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WORKFLOW-2007
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Objections to Flight vs Digital
• I am not a flyer
• It weighs to much• I can crash and burn• I could never learn
those controls• It will get in the way of
my walking
• I am not a computer type person
• It costs to much• I can crash and burn• I could never type
• It will get in the way of my patients
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Process
• Not all will be happy-10-15% love island and will not move
• It will be painful at times• We are all in this together• -Basic computer skills-typing
– 15 dollars for typing program
• Failure and non-participation is not optional• We have clear goals and excellent technical
support
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Biggest Obstacle to Speed and adapting digital methods
It Requires a Paradigm
shift
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4 FACTORSTHE JEDI INCIRCLE
ACCESS FOR PATIENTSINCLUDES SATISFACTIONSENSE OF BEING CARED
DECREASED COSTS
IMPROVED QUALTITY OF CARE
HAPPIER PROVIDERS
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WE NEED TO KNOW THE ENEMY
Anytime you see paper, it is a sign of inefficiency
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PAPER
• MANUAL LABOR-$$$$$
• AUTOMATED LABOR
• PRIMARY CARE LOW MARGIN
• DO WE HAVE A MARGIN FOR OUR MISSION?
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Time
Cost
Paper
Cost of Doing Nothing
Compliments Dan Russler, McKesson
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Time
Cost
Paper
EMR
Cost of Parallel Systems – Paper and EMR
Compliments Dan Russler, McKesson
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Do you feel like a peasant?
“We are at the mercy of Chevera…
Government,
Insurance companies,
Regulators,
Politicians,
EMR
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Does this sound like the doctor’s lounge?
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Going to the Mountains
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Magnificent 7 Basic Concepts of Workflow
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The Magnificent 7
1. Computers don’t improve anything
2. Productivity is how you use the computer
3. Deep change hurts - Kakushin
4. Continuous improvement helps - Kaizen
5. Workflow is hard work - Keep at it
6. Empower the Patient – Ease the burden
7. Finish it – Enjoy it
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Concept 1 - Computers don’t improve anything
• Understand the Productivity Paradox
• Automation may not fix bottle necks
• Your EMR is not the gold mine -YOU are
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y
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If you have a mess and computerize it
You end up with a computerized
mess
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Concept 2 Productivity is how the
computer is used
it is thesame all over
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Viewers
• Paper in an electronic environment
• Chart can be in several places
• Productivity none• Minimal Interaction
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Basic Users
• Interaction is limited
• Dictation is used• Ordering• Past medication• No large
productivity gains
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Strivers
• Use Templates to enter information
• Early in program first 1-2 years
• More efficient • Replacing
transcription but spending time on machine
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Arrivers
• A lot of time invested and now not needed
• Extremely good at their systems
• Reaping productivity gains
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System Changers
• Maximum Productivity
• Incorporate add-ons and workflow changes
• Bend it to their will
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Concept 3 -
Workflow change depends ondeep change -
Kakushin革新
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Kakushin
A Deep Change
revolutionary change or radical improvement
Everything will be different
Think in the Future
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Mechanical Swiss Watch
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Kakushin = 革新 which means innovation
You make a large investment in a new direction Some people revolutionary
change
Efficiency
Transition
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Luxury Auto
• Mercedes Benz Quality investment value sturdy
• BMW Style, handling, functional
• Audi Style, space, affordable
• Volvo Safe, Reliable, Quality
• Jaguar Attractive
• Toyota cheap dependable
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Bottom Line
• Status and Prestige
• High Quality
• Resale Value
• Performance
• Safety
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Build the Car but different
• Great handling but a pleasant ride
• Fast and smooth but a low fuel consumption
• Super quiet but light
• Elegant styling but aerodynamic
• Warm but functional
• Great Stability and yet low friction
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First Year
• Sold 2.7 times more Lexus the Mercedes Benz the leader
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EMR
• Improve Quality but decrease costs
• Improve Documentation but have more time with patients
• Improve access for patients but leave for home at 5
• Increase R and D but improve margins
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Kaizen
改善
Concept 4-Continuous improvement
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Kaizen
• Incremental continuous quality improvement
• You get a little better each day
• Limited by technology
• Significant Limitation
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The Toyota Way-
Measure Everything
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Patientarrives in
Preop
Arrivedon time?
StartIV
Spike &hang
antibiotic
Circulatorgive Abx.
on the wayto OR
PatientcompletesAnesthesia
Questionnaire
Physician'spreprinted order
for antibiotic
Surgeon givestelephone orverbal order
Hand writtenon
chart
Nurse notes order
Four Routes for Preoperative Antibiotic Orders
Antibiotic to patient
before incision
PhoneOrder to
Pharmacy
Nurse tellsPharmacists:
pt name, allergy,M#, ordering MD
Labelgenerated
Techlabelsbag &
fillsorder
R.Phcertifies
order
Antibiotictubed to
PAAMain
Pharmacy
SatellitePharmacy
YES
NPO?
