Saturday, March 24, 2007

Doing a preventive health exam with EMR

Doing an "annual check-up" has changed with the EMR. I have programmed a template, using the preventive health tables, to make the whole thing easier. The template includes a check-box stating that I have reviewed and updated the CPP, the age/gender appropriate Preventive Table, a review of systems, and a physical examination. This makes recording the exam fast and thorough.

When a patient comes in for their complete check up, my secretary measures their height, weight, blood pressure (using the automated BP machine) and waist circumference. She records this in the EMR, and the patient is then shown to one of the exam rooms, and undresses. My secretary puts the room number in the EMR scheduler, which flags the chart and tells me that they are ready to be seen.

Before going in, I load the chart Summary (which shows me if there are any alerts or preventive services due), and then I come in the room. This gives me a chance to remind them of overdue services first. I then load the CPP, and put the Tablet on the exam table beside the patient; the screen is turned so that they can see it. I point things out as we review them together, and make any needed changes. When this is finished, I print the CPP for the patient. The majority of my patients now have a copy of their CPP, and I expect all patients to eventually have this.

Once we are finished with the CPP, I load the encounter. The BMI is automatically calculated, along with a note stating its range (underweight, ideal, overweight, obese); I show this to the patient. Since we started using the automated BP machine last summer, my patients know what their BP is, because my staff tell them. I then load the preventive health template, and put the Tablet aside to do the exam. I will sometimes glance at the template to make sure that I have done everything.

Once this is finished, I print medications, and then give my patient a verbal summary about their health. To emphasize preventive measures, I print a handout with common recommendations; I modified the handout from the Practice-based Small group's module on prevention. I circle things that I would like them to concentrate on, and then give the handout to the patient. A copy of this handout is reproduced below; I keep it in the handout section of the EMR, it is personalized with the patient's information on top, and the patient's record keeps track of the fact that it was printed. I have already remotely put a copy in the EMR of one of my FHN colleagues.

Then, I come out of the room to let my patient get dressed, and load the lab (usually one of my pre-programmed lab reqs, with additional tests as needed), and I send the req to the front printer. The patient comes to the front, and my lab technologist takes them for bloodwork, ECG, etc. If necessary, I also send a pop-up message to my secretary to book a follow up appointment.

This is very efficient and complete. There was a recent research paper which stated that family physicians would have to spend about 7 hours each working day just to get through all the recommended preventive interventions for their patients. With EMR, this is not true. My preventive health exams are booked for a half hour, and it is rare for them to take longer. The preventive health exam is very structured, and exams are very similar; the EMR can be used to guide the visit. It is worthwhile to think about the process of a visit, and to ensure that EMR tools are used to make the visit as effective and efficient for the patient as possible. Having the patient see their own information and share in building their chart, using a templated checklist at the point of care, giving written, relevant feedback, having your staff help you, and having point of care reminders are all easier to do with EMR than on paper. I have described the process in some detail to outline the changes that have happened in my practice, and to show the improvement in care that can result from the use of EMR tools.


Here is the patient Handout:

Thank you for coming in for your Preventive Health Exam; your health is important. Here are some things that you can do to stay well:

General Safety

• Wear a seat belt when you ride in a car or other motor vehicle

• Wear a helmet when you ride on a bicycle, motorcycle, or all-terrain-vehicle (ATV)

• Have a smoke detector on each floor of your home

• Regularly test each smoke detector

• Do not use alcohol or drugs when you are involved in activities such as driving, boating, cycling, or swimming

Please protect your hearing against excessive noise

If you are over 64 years old:

• Make sure that you do not have hazards (such as loose carpets, exposed extension cords, and stairs with no handrails) in your home that could cause you or someone else to fall or be injured

Dental Hygiene

• Brush your teeth with a fluoride toothpaste daily

• Floss your teeth daily

• See a dentist at least every year

Physical Activity & Exercise

Your daily physical activity should add up to at least 30 to 60 minutes (Include each 5- to

10-minute interval of activity or exercise.)

Pre-Conception Care

If you are planning to be, or could get pregnant, take a folic acid supplement

Potential Risk Behaviours

If you are a smoker:

• Would you like to quit?

