Patient Charting and Documentation: Using and EHR for Nurses and Allied Health Professionals

By: HRSAtube

Operator: Ladies and Gentlemen, thank you for standing by and welcome to the "Patient Charting and Documentation: Using an EHR for Nurses and Allied Health Professionals" Webinar, presented by HRSA OHITQ. During the presentation, all participants will be in a "Listen Only" mode. However, you may submit questions to the speakers at any time today by submitting them in writing using the Chat Feature located on the left side of your screen. Questions will be addressed as time allows. As a reminder, today's Webinar is being recorded. It is now 2 PM Eastern Standard Time on November 16, 2012.

The presenters for today's Webinar are Pamela Ferrari, RN, and Frances Johnson, RN. I would now like to turn the conference over to Natassja Manzanero from the Office of Health IT and Quality at HRSA. Please go ahead, Ms. Manzanero. Manzanero: Thank you Chris and thank you for joining us this Friday afternoon. Before I introduce Lieutenant Michael Banyas to introduce the speakers I would like to make a few announcements relevant to today's participants. First, the Office of the National Coordinator is offering free vouchers to Safety Net Provider staff interested in taking the Health IT competency exam.

This exam is a wonderful way for staff who have received Health IT training or work in this area to receive accreditation in one of the several Health IT workforce areas covered by this exam. Please email healthit@HRSA.gov for more information or to request a voucher. The next HRSA Health IT and Quality Webinar, titled Meaningful Using Computerized Provider Order Entry, Expertise From Two Safety Net Providers, will be on Friday, December 14th at two o'clock PM Eastern Time. Registration is now open on the HRSA Health IT website's Webinar area. Several months ago HRSA debuted its new clinical quality and performance measures tool kit on the HRSA Quality website. This tool kit provides training on how to use clinical quality measures such as breast cancer and hypertension within a Safety Net Provider setting. In addition, it includes resources to help providers implement quality improvements and tools such as PDSA plans within their practice setting. Please visit the HRSA Quality website to access this new tool kit.

There are two new Meaningful Use resources I would also like to point out. The first is that ONC has released new case studies on providers who have become meaningful users of Health IT. In addition, the centers for Medicare and Medicaid services recently released the Meaningful Use Quality Measures Specifications for 2014, both of these resources can be located on the HRSA Health IT and Meaningful Use webpages. Lastly, HRSA's November Health IT and Quality newsletter is available online.

Patient Charting and Documentation: Using and EHR for Nurses and Allied Health Professionals

The newsletter provides many news items and announcements relevant to Safety Net Providers in the areas of health IT and quality improvement. Two features I would like to specifically point out because they focus on November's Veteran's Day are the grantee spotlights on Health IT's webpage on Colorado's Community Managed Care Network hiring veterans to help health centers with Health IT. In addition, the HRSA Quality Improvement website grantee's spotlight highlights Fort Drum Regional Health Planning Organization, coordinating high quality health care for veterans and military families. Please see both these grantee spotlights to see a glimpse of the active role Safety Net Providers play in working with veterans and military families. I would now like to introduce Lieutenant Michael Banyas to introduce today's speakers.

Banyas: Good afternoon everyone and thank you for joining us on this Friday afternoon. I would like to welcome all HRSA grantees and members of the Safety Net community to the Health Resources and Services Administration's Health Information Technology and Quality monthly Webinar. This month's Webinar is entitled Patient Charting and Documentation in an Electronic Health Record for Nurses and Allied Health Professionals.

Today's technical assistance Webinar will provide tips and examples from experts on how nurses and Allied Health professionals use Electronic Health Records for patient charting and documentation. These individuals are usually the first clinicians that patients encounter to assess their health care needs and concerns. This assessment often includes documenting patient data into an electronic health record and chart to provide the patient's care team with accurate information to help identify treatment options. As health centers, critical access hospitals and rural health clinics increasingly become meaningful users of health information technology it is critical to train, support and fully integrate nurses and Allied Health professionals into system and clinical transformations. Today's speakers represent a variety of Safety Net Provider environments and will focus on who will share their experiences from a health center, a primary care perspective as well as from a rural provider viewpoint. Before I introduce this afternoon's presenters I would like to read a disclaimer. HRSA would like to add that this Webinar is intended to serve as a technical assistance resource based on the experience and expertise of independent consultants and HRSA grantees and its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.

In addition, HRSA does not endorse any health information technology vendors or software systems including the health IT systems featured in this Webinar. Now I'm pleased to introduce this afternoon's presenters. Ms. Pam Ferrari is the Director of Performance Improvement at the Open Door Family Medical Center in New York state. She has played a critical role in Open Door's shift to integrate electronic medical record technology with data warehousing and reporting. This approach has effectively transformed patient care delivery and improved the organization's clinical outcomes. Ms. Ferrari joined the Open Door leadership team in 2000 after 20 years of practice as a visiting nurse.

Her clinical background and dexterity with clinical information in data bases has allowed her to identify the clinical indicators that Open Door uses to meet and exceed national standards. Her efforts were instrumental in allowing the health center to roll out a robust organization wide performance monitoring system which addressed clinical, operational, financial and patient safety metrics. She has also lead the effort to develop clinical report cards on key clinical metrics which have allowed Open Door to demonstrate the effectiveness of its programs. She has given lectures across the country on her experiences and successes in implementing clinical informatics at Open Door and she continues to design reports and conduct trainings for users across the country. The next presenter is Ms. Franny Johnson from the Colorado Visiting Nurse Association. Ms.