YES
YESNO
PAA nurse writesABX on MAR
PAANurseMixes
Antibiotic
Anesthesiagives atstart ofcase
MD writes antibiotic onAnes record
YES
Time to preppatientbeforecase?
NO
NO
Nurse picksup antibioticfrom tubes
Revieworders for
preopmeds
Anesthesia verbalorders
Four Antibiotic Sources
Pharmacy Pyxis OR Drug BoxAnesthesia
Tray
Recordsadministrationcomputerized
OR case record
Inputs orderinto computer
NO
YES
MedicationAllergy?
PAA nursereviewspatientallergy
NO
SelectalternateantibioticYES
Medicationallergy Select
alternateantibiotic
YES
NO
Anesreviewspatientallergy
Medicationallergy
Selectalternateantibiotic
YES
NO
Contact Surgeon
Delaycase
YES
NO
Cancelcase
Process map patient care
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Time- from Drucker’s The Effective Executive
The Supply of Time is totally inelastic. No matter how highthe demand, the supply will never go up. There is no price for
it and no marginal utility curve for it. Moreover, timeis totally perishable and can not be stored. Yesterday’s time is
gone forever and will never come back. Time is, therefore, is always in short supply. Time is totally irreplaceable…
There is no substitute forTIME
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The Toyota Way
Look for what is valuable to the customer (patient)……..
NOT what you may value
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Waste
• Not safe 50000-100000 deaths due to errors
• 42% respondents experience poor or inefficient care
• 45% recommended care not given (not insurance related)
• ¾ of US population wants change
• 47 million uninsured
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Workflow to find waste
• Overproduction
• Waiting
• Unnecessary transport
• Over processing or incorrect processing
• “Seeing someone who you should not-hospital rounds
• Patient Staff
• Movement back and forth
• Prescription in pt with allergy
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Workflow to find waste
• Excess inventory
• Unnecessary movement
• Defects
• Unused employee creativity
• Prescription refills
• Clickitis
• Pt left without needed shot
• I am the boss
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Patient Perspective
Start Done
PatientArrives
ChecksIn andWaits
Room
Nurse
Wait Doctorsees
GetsTests Gets
Rx
WaitsForRx
WaitsFor tests
DoesPlan
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Workflow Digital and Not Digital
Concept 5 Workflow Workflow Workflow
You can not go Back-Lower the ODDS
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Let’s Lower the OddsLet’s Go to the Office….
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First Step – Patient comes to Clinic
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Patient Value to See You
Decides to comePhone Call 9 pmGive InformationRememberGet in Car Go to Office
68 minutes 68 minutes for 6 minute for 6 minute office visitoffice visit
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Did they need to come?
To pay a billPick up something
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Physician View of Patient (who did not need to see me)
• Low margin revenue– Exchange of data– Rechecks– Patient who does not need to be there– Could someone else do it?
• Non-visit care tomorrow (e-Visits)
• Work smarter – not harder
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Patient comes to a receptionist
Think about your office
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Waste?
• Efficient
• Paper there Did we need it? How did it get there?
• Looked in computer Phoned
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WASTEWASTE
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Patient Enters the Clinic
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VALUE
WASTE
Pt coming toOffice
PatientRegistering
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Lobby Waiting
• 19/20 were waiting one filling form
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VALUE
WASTE
Pt coming toOffice
PatientRegistering Patient in lobby
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Vital Signs
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Vital Signs
WASTE
Accurate?
Paper?
Time to Log in?
