

42. “AIM Form” note creation Defense Health Clinical Systems

43. “Expanded” Neck to find Stiff Neck Defense Health Clinical Systems

44. “Aim Form” note creation • Couldn’t find “cap refill” • Switch to Tree view • “Find Term” on refill Defense Health Clinical Systems

45. “Aim Form” note creation • Select “a capillary refill test was abnormal” • Switch Back to AIM form view and continue on Defense Health Clinical Systems

46. “Aim Form” note creation • Petechiae and purpura not on form. • Less time to add comment to “Macule” than to “Find Term” on petechiea and purpura Defense Health Clinical Systems

47. “AIM Form” note creation Defense Health Clinical Systems

48. “AIM Form” note creation Defense Health Clinical Systems

49. “AIM Form” note creation Defense Health Clinical Systems

50. “AIM Form” note creation Defense Health Clinical Systems