Johnson graduated with a Bachelor of Science in Nursing from Michigan State University. From there she worked in the acute care setting with a focus on cardiac care for four years in both Michigan and then Colorado. She started with Northwest Colorado Visiting Nurse Association in Steamboat Springs, Colorado as a public nurse and continues to work there today. Her focus as a public health nurse included both the immunization program as well as the Woman's Wellness Connection program doing case management for women in need of breast cancer and cervical cancer screenings. Her current role within the Northwest Colorado Visiting Nurse Association is as a Clinic Manager of the new Access Point Community Health Center in Routt County. I would like to thank HRSA and its grantees and the Safety Net community for participating in this event. I would now like to turn the event over to Ms.

Ferrari. Ferrari: So, hi everybody. I'm gonna move to the next slide, I think. There. Okay. So, as they said I've worked here at Open Door, which is a community health center in New York, we're just outside New York City about 32 miles and we're still recovering from Sandy so, but our technology is up and running so we're really pretty happy about that. What we have done here at Open Door about, we applied three years ago to become a patient-centered Medical Home and we're up this year to be recertified as a patient-centered Medical Home level three and we're also, of course, working on Meaningful Youth.

We implemented an electronic medical record five years ago and that's been fantastic for us. I'm a real data geek, I love data and love to use data to try to improve patient care so I was really excited when we first started using an electronic medical record thinking that I was gonna get my hands on all the data. And I can still do a much better job because of it because I can sit in my office and look at what's going on anywhere in the organization. But, this presentation you're gonna see today is really taken from a training that we do within our organization to talk to our staff about the patients in our Medical Home and everybody's role.

So when HRSA first asked me to talk about the nurse's role I had to explain that here in our community health center, at least in the New York area, we really don't have very many nurses. You know, I'm a nurse and work in an administrative capacity, most of our nurses that are working with patients are either LPNs or Medical Assistants and other Allied Health professionals. So I wanted to really talk about what the clinical support staff, in general, do to work together at both the Medical Home and as meaningful users of the electronic medical records.

So what we've told our staff is that Open Door's a place of choice for our patients, the patient should be able to trust that they're going to receive quality care and caring. Number one is the patient should know who their primary care provider or care giver is and that staff will assist with scheduling visits with that provider. The first tenant of the rules of a patient-centered Medical Home is that you have a relationship with your primary care provider. In the past, Open Door and most health centers were so focused on access and getting patients in and making sure that when they call they can get right in, that nobody really cared about who they saw and there was not a focus on making sure that they had an ongoing relationship with one provider. So both when we moved to an electronic medical record and then as we've been moving forward as a patient-centered Medical Home we have absolutely made this a huge priority because, I'll tell you, we've seen that the outcomes are better when the patient sees their own provider routinely. And I've actually looked at the outcomes both ways for patients that have had more than two visits in the calendar year with their primary care provider and patients who've had less than two visit in the calendar year with their primary care provider and patients that have had those visits with their primary care provider their outcomes are much better. The Open Door also assists staff with transitions in care to other locations, the patients are informed so when there's a wait someone goes out and talks to them, the patients are engaged in the planning of their care so somebody helps them with self-management goals and information is readily available through our electronic medical record.

So the challenges of implementing a family-centered Medical Home primarily, if you ask all of our providers and all of our staff, is time. In order for us to run a functioning organization that is in the black, that we can keep the doors of the Open Door open, our providers have to see 23 patients a day. That's a lot of patients to see in a short amount of time. We also have, you know, lack of organized systems with defined roles, that's how we walked into this. We had inadequately developed patient/family relationships and partnerships, that's not the way we did business in the past. Our providers, when we started this, were used to having the patient come in, doing their assessment, writing scripts and have the patient go out. There were knowledge and pathways..

there were gaps in that not every doctor knew how to do everything well. There was lack of coordination of care, who's supposed to do that, it's not my job, there was lack of awareness of community resources and programs, what's out there, what can help my patient and then, of course, there's reimbursement. Is somebody gonna pay for that? So because of all of these challenges we had to come up with a team approach. No one doctor, no one nurse can do all of it so we came up with a team approach. I'll talk from my own personal message is that when I came to the Open Door 12 years ago I had been a public health nurse for a very long time, over 20 years, and I was used to a real independence as a nurse and I came to the Open Door and I saw that nurses really were not working that independently or that high functioning and I was sort of appalled at the way the nurses were working at the Open Door.

And what I found though is that there weren't enough bilingual nurses to go around, to really do the job the way it needed to be done so we actually had to train more staff, other staff besides nurses, to do the jobs that I thought really needed to be done. But the whole idea of a patient-centered Medical Home starts with a personal relationship with the provider, each patient has an ongoing relationship with a personal clinician who's trained to provide continuous and comprehensive care. And here at the Open Door, we've been around for 40 years and the woman that started this organization, she had a philosophy, that just because we were... because we were a community health center we, she didn't want it to be a clinic, she didn't want it to look like the Department of Health.

So our center's beautiful, it has framed art on the walls and we have always tried to run ourselves as if we were a private doctor's office, we want to look like one and act like one. We don't want to look like the Department of Health. And so, that's been our philosophy all along and I think that's carried, as well, as we move into the idea of a patient-centered Medical Home. The patients really do have a relationship with their doctor they don't just come, get in line and see the next doctor that's around. But, I have to admit that's a change in philosophy for a lot of people. But on the other hand, as we say, not all the glory goes to the doctor. Because it starts with one person it makes it impossible to give the best quality of care to the greatest number of patients by the doctors so you have to have a team is what we decided.