VALUE
BP/Pulse/Weight
60 seconds
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VALUE
WASTE
Pt coming toOffice
PatientRegistering Patient in lobby
VS
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Vital Signs pulse BP
• ..\Movies 2006\MVI_2995.AVI
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Patient waits for doctor
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Pt coming toOffice
PatientRegistering Patient in lobby
VS Waiting forDoctor
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Doctor needs to know you are ready
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NOW THE DOCTOR ARRIVES
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Doctor does the writingDoctor does the data entry
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MD Documenting – IS IT WASTE OR IS IT VALUE
Hand Writing
30 words per minute
Typing 60 words per minute
Dictating 180 words per minute
Editing 7200 words per minute
$$$$$$$$$$$$
$$$$$$$$$$
$$$$$$$$
$$
$$$$$$$$$$$$$$$$$$$$$$$$
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Options for Data Entry to EMR
1. Handwriting recognition
2. Typing
3. Dictation
4. Voice recognition
5. Templates
6. Patient entered data with editing
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1. Doctor using Handwriting Recognition
Slow, but seems great until have more than 6 words or misrecognition occurs
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VitalsCheck-in
21 15 12 = $32Doctor for Data EntryHandwriting or Handwriting Recognition
PhysicianDocumentation
EMR and 15 Minute Office Visit Doctor Handwriting
Checkout
EscortPhysician Exam
NursingDocumentation
Escort
4
Graphic derived from Dan Russler, MD, McKesson,
Making Money
Wasting Money
Money Spent
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Doctor Does the Data Entry
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0
24
68
10
121416
1820
Initial Install 3 Mo 1 Yr
Paper
EMR
Productivity Drop with EMR
Kaiser Northwest, Portland, OR
Time of Office Visit
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Revenue Drop after EHR
-7.00%
-5.00%
-3.00%
-1.00%
1.00%
3.00%
5.00%
7.00%
RVU % decrease
1st quarter
2nd quarter
3rd quarter
4th quarter
Total
Carilion Health Care – Carilion Health Care – Roanoke, VARoanoke, VA
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Where did they put the Computers?
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13
VitalsCheck-in
21 4 12 = $42
Using the Doctor for Data Entry
EMR and the 15 Minute OVDoctor Typing
Checkout
EscortPhysician Exam
NursingDocumentation
Escort
2
Making Money
Wasting Money
Money Spent
8
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We could have nursing do this
What would that look like?
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Data Entry into a Field-Prevention
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PREVENTION REVIEWThis review was done when the adult was 55 years old on Thursday, October 14, 2004.
We have discussed the following topics which are important for all people in your age group:cholesterols every five years (see past medical history for your value),
smoking habits (can be found in past medical history), alcohol use, abstinence, and being in a car with a driver who has been drinking,
recreational drugs, aspirin should be taken daily , sexual practices, Prostate check yearly:last exam 2004 and offered counseling.
The following should be done yearly:height, weight, and blood pressure: done this year
Injury prevention is as follows: seatbelts: yesSmoke detectors: yes
Bicycle and motorcycle helmet does not bikeGuns and violence: no gun in home
Other risk factors reviewed: passive smoke: not at riskExposure to tuberculosis: yes-(you are at risk and need a TUBERCULIN TEST YEARLY)
Sunscreens: no-(you should WEAR SUNSCREENS 15 OR ABOVE)Radiation to neck no
Have a family history of colon cancer, familial polyposis: noColonoscopy or alternative examination recommended after age 50 colonoscopy 2004
Risk for back problems: not at riskBrushing teeth and dental care: yes
Exposure to loud noises: not exposedYou are at risk for diabetes: no risk
Your risk for cancer is related to these relatives: none. You have had a divorce in your family or separation, felt sad or are grieving: no
You are angry or are frequently angry: YESYour shots are up to date: yes and can be found in past medical history. We recommend all families know CPR.
REVIEW OF SYSTEMS:
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VitalsCheck-in
21 14 12 = $42
Using the Doctor for Data Entry
PhysicianDictating
The EMR and the 12 Minute Office VisitNurse for Documentation
Checkout
EscortPhysician Exam
NursingDocumentation
Escort
VitalsCheck-in
21 112 = $32
PhysicianDocumentation
Checkout
EscortPhysician Exam
NursingDocumentation
Escort
12
Nurse for Data Entry18% ReductionLabor Cost
3
2
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We can dictate
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3
VitalsCheck-in
21 14 12 = $38
Doctor for Data EntryDictation
PhysicianDictation
EMR and the 15 Minute Office VisitDoctor Dictating
Checkout
EscortPhysician Exam
Nursing Documentation
Escort
2
Staff management of dictation
1
Inability to answer problemsPoor referral managementInsurance rejection issues
4
10
2
? Decreased patient safety & satisfaction
Making Money
Wasting Money
Money Spent
3
Transcription cost
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• Physician
• Nurse
• Patient
21 16 12 = $4210
Cost Comparison of EHR Data-Entry Workflows
21 112 12 = $374
Where is the WASTE? Where is the VALUE?
21 13 12 = $294
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What are we doing in the exam room?
WASTE vs VALUE
1. History
2. Physical Exam
3. Plan
4. Write Prescriptions
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Who is the owner of a person’s health?
Who is the customer?
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Instructions
• 40% lost in minute
• 80% lost in 30 minutes
• Incorrectly remembered
» J Royal Soc Med 2003 96:219-222
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Information
71% of time patients are given nothing following their visit
68% of patients of Mayo Internists did not report what physician thought was a problem
54% a major problem
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Concept 6 - Empower the Patient
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You are at the office
• A partner’s patient who has hypertension comes to see you because in the last ten days she has noted that her blood pressure is elevated from its baseline.
