The Efficient Clinical SessionThe Efficient Clinical Session

October 14October 14thth, 2010, 2010

Peggy Chou, MD Peggy Chou, MD Craig Noronha, MDCraig Noronha, MDSection of GIMSection of GIM

ObjectivesObjectives

At end of this seminar we hope that providers canAt end of this seminar we hope that providers can

1)1) Work more effectively during their clinical sessionsWork more effectively during their clinical sessions

2)2) Manage patient interactions more efficientlyManage patient interactions more efficiently

3)3) Develop advanced logician techniquesDevelop advanced logician techniques

What makes you slow down in the What makes you slow down in the clinic?clinic?

Current Reality vs DreamworldCurrent Reality vs Dreamworld

BMC is NOT getting a new electronic medical BMC is NOT getting a new electronic medical record system in the near futurerecord system in the near future

Electronic medical records are NOT going to Electronic medical records are NOT going to disappear from the United States health systemdisappear from the United States health system

We are being asked to see more patients with We are being asked to see more patients with more medical problems in shorter periods of more medical problems in shorter periods of timetime

Our patients problem and medication lists will Our patients problem and medication lists will get longer as they age and acquire medical get longer as they age and acquire medical morbiditiesmorbidities

So what can we do????So what can we do????

Develop Habits that allow us to be more Develop Habits that allow us to be more efficient in clinical settingsefficient in clinical settings

Use our clinical interactions with patients Use our clinical interactions with patients more effectivelymore effectively

Use the EMR system to our advantage or Use the EMR system to our advantage or at least speed up what we are doingat least speed up what we are doing

Helpful Habits Helpful Habits

Make the chart easier to focus:Make the chart easier to focus:

- Reorder/Clean up medication and problem listsReorder/Clean up medication and problem lists

- Add comments to medical problems to help you Add comments to medical problems to help you in future visitsin future visits

- Add titles to visits i.e. visit for knee painAdd titles to visits i.e. visit for knee pain

Being ProactiveBeing Proactive

Look at the patient’s chart BEFORE you Look at the patient’s chart BEFORE you sit in front of the patient. sit in front of the patient.

Looks up labs, review ED reports, other Looks up labs, review ED reports, other provider visits etc provider visits etc

Start placing orders before seeing patientsStart placing orders before seeing patients

Show up earlyShow up early

You cannot control if the patient or staff You cannot control if the patient or staff are running late. BUT if you start late you are running late. BUT if you start late you will never finish on time. will never finish on time.

Do only clinic work during sessionsDo only clinic work during sessions

Do not check emails or web browseDo not check emails or web browse

If you have down time- sign notes, sign If you have down time- sign notes, sign forms, review patients for tomorrow etc forms, review patients for tomorrow etc

““Do Today’s work Today”Do Today’s work Today”

The longer you leave notes the longer it The longer you leave notes the longer it will take to finish themwill take to finish them

If you see labs that are normal– do a quick If you see labs that are normal– do a quick follow-up letter. follow-up letter.

Use a results letter/form in logicianUse a results letter/form in logician

Do Not Leave the Room Unless Do Not Leave the Room Unless You Have ToYou Have To

Page the staff or call them if you need toPage the staff or call them if you need to

Minimize interruptions by negotiating with Minimize interruptions by negotiating with staff up frontstaff up front

In the room…In the room…

Computer-patient-MD triadComputer-patient-MD triad Setting the agenda…..and setting limitsSetting the agenda…..and setting limits Letting go…Letting go… RefreshRefresh

Working with the computerWorking with the computer

Most efficient if type while talking with Most efficient if type while talking with patientpatient

Position computer if possiblePosition computer if possible Acknowledge the computer, apologize if Acknowledge the computer, apologize if

necessary (especially if positioning is less necessary (especially if positioning is less than ideal)than ideal)

Setting the agenda…setting limitsSetting the agenda…setting limits

Negotiate agenda up front. This allows Negotiate agenda up front. This allows you to set limits lateryou to set limits later

Let the patient control as much of the Let the patient control as much of the agenda as possibleagenda as possible

““In the time that we have….” “We need to In the time that we have….” “We need to stop for today…”stop for today…”

““Do today’s work today” BUT balance with Do today’s work today” BUT balance with continuity of carecontinuity of care

Baker, LH et al “’What Else?’ Setting the Baker, LH et al “’What Else?’ Setting the Agenda for the Clinical Interview” Annals Agenda for the Clinical Interview” Annals

2005 143 (10): 766-7702005 143 (10): 766-770

Letting go…Letting go…

Patient in control of the agendaPatient in control of the agenda

++ Staff in control of the flowStaff in control of the flow

==

You can focus on the patientsYou can focus on the patients

RefreshRefresh

In the middle of the session, take a 2 minute In the middle of the session, take a 2 minute break:break:

Quick walkQuick walk

SnackSnack

EtcEtc

Logician TipsLogician Tips

Quick text- how to make one and use oneQuick text- how to make one and use one

Using previous notes to your advantageUsing previous notes to your advantage

Flag managementFlag management

Result managementResult management

Organize medications and problem listsOrganize medications and problem lists

Quick TextQuick Text

htnros htnros

==

Patient denies any headache, blurred vision, chest pains, shortness of breath, orthopnea, Patient denies any headache, blurred vision, chest pains, shortness of breath, orthopnea, or leg swelling. Patient reports that she takes all medications as directed.or leg swelling. Patient reports that she takes all medications as directed.

How to “future” flag yourselfHow to “future” flag yourself

Flag yourself WHEN you need to worry about Flag yourself WHEN you need to worry about something something

Helps prevent “overflagging” so that you loose Helps prevent “overflagging” so that you loose track of important thingstrack of important things

Good way to remind yourself about following up Good way to remind yourself about following up on patient’s studies, outcomes, visits with other on patient’s studies, outcomes, visits with other providers etcproviders etc

Good way to remind yourself to ensure that tests Good way to remind yourself to ensure that tests got done ie CT scans that need repeating etcgot done ie CT scans that need repeating etc

How to manage results???How to manage results???

If you have several results for one patient If you have several results for one patient sign all but one of them- makes your sign all but one of them- makes your desktop look cleanerdesktop look cleaner

Result letters- use them to your Result letters- use them to your advantage for stable or normal resultsadvantage for stable or normal results

Call the patient only if you have toCall the patient only if you have to

Organize your Medication and Problem listsOrganize your Medication and Problem lists

Place the highest priority or cannot miss Place the highest priority or cannot miss diagnoses/medications at the TOPdiagnoses/medications at the TOP

Place less important Place less important diagnoses/medications at the bottom and diagnoses/medications at the bottom and indent themindent them

Add comments to your Add comments to your diagnoses/medicationsdiagnoses/medications

Remove old resolved diagnoses ie URI in Remove old resolved diagnoses ie URI in 20042004