Clinician directed team, and that means that the provider really has to take responsibility for the group of people that are working with them. That means they sometimes have to come in early, they have to have team meetings, they have to have huddles, they have to do some pre-visit planning, they have to designate responsibilities and not every unit and every team works the same and we have to see that and understand that. All right. So, let's talk about the team.

Well the first thing about the team is that they have to provide care coordination. What is it? Care coordination is patient- and family-centered, it's assessment-driven, team based activities designed to meet the needs of the patient while enhancing self-management for patients and families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational, financial needs in order to achieve optimum health and wellness.

Now, that sounds like a lot, right? And it is a lot and patients come in to the health center with a sore throat and they think they're gonna get a throat culture and prescription for amoxicillin and be out the door but in our health center, as a patient-centered Medical Home, there's a lot more to it. We have to stop, we have to take a look at whether or not that patient, whether it's a child, are they up to date with their immunizations and whether it's an adult, are they up to date with their cancer screenings, have the women had Paps, have they had mammograms, does that guy need a colon cancer screening, do they need HIV testing, don't forget to do a depression screen, all that stuff has to go on. Have they been in the hospital since the last time we've seen them, are they on any new medications from another doctor, all that stuff has to get done and it takes time. So the goals that I just said about family-centered, community-based, proactive, provide planning, everybody's talked about planned care, everybody knows about planned care, the development of self-management skills, cross-organizational linkages between hospitals and that sort of thing, how does it all get done, who's gonna do all this stuff, right.

The functions are that we provide separate visits and care coordination interactions, sometimes. Sometimes they're part of the regular visit. We manage continuous communications, we have to complete and analyze assessments. Now that means that not only do you have to do an assessment and write it down and record it in the electronic medical record but somebody has to analyze that data, somebody has to be in the background and say, well, how many of the women who are over 40 that came in last month actually got a script for a mammogram is they needed one.

So it's not enough just to gather the information but it has to be analyzed in order to really coordinate care for patients so you have to manage and track both tests, referrals, outcome, you have to coach patients, integrate critical care information into the care that you're providing, support transitions in care when they're going to the hospital, when they're going to an outside provider or specialist, nursing home, whatever, in our case oftentimes it's when they're going back to their home country. You have to facilitate team meetings, these are oftentimes patient huddles, we do them sometimes electronically, which I'll show you in a minute how we do an electronic huddle, and you really have to use information technology. When we first went on electronic medical records they absolutely thought that it was all about just putting information in there so that you didn't have to look in a paper chart any more but it's so much more than that. You have to put the information in in a way that you can get it out and use it and let the information that's in your computer tell you a story.

That's what my job here is at the Open Door, is to really supervise the information that goes into the computer, to get it out, to look at it and to really look for the story. Look and see how come mammograms aren't getting done, you know, is it, are they not being ordered or are the patients not going to them, are we getting the results back, what's interfering with that sort of thing, is there a higher use of antibiotics this month, are patients... is it because patients really are sicker and have an infection, are fevers going up, take a look at that information and look for the story that's there in the data.

Okay. So Open Door's care coordination team, here we are talking about what our days, what we're really supposed to be talking about. We have three or four providers in any combination, that's a doctor, a PA or an NP.

One medical assistant for each for provider, one nurse or LPN per team, one patient service rep, that's really the front desk staff, one patient advocate and I'll tell you about their role because not everybody has that, we have call center staff, we have designated behavioral health staff, reach team, we include the patient and the family in this care coordination team and we also have the community pharmacist which we include in that team. So the core team, a mini-huddle, we expect every morning for people to come in early or at least on time and prepared. Sometimes they sit and look at today's list together and because it's electronic they can click into each patient and see what needs to be done. Sometimes they sit in their own offices and assess, they do what we call pre-visit planning and you can see..

Oh, should I use this little thing? Oh my God, I'm afraid to but I will. Okay, so you can see down here, this is a little running tag line on top of our electronic medical record. What that does is, whoever's previewed the chart can look in the little yellow sticky note and see what the communication was so if the nurse is rooming or the MA is rooming the patient and does, and gets some information from that patient she can communicate it right back to the provider. If the provider's prepping their charts the day before he can tell the LPN these are the immunizations I want this child to have so she can be getting it ready while the provider is starting with the patient.

So this is a way of doing a pre-visit huddle and pre-visit planning which we absolutely find this, find it's totally essential. Now, I'm not telling you that our doctors are working a nine to five, everybody has a VPN access to the electronic medical record from home and 90% of our providers sit up at night after their kids are in bed and take a look at their charts and do some pre-visit planning and huddling from afar. So the provider's the leader of the team, he leads the team, prioritizes high risk patients for care management, so tells our care managers these are patients I want you to take, to help me out with, designates who needs a PHQ-9 and who needs their smoking assessed, creates standing orders and says let's have these done, does the pre-visit planning, reviews clinical decision support, so looks in the EMR for tips and reminders 'cause no doctor's gonna remember everything. Does this patient have an LDL, does this patient have an A1C, does this woman need a Pap, look at the clinical decision support that's built into the electronic medical record and let that enlighten them.

They provide care-based organizationally-endorsed standards of care and that's our responsibility as administration to make sure that those standards are out there and that our providers are being reviewed and assessed according to those standards of care and that they're receiving feedback on how well they're doing, that's my job. I provide that report card monthly on 35 different clinical measures that get fed back to the providers. What percent of your patients have been assessed for smoking, what percentage of your women have had mammograms appropriately, what percent of your kids at two years old are up to date on their immunizations, all of those things are fed back by our Medical Director and then the doctor also directs patients to other team members that are there for them, smoking cessation groups, nutrition, diabetes groups, that sort of thing.