• Meds Lisinopril 20 mg daily
• BP 152/93
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What did we learn?
• We can not judge quality of care by reviewing a chart!
• Inputs are important
• Computerized history provided more information that was critical to this case, and was valuable to the clinician
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Vendors
• The literature has been around for forty years
• Without an EMR not all that practical
• Names are in the handout-None are here except one
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Instant Medical History (IMH)
• Software program you buy 50 dollars a month from Primetime Practice
• 75000 questions• Install into a computer• Tool on e-mail/internet for patients to use-
Medfusion AAFPs portal• 45 EMRs have as the interface to patient-This is
hugewww.medicalhistory.com
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How does it work?
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Patient Doing History
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OUTPUT IS GIVEN TO YOU
• Given to you on paper• Given to you in
electronic form like into Word
• Directly into an EMR
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ADVANTAGES
Collects more data then a clinician and organizes it into a readable form
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Patient is better organizedPatients can do this
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Patient collects information that the clinician misses
• 40% of time provided useful information not typically elicited
• Essential Questions missed
• Pilot’s Checklist
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How dangerous is health care?
Number of encounters per death
Dea
ths
per
yea
r
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
Mountain Climbing
Bungee Jumping
Driving
Manufacturing
Chartered Flights
ScheduledAirlines
European Railroads
Nuclear Power
Note: both dimensions are logarithmic scales
10 10,000 100,000 1,000,000 10,000,000
10
100
1,000
10,000
Health Care
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Socially Sensitive
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Documentation
• Most Clinicians do E4 work 55904
• Most Clinicians Code E3 work 55903
• Most Clinicians document E2 work.55902
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Others
• Patient controls interview-length of time
• Doctor only deals with positives
• Research
• Multimedia
• High patient acceptance
• Scales
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Scales
• Zung Depression• Rahe Stress Scale• Urology Scales• Wast• Conners• Anxiety• Pain impairment• Patient Education Needs
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Tough Diagnosis
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8
20.1
2012345678
Min
utes
Traditional
S
O
A
P
E
Time of a Routine Office Visit
Subj.Subj. Obj.Obj.
PlanPlan
Pat EdPat Ed
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3 2 0.13
2012345678
Min
utes
Software
S
O
A
P
E
Future Time of a Routine Office Visit
Subj.Subj. PlanPlan
Pt. EdPt. EdObj.Obj.
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Complete PhysicalComplete Physical
35
7
0.1
58 7
0.1
1517
0
5
10
15
20
25
30
35
Minutes
OLD NEW
S
O
A
P
E
SubjSubj
ObjObjPlanPlan
SubjSubjObjObj
PlanPlan
Extra TimeExtra Time
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Jane DoeChief Complaint Sore throat
VS stableSore throat 3 days duration
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Lets look at history
80/20 Rule
20% of your questions get you 80% of the content
Negatives are time intensive
Analogy Mining for Diamonds!
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Mining-Topsoil sand it is easyOpen ended questions
Listening 2 minutes
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What are the results of All this labor
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It is like MiningYes/No questioning-tailings
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You can use a machine toDo the hard time consumingWork
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You are in controlYou will trust the work doneCheck out a few things
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A Clinic Story They see it and own it
• History was done on 5-page paper form, then translated into EMR
• Patients often forgot to bring form
• Office staff could see pt. on same or next day basis
• “Insurance problems” was common barrier to early-OB care
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A Clinic Story
Call for Visit
Come in Today or Tomorrow for Intake
Intake VisitIMH
Rx Vitamins
Insurance Forms
Video
Prenatal Labs drawn in office
MD Visit – 1-2 wks laterHistory reviewed
Exam
Plan/Discussion
Call for Visit
Wait 1-2 Weeks
Send History Form in Mail
Initial New OB VisitInsurance Forms
Video
MD Visit
History reviewed (or re-collected if pt. forgot questionnaire)
Exam
Prenatal Labs ordered, pt. sent to lab
Rx Vitamins
Plan/Discussion
PLAN: Change workflow, add IMH
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A Clinic Story
RESULTS in FPC
PRE:
NO Show rate: 40%
MD Time: 1 hr/pt
Indicators: missing
POST:
11%
45 min/ pt
all met
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You have the Subjective Portion
• Answers to a series of yes and no questions
• Minor alterations• Documentation has improved• Quality has improved-
– Pilot check list– More complete inventory– ATMs and electronic tickets
• Computer has had structured data entry
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Impression and Plan
• Using the Internet for plan if you do not have a template
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Concept 7 – Finish IT, Enjoy IT
Go home at 5PM with work done!
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Go get em
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References
• Bush Roger W Reducing Waste in US Health Care Systems JAMA 2007 297 871-874.
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