• Have you ever tried to quit before?

• Are you interested in medication to help you quit?

• Are you interested in a smoking cessation program to help you quit?

• Do you have a “quit date” in mind?

I am always ready to help you quit; please use the tools (booklet, helpline, medication) available from my office

If you are sexually active, please:

• Take precautions to prevent an unplanned pregnancy

• Always use a condom to protect yourself from sexually transmitted infections (STIs)

• Avoid high-risk sexual behaviour

Diet

Please eat the right number of calories (enough to maintain a healthy body weight) every day?

Limit your intake of fat and cholesterol

Emphasize grains (such as cereals,whole grain breads, pasta, and rice), fruits, and vegetables in your daily diet

Take enough calcium and vitamin D for a healthy body and bones

3 comments:

Rene said...

Can we see what a sample CPP looks like?

Michelle Greiver said...

Here is my Dummy Patient's CPP (too many tetanus shots)

Problem List
Date Saved Onset Date Problem Status Comment
Dec 31, 2006 Dec 31, 2006 917 - ANNUAL HEALTH EXAMINATION ADOLESCENT/ADULT Acute
Dec 21, 2006 (none) 401 - ESSENTIAL, BENIGN HYPERTENSION Chronic

Medications
Dates: Last/(Original) Drug Directions #Refills Comment
Feb 20, 2007/
(N/A) Synthroid 100 mcg (0.1 mg) tablet 1 Tab(s) PO OD for 100 Day(s)
Dispense: 100 Tab(s) 0
Feb 20, 2007/
(N/A) amlodipine 5 mg 1 Tab(s) PO OD for 100 Day(s) 0
Feb 20, 2007/
(Jan 11, 2007) Linessa-21 1 Tab(s) PO OD for 3 Month(s) 0
(N/A) Aldara 5% cream 1 application(s) TOP 3 x per week for 6 Week(s) 0 poke tiny hole with pin into packet and apply a small amount to the affected area.

ASA Enteric Coated 81 mg enteric coated tablet 1 po od

Allergies
Type Allergen Status Reaction Severity Comment
Non-Drug none Active High
Non-Drug cats Active High

Social History
Category Type Description # of years
Alcohol Non-drinker
contraception (condoms)
marital status (single)
occupation (teacher)
pregnancy history (G0P0)
Tobacco (1ppd)

Family History
Relation Diagnosis Age at Dx Cause Of Death Comment

mother 174 - MALIGNANT NEOPLASMS - FEMALE BREAST N/A 65
brother 244 - HYPOTHYROIDISM - ACQUIRED, I.E. MYXEDEMA N/A

Past Medical History
appy 1967
GB surgery 2001
whatever

pap 6/03

Procedures
Dates Procedure Type Facility Reason Comment
2001 colonoscopy operations normal
Unknown Mastectomy System

Immunizations
Date Vaccine Drug Dosage Reaction Comment Status
Jul 20, 2006 Td - ADULT TETANUS AND DIPHTHERIA TOXOIDS ADSORBED ADULT 0.5 ccs None Acc
Jul 18, 2006 Td - ADULT TETANUS AND DIPHTHERIA TOXOIDS ADSORBED ADULT 0.5 ccs None Acc
Jul 14, 2006 Td - ADULT TETANUS AND DIPHTHERIA TOXOIDS ADSORBED ADULT 0.5 ccs None Acc
Jul 11, 2006 Td - ADULT TETANUS AND DIPHTHERIA TOXOIDS ADSORBED ADULT 0.5 ccs None Acc

Lab Results:
Date Collected Test Flag Result Reference Comment
Jan 19, 2007 ACETAMINOPHEN H
2
0 - 0 0

Dec 6, 2006 HIV N
0
0 - 0 0

May 12, 2006 PAP SMEAR 0 - 0 0

Jan 19, 2007 Prothromb. time H
2
0 - 0 0


Consultations
Date
Category
Type
Specialty
Consultant
Comment

Feb 24, 2007
Medical A Referral letter with footer GENERAL SURGERY Smith, Andrew J.

leoni said...
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