And so then the medical assistant, here in a community health center... I'll make that little green guy go away... Here in the community health center the medical assistant has a big role. They take responsibility for both prepping the rooms to make sure everything is there when they need it, they do the pre-visit planning and they review the charts, they know what the standards of care are, they know... they can put a reminder that the patient needs a Pap or that this patient is a diabetic and don't forget to take off their shoes. They're the ones who put the patient in their room, they do the vital signs and they record them appropriately. I have to, we constantly give them feedback that their blood pressures are not recorded properly or whatever. Make sure that you get a height and a weight on everybody so the computer can calculate a BMI, they calcula..

they get the chief complaint from the patient, they start the relationship with the patient. We have standing orders so that they oftentimes start HIV testing and they do much of the initial history, the family history, the OB history and the social history, they capture where was that, where did this patient, where was the patient born, who's in their family, excuse me, numerous things that are part of the social history, they get that information first. The provider then goes in and looks at it and discusses it with the patient but it's the MA who captures this stuff and I'll tell you when we first went to an electronic medical record our medical assistants loved the fact that they were given the autonomy to go ahead and document in the patient record. Before they would, all they would do is go in and do the vital signs and sign their name. They never went in and did the smoking history and the OB history and all these things that they do now. They carry out the standing orders that have been set up by the provider which is great.

They oftentimes function as interpreters because we really need that here at the Open Door. They assist with all procedures, they reflect back patient's goals and achievements so since we do have a self-management goals template that's here for every patient, it's the medical assistant's responsibility to reflect back achievements to the patient. So if indeed they're self-management goal was to lose weight or to lower their A1C or to exercise when they're putting that patient on the scale or when they're getting the results of their A1C they can easily give the patients...and they do, a cheer and feedback, oh look how well you're doing, great. The patients love the fact that everybody notices what they're working on. Then they reinforce the provider plan, direct the patient that needs additional care coordination to a patient advocate or whoever's gonna provide that service. So they, you know, they're sort of the traffic director, they move them around the health center and tell the patients where they have to go next in order to get what they need.

And then the nurse, here the nurses that work with patients are primarily LPNs. We only have RNs in two roles at the Open Door, really, and both of them are in OB and that's sort of a carryover from the past when the New York State Department of Health required a registered nurse in that role. It's really hard to find a registered nurse that is bilingual that's able to work in that capacity. So those are the two roles that we have nurses in, registered nurses in, otherwise we have LPNs. What they do, also, is pre-visit planning, they identify patients that require immunizations, that's a huge role for them is the immunizations, they check the New York State Immunization Registry but they also perform outreach to patients who need immunizations or PPDs and lab follow ups, they do all of that. Patients that are on medications that need lab tracking and back up they maintain those registries both for patients that are on INH or patients that are on Coumadin that need labs, they carry out standing orders as delegated by the physician leader, they are the ones who give the immunizations and treatments and shots, whether the woman is in for a Depo shot or is a child that needs his childhood immunizations or an adult that needs an immunization, here, in New York State anyway, it's an LPN that gives those shots.

They coordinate referrals and obtain preapproval, this is a big part for patients that are insured, they provide teaching as allowed by their scope of practice and this is a caveat here because, you know, that the role of the LPN is somewhat limited with regards to teaching so there's not a huge amount of teaching done by the LPNs. That's why we had to, that's why we've moved to this additional role of someone called a patient advocate but they do reflect back patient goals and achievements, as I had said before, and encourage people in their own self-management goals. The call center staff is a huge member of our team. They answer the phones and initiate telephone encounters, they make appointments, they educate new patients about what to bring in for their first appointment, they preregister patients and it's just so important that we have someone conscientious doing this so that we get the right phone numbers and addresses so we keep track of our patients when there's things we need to get in touch with them for. So they take responsibility for all that initial information that starts, that really starts up the medical record. I want to, I might want to point out here that it's the call center staff that is often involved in making sure that initial, that patient sees their same provider over and over.

They have to, that's one thing that we do a lot of training with them with is to how to talk to patients about, we don't want you to just come in and see the very next patient, what we actually want you to do is, you know, it's really important that you see your provider, he wants to see you or she wants to see you and follow up with you with what's going on. The PSR, that's what we call it here, it's called a patient service representative, this is the front desk staff. They verify the insurance, they identify patients who need care coordination related to insurance so if somebody doesn't have insurance they can assist the patient, direct the patient to our staff that helps the patients find out what entitlements they might have. They maintain updated demographic area, data, I'm sorry, so has your telephone changed, has your address changed, do you have email, let me register you for our patient portal, that sort of thing, they get all that information. They facilitate the follow up appointments with the primary care provider, once again making sure that the patient is seen as a follow up with their own doctor, ensure the patient is assigned appropriately and direct patients in need of care coordination to the patient advocate. And then the patient advocate. This is a role that's somewhat unique at the Open Door.

It was unique... it's not unique anymore. We started this about eight years ago and it has, and we've shared our best practice with numerous health centers around New York and actually around the country now.

The patient advocate actually works under the Department of Performance Improvement. So they start out by understanding, they start out from population rather than just the patient in front of them they start out from the population of patients that use our health center. They use registries to identify patients who need services so they know to run reports to say give me a list of all the diabetics who should have come in this month that didn't come in, give me a list of all the diabetics who's last A1C was over nine but they don't have a follow up appointment, that sort of thing, that's what, they do that. They also review chronic disease and preventive health standards related to each patient and make sure the providers' recommendations and reminders are appropriate. So they know what our standards are for our chronic disease patients, patients such as diabetes, diabetics, hypertensive, patients who need the preventive health screenings, cancer screenings. They know what all of those algorithms are and they can, they assist our providers in making sure that their recommended services are being provided. They provide ongoing case management to a group of patients.

This includes telephone support for high risk patients and also one on one case management. They do pre-visit planning and they identify patients that need care and can put one of those sticky notes that you saw on the patient's chart, please have patient see me after the visit. They provide teaching related to chronic diseases. They're not licensed so that they can be taught to teach. This was something that I learned. When I first came to the Open Door I had spent 20 years as a visiting nurse and I said I taught so many families how to take care of their wives or their husbands or their kids or their kids to take care of their parents.

I taught them how to take care of their parents with chronic diseases I figure I can teach my patient advocates to teach families how to take care of themselves. Our patient advocates are not nurses, they're not licensed but they're college graduates, they're from the community, they speak the language, they know the culture and they have the mission. After that they're just taught by us. They have a three month curriculum, it's both didactic and one on one and they pass a lot of tests in order to be sure that they really know what they're talking about and they, you know, so that they, when they, the review of their providers so that the providers have faith in them to be able to go out and teach their patients what they need to know. They've also been taught in, they've been taught about self-management and how to establish self-management with their patients. They've each taken a self-management course, they meet the patients where they are, they don't push things on them, the goals are the patient's goals, that sort of thing. And every time they sit down with a patient they have to establish a self-management plan with that patient. They also do some referral coordination, this is primarily for uninsured patients.

The nurses do the patients that have insurance because oftentimes the insurance want to talk to a licensed professional and our patient advocates do the referral coordination for the patients that are uninsured primarily because this takes a lot more coordination and time in order to try to find a specialist or whatever to see our uninsured patients. And we do, by the way, have a population that's 50% uninsured. And then they explore entitlements. They sit with these patients and they really, they say, you know, you don't have insurance, I wonder if there's something that you might be eligible for. So they do explore those entitlements, for patients that are newly diagnosed with cancer they are able to enroll them in the cancer services program, that sort of thing. And then the behavioral health provider, they assess and refer patients who require Article 28 level services so that means if a patient comes to us and we're not the right level of care for them, they have a severe behavioral health situation, they refer them out to someone who's more qualified.

We do short term therapeutic care here at the health center which is really to support patients with chronic disease and mood disorders. Patients that have more severe diseases really need to be treated elsewhere and then our behavioral health providers might coordinate that care between the primary care and the external organization. But they're also available for a warm hand off. This has been a change in our organization in the last few years, our behavioral health providers used to be like every other behavioral health provider and sit there and keep their sacrosanct 45 minute office hours with each patient and didn't want to be disturbed. We've changed that now, everybody can be interrupted because if we have a pregnant teen, if we have a patient in acute depression, a patient with active domestic violence, we've taught them how to be able to stop what they're doing and be available to come down and meet immediately with those patients so that our primary care providers aren't stuck holding the bag, they have assistance, the patient sees and gets what they need immediately.

And then the care transition team, this is the newest member of our team. We have both an RN and a patient advocate that run this team and first of all they forge relationships with local hospitals and specialists, they receive daily communication about hospitalizations and ER admissions and hospital discharges. So, what I mean by that is every day a fax comes in from our local hospital telling them who's been either admitted or discharged from their hospital that they know we're the primary care provider. They send patient's medical summaries to admitting hospital if needed so if we find out that a patient has been admitted to the hospital in the last 24 hours we go ahead and send a medical summary to that hospital. Not everyone has a process for being able to receive that or knows what to do with it but we still are trying to work on that. They follow up with patients to ensure that a post hospital visit with a primary care provider has been made for medication reconciliation. We would love to be able to do that within three days, that's never happening here so we're now shooting for seven days and hoping that we're gonna be able to make that happen.

We track high priority refer... they track high priority referrals and obtain consult notes so, for example, we don't, they don't work on every single referral if we make a referral to an orthopedist because somebody has some low back pain and they never go we probably don't follow up. But, if we make a referral for a diabetic patient to, for cardiology we do follow up. And then there's the family, this is the little bit about self-management education, patients need to be able to identify their own problem, they need to develop problem solving skills, decision making techniques, they build and rely self-efficiency...self-efficacy, excuse me, and they talk about communication skills, lifestyle change, medication adherence, mood challenges, new treatments, all of these things happen and they are the primary responsibility of the patient advocate who actually has the time to sit down with patients and talk about these things. The patient advocates have learned how to really, do really good documentation about this but then they're reviewed by everybody and seen by everybody every time the patient comes in so that they can be given feedback as to how well they're doing. So we don't want people to think patient self-management is just something they talk about with the patient advocate, we want it to be part of their whole medical team. So these are just some links. The Stanford Model is where we developed our self-management program and the motivational interviewing that we do as part of our education for our patient advocates and for our whole clinical support team.

So that's the story about the team that happens at the Open Door. I'm happy to take any questions if you have them, I know I talk fast but I wanted to get through it. Okay? Johnson: All right. So I think we're gonna move on to the next presenter. So, my name, this is Franny Johnson.

I am just calling in from the Visiting Nurse Association in Steamboat Springs, Colorado and I'm gonna start presenting here. So, getting to know your electronic health record, one of the most important working relationships you can develop. So I just want to talk to about what our, who I am, where we're coming from. The Northwest Colorado Visiting Nurse Association was established in 1964. We currently operate out of two locations, one in Moffat County, which is in Craig, Colorado, and the other one is in Routt County, Steamboat Springs, Colorado.

The facilities are located about 44 miles from each other in northwest Colorado. So the VNA provides residents of northwest Colorado the ability to prevent, manage and care for their health regardless of age or economic circumstance through our comprehensive health service in five program areas. So the first area I want to talk about is hospice and palliative care program. It offers terminally ill patients and their families complete support and skilled, personalized end of life care. Home health provides skilled nursing and other personalized health care services in the comfort and security of the home.

Our wellness and aging services are a comprehensive community based program promoting healthy aging and independent living for individuals 50 years and older. And then the community health center we have and that gives every person in the region an opportunity to establish a Medical Home regardless of their income. And our public health area, prevents disease, protects against avoidable injuries and promotes healthy habits to ensure the health of the whole person, whole family and the whole community. A large focus of our public health program is to provide immunization services for people of all ages including travel immunizations. So the VNA is the primary provider of community outreach, preventive care, wellness and chronic disease management for those community members who are unable to pay for health services in addition to food, clothing and shelter. All VNA services are offered on a sliding scale so no individual is denied services or care that is within the capabilities of the agency. In 2005 we started operating the community health center in Moffat County and by 2008 we were recognized as a federally qualified health center, FQHC. We currently have five medical providers, two doctors, one nurse practitioner and two physician assistants.

We recently have been awarded a second HRSA grant to start providing FQHC services in Routt County or Steamboat Springs and we're planning to open this clinic soon. So just to talk about the electronic health record that we use, we made the switch to our current electronic health record in 2009 after our official transition to being an FQHC. After researching many electronic health records we finally decided on eClinical Works because of it's relative low cost, being user friendly for providers and customizable for our needs as an agency and it was a bit of a process for this change to take place. In March of 2009 our transition began at our Moffat County CHC only and then we made the transition in public health to electronic charting in January of 2010, about 10 months later. And currently our staff that uses the electronic health record includes out CHC staff, our public health nurses, HVP for children with special needs, our dietitian and our staff working with our eligibility program and sliding fee scale including processing Medicaid applications. So who doesn't use it is our health, home health and hospice staff and our WIC program. So throughout this transition a few lessons that we learned along the way were that we really didn't allow enough time for training and implementation, the learning curve was high for implementation as it took much longer than anticipated so where eClinical Works is user friendly and customizable are both positive attributes it does take a while to truly understand the system and configure it to meet our needs.

So I'd say today we definitely wouldn't be sitting where we are without the help of wonderful and talented Maria. She's our VNA employed, full-time ECW support staff and her job role is strictly devoted to ECW so without her and her involvement in integrating our clinic world into ECW and vice versa we would not be where we are. From the start of our ECW integration I would say it probably took us about one and half to two years to really understand ECW workflows and make them meaningful and useful in everyday practice. So, and then the final thing that we learned with this is that eventually we found that we needed to purchase a third party reporting system known as BridgeIT and that was so that we could help run our registry reports.

We could use ECW for some reports but it couldn't do everything we needed for our reporting purposes and since this really isn't my realm, it's Maria's forte, but what would happen is we'd try to use ECW to find the number of patients missing a hepatitis A vaccine and it would come back and tell us that there were 10 people missing hepatitis A vaccine but it wouldn't tell us the name or any demographic information so we really couldn't really do anything with the information. So BridgeIT made it so that we could access this information, implement it and hopefully improve our practice. So what I want to you about today, getting onto the important stuff now that you know a little bit about where I'm coming from with this, there's just four general areas that I just want to touch on that we, as nurses, use, and medical assistants, within the clinic.

So I will first start with the recall system that we use. So the piece that initially drove our recall system was our immunization world so it continues to be used in the world of immunizations, we've tried to implement it into other areas but for application purposes today it helps to think immunization. So three things that really drove our system, the first three registries is finding that patients of all ages weren't following up with their vaccine series, many were incomplete. Our focus at first for kiddos not being complete with their vaccine status so whether they started with us and finished with another provider we weren't sure but we felt it was important to make sure they were complete in those vaccines. The other thing too is that when you vaccinate many teens prior to heading off to college starting the HPV series with those and we found that many would fall through the cracks and not complete their series unless being prompted when off at school and because our Routt County location is in a resort town of Steamboat Springs we have a very high transient population within the clinic so many young adults are here only for a season. And, finally, we have many adults in our travel clinic and they come in prior to traveling all over the world and they're really interested in vaccines before they are off traveling but once they return disease free their motivation definitely goes down for follow up and preventive care. So overall our goal was just to increase our immunization rates for the good of our patient population.

So out with our old system, in with our new system. Our old system is that we'd have patients come in for vaccines, fill out a postcard, date it to the day they were due for the vaccine and then send it. We wouldn't follow up as to whether or not they came in but we just know that we had made an effort to bring them back. So we decided the system didn't work well for our transient population. Addresses would constantly be changing and we felt the need to attempt contacts from multiple avenues.

So now it's a bit of a process so, we use a postcard dating it for the original due date and if the patient doesn't come in we have an alert set for one month beyond the postcard send date and that alerts us when the vaccine is overdue. If we haven't seen the patient at that one month beyond point we make a phone call. We reset the alert for one more month and then we are alerted again and the patient hasn't arrived we're able to link the patient information with their name and address it into a letter that gets populated and then is ready to be sent out and we're able to mail it to the patient as our third and final reminder. So there's definitely some pros and cons to this whole system. And that is what that system looks like, sorry I didn't scroll ahead to this, but that shows what the alert looks like, this is our registry that comes up and then going ahead to looking at what our letter will look when it goes out and this is the auto-populated name and address that goes in.

So the pros and cons to that basically is that we've seen an increase in patients coming in, definitely, waving a postcard, saying that a phone call brought them in to be vaccinated and even if a patient has moved and the only way we can contact them by phone, like a student off at college, we're definitely still encouraging them to get vaccinated even if it's in the health room at school and many people, even teens, are happy and grateful for a reminder phone call. So overall we definitely feel like we're doing all that we can to get these patients vaccinated and we see improvement which is good, the downside to this system is that it does take time. Increased charting time to make the alerts and set them, run letters and mail them.

With this, we don't use BridgeIT for this, this is strictly all ECW use so we, as nurses, are able to run this registry report or medical assistants which is a great way to do it. The one down side to this is that the alerts don't pop up right in front of you on the main screen to let you know that a patient's due for a vaccine so you have to click on a specific alert button and know what you're looking for so our medical assistants in the clinic that are thinking about a variety of health concerns from well woman exams to chronic disease to strep throat, the system's really hard to put into practice so for now we're keeping only to public health. Okay. So the next area I want to talk about is case management. This slide basically just demonstrates a large number of contacts the case manager makes for one patient on the average day so I personally do some case management within the VNA for a program called the Women's Wellness Connection program and it's a program funded with grant money to help give women access to breast and cervical cancer screenings so this is the world that I live in some of the time. There's three documentation and communication areas that we, as case managers, use within ECW.

The first one I want to talk about is the referrals. So the referral is generated by a provider to communicate the need to, obviously, refer. So we can do outside referrals like to a breast specialist or you can develop your own referrals for internal management and that's what I use for WWC or the Women's Wellness Connection program. So to use that, as an example, we do referrals to the WWC program which gets assigned to me as a case manager and within that referral I'm able to use it to document many things. We have structured fields where the provider is prompted to answer questions of whether, like, a CBE was done at the visit or a Pap was done which cuts down on the need for a case manager to constantly have to look through the chart and the provider also can free text any notes they feel necessary such as if the woman had an abnormal CBE and a diagnostic mammogram needs to be done and the MA can also write in the referral and provide any additional notes as well. The second type of documentation I use is in the form of an action.

So when the woman is scheduled for her mammogram appointment I'm able to set an action to call and remind the woman of her appointment date and time. The action pops up on my schedule so I'm able to call the patient and remind her. And then the third form is just a telephone encounter and these are used to communicate, you know, back and forth between the patient and myself if there's any type of communication that was had. If the patient hasn't had a follow up for diagnostic mammogram when it was recommended I can alert that to the provider through this or if the patient, you know, hasn't been compliant with recommended care treatment.

So there is definitely, once again, pros and cons of these communication forms. So the advantages of the actions is that are not a permanent part of the chart and we'll talk in a minute about how that's both positive and negative. The good thing is is you can send information back and forth to the MA and the provider and the nurse just notifying of things that don't necessarily need to stay in the chart. Whereas with the telephone encounter, the next one down, that's easily accessible and it is a permanent part of the chart, it can viewed from the same window as progress notes so you don't have to look very far to find it and then with the referral, the great thing about that is anyone can access it. If something is done it can be documented by anyone at any time. Some disadvantages, with it not being a permanent part of the chart, the actions, then if somebody put something in there that should be important and should be a permanent part of the chart it could get lost unintentionally so that's one negative piece. And then telephone encounters, they can be overused or misused.

Some pieces that aren't necessary for patient documentation can get documented there and then the patient chart starts to get filled with unnecessary documentation. The last thing with the referrals is that they can be closed so anyone can access them but then anyone can go in and close them out so that they can, the case can be forgotten if that's the system that's used to track patients. The next area I want to talk about is templates. Templates are used as a guide for the visit. As you can see from the slide, right here, this is where we're able to go in, on the left side here, to go in and choose which type of template we want to use. So on the right side it shows you what, this is a diabetic nurse visit, so on the right side it shows you the question of the patient complains of and then a box pops up with automated answers of blurred vision, fatigue, if you continue to click next it will bring you through each question to the end of the progress notes and in this template you can also have pre-populated education and billing notes selected. So who uses them? All staff but mostly focused on our community health center staff.

We use them all the time. It does depend on who walks in and who needs to be seen but our more common patient visit such as positive or negative pregnancy tests, diabetic nurse visits, Plan B, we can use that for all these things and they're developed through a team, so Maria, our ECW wizard is definitely a part of this development but it's important to include the health center staff as well and they are that clinical guide for how it should be used. So I'll just quickly go through this. Just consistency is really nice because anyone that comes in looking for Plan B, we know that either Joe or Susie, whoever's charting on Plan B will charting the same thing.

Referrals are really nice and when you refer to an ophthalmologist that we have in town and he's asked us to include specific information in our clinic charting prior to sending patients over such as their last A1C so we're able to integrate that into our template so we're consistent with our charting and also in developing strong relationships outside the agency as well. And then one other nice feature of the templates is that you can merge multiple templates into one visit. So if a patient comes in for a pregnancy test and a Plan B both templates can be merged into the same progress note and, you know, it's customizable so we can make them to whatever we want them to be, you develop your own template. The negative side to this is that, improper use. So even though it's great, we can pre-populate what the education is when we're going back through and saying, oh did the patient get this correct information? It doesn't mean that we know education was given 'cause it's automatically populated from the template so sometimes it just leads us to more questioning about what was really said in the visit. The other problem is that there can be duplicate coding with that and then the other thing is just the time and energy to develop these. It takes teamwork, not one person can do it completely on their own.

The last area that I just want to talk about is our use of the registry. So this is where our third party reporting system comes in in using BridgeIT. So within our community health center we've developed teams of a provider, a medical assistant and a front desk staff. This team meets once a month to sit down and discuss an area they would like to focus on for the month with their patients and develop a goal they'd like to reach. There specific patient population and focus is on diabetic and cardiovascular disease patients and the patients have to have come into the clinic in the last year and been diagnosed with diabetes and we're able to track this by the assessment code chosen at the visit or if they have cardiovascular disease the focus is on hypertension.

So they had to have had a diagnosis of hypertension for greater than three months. So with these chronic disease patients we're focusing on A1C values, blood pressure, smoking cessation and weight management. The teams choose what they would like to get their patients focused on such as having a certain percentage of diabetic patients with their A1C's less than eight and the team comes up with a plan of how they'd like to do that such as getting a referral to our dietitian or our health educator. So this is what the registry looks like and I'll break it down a little bit. So, like I said, Maria creates this. Each patient receives one line and the values there are color coded according to the ranges provided by the medical team values they'd like to pay more attention to and the dates are color coded for whether or not they are due to be checked such as for their A1C. So the MA is alerted to the fact that the patient is due for this test.

So the positives and negatives to this, the registry can be really good, you know, ultimately improving patient care. All members of the staff starting with the first encounter the patient has at the clinic, at the front desk, are involved in helping improve the patient screening and ultimately helping them seek better care. I think as a medical team it can be really overwhelming to have patients with chronic disease. It's hard to know where to start and this process really gives the team a focus for these patients and an attainable goal to reach for everyone to work on, really helping improve their health. So the medical team piece of it is really good on many levels 'cause it involves the front desk to really understand, to be accountable for the patient care as well and it really reiterates the importance of teamwork because truly it does take all three team members to help the patient receive optimal care.

On the negative side, as you saw, it's really overwhelming and some days it feels like we are stretching our limits here in the clinic so it's hard not to feel really overwhelmed by the tasks at hand already. So where the registry does help us focus there are days when it can just be too much on our plates to get done. So that leaves the next piece is that it takes time. The teams have designated time to work on this outside of clinic once a month but the reality is it's just one more thing when providers could be catching up notes or MAs could be calling patients back to notify them of lab results, it's not always first priority and some people just aren't numbers people so some people look at this registry and they completely shut off wanting nothing to do with it because it's too complex for them to breakdown and do anything about. The other issue with the registry is it takes the initiative of one person so, once again, Maria is the one that pulls the report so when only one person is invested in gathering this piece of the data the excitement about what this registry can do only really can go so far. So I know we're running short on time but this is just a summary of what we're using and overall I guess what I wanted to summarize is that it is a learning curve. It does take increased training time, that's what we've really learned and we're prepared for that now, I think, and allow more time for it but in the beginning that really was our struggle. And it's time consuming so just like I showed you in the example the referrals, actions and alerts, they're all extra steps and ultimately more time consuming in order to really accomplish what we wanted to in the goal for improved patient care.

And sometimes people feel that it's too complex and they want to work in a healthcare setting and do just that, they don't want to have to work with workflows or data or any piece of technology. The areas that we're enjoying are definitely the consistency of care with patients. We're able to provide care that's beneficial and consistent through using the educa... the templates to make sure that our education, our coding, our questions asked, all of those are the same. Definitely saves time as far as having to look for charts, just that paper chart comparison is definitely without a doubt nicer and being legible. It also definitely takes dedication and a committed knowledge of all staff which some people would think is a negative piece but I think, gosh, without it there's no way that we could do it.

Without that team involvement our system certainly wouldn't be effective. Our ease of communication with outside referrals and our improved patient care. So, in closing I would just say that where it does take time, lots of frustration and trial and error until you're sick of being creative any longer I really think that when you get to know you EHR and all of the complexities it has to offer I would say doors are open in ways that your EHR can really benefit your clinic world. The one thing I would say is don't be afraid or hesitant to ask can we do this or why can't we do that, that has probably been the biggest thing for me. If I don't ask I'll never know and ultimately it does take a team in this system.

I know I've emphasized the team word over and over but as wonderful as our support person is, as Maria, and I don't know how we would survive without her, she also needs to know from us in the clinical world about what is or isn't working so it certainly takes both worlds, the tech world and the clinic world, to collaborate and let the other know what the possibilities are in both directions. So I would say use your team, know your resources and ultimately don't limit your possibilities. I don't think you ever know until you ask. So thank you. Moderator: Let me find a couple, just given the timing we'll just do two questions then we'll follow up with, just to let everybody know we'll do a question and answer session summary will posted on the HRSA OHITQ website along with a recording of this Webinar. But given the timing we'll do two, first one to Ms.

Johnson. Can you give an overview, what types of things do you do to obtain staff buy in? Johnson: I think the biggest thing is really, like I was talking about with our registries and really having the team, the team effort and team approach. I think anytime that we as individuals or as management or whatever that looks like, approach staff and say this is what you're going to do there's really no buy in and so I think what you have to do is have staff really develop ideas and say you know we think this could work, we could try it in different ways and really making sure that they're investing in it. I think that's how you have to get them to buy in otherwise I just don't see that you have anyone following through with anything 'cause there is a lot to remember and a lot to do.

It means visits and I think the patients we see are complicated so I think, I think it's really just making sure you have employees invested in it and really know that it's worth the time and I think along the way it's certainly not great but you have to really just give that positive encouragement and I think you have to have positive feedback as well. Saying, you know, great job, you guys are doing a great job, look at this improvement. I think you have to set goals as well and show them how the goals are, you know, how you're able to measure those goals and see how things are following through. Moderator: Thank you.

Ms. Ferrari the next question's directed to you. Do you find, given the monthly cost, do you find it cost effective to use EMR? Ferrari: Oh, the cos

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