Friday, May 04, 2007

The patient Dashboard: improving communication

I was talking with a colleague who uses a wired EMR. He walks into the exam room, and then quickly logs on. He then sees if there are any alerts or messages for that patient. He told me that this is different from the paper-based system, because the chart was on the door, and he looked at it before going into the room.

I don't do that. I can see when a patient is shown to a room (and which room), because my staff indicates this on the scheduler. I load the chart on my Tablet before I go in, and see the Summary (which I increasingly think of as the chart dashboard). Summary has today's visit and reason, all upcoming booked appointments (so I know if the patient already has an appointment for a full check up in the future), any upcoming recalls (example, colonoscopy due in 8 months), Follow ups that I set during a previous visit (example, 1st script for HCTZ, check potassium), overdue preventive services, and staff messages that have not been archived. I like to see this before I go in. If I need to, I take a quick look at the CPP, I open the encounter and then I go in and greet the patient.

This allows to say hello to my patient instead of to the computer. I can remind my patient to make an appointment for a follow-up abnormal pap if I can see that this has not been booked yet. I remind him or her about overdue preventive tests first, so this is done. We then address the presenting concerns together.

I know that this is not very patient-centered, but it does allow me to remember to do things that are in my patient's best interest more consistently. I think it is possible to do this with a wired system, but you do have to look at the chart before you go in. It may work better with wireless: just open the chart, look, and take it in the room.

I was talking about this to the Team pharmacist: we have to figure out ways to communicate effectively within the Chart-in-common. I referred the first patient to her via emessaging in the EMR; she will see him at the hospital, where she has her office. If she needs to have me see the patient as a follow-up, she will set this in her Encounter. She will assign a Follow-up to me, with a short explanatory note (example: LDL high, Lipitor was increased from 20 to 40). When I load Summary, I'll see it before I go in; I can load her past Encounter if I need to review it ahead of time. She has been practicing with the Dummy patient chart, and I have been looking at that remotely. I think we're ready to go.

We've set the Standing orders according to the toolkit for Medical directives. We are going to start with Diabetes. Here is an example of a Standing order:

In order to optimize care for diabetic patients, the Team has agreed to the following standing orders. These orders conform with the Guideline recommendations from the Canadian Diabetes Association. The CDA has also recommended Team Based care for Diabetics. Goal-based optimization of therapy has been found to improve achievement of diabetic targets (Level I evidence, Gaede et al).

The Team will use a common Electronic Medical Record, with all encounters, medication changes, laboratory requests and results to be entered in the chart. Each Team member will have access as appropriate to their professional roles; all accesses to the chart will be electronically logged.

Standing orders, optimization of dyslipidemia management

The goal for most diabetics is LDL 2.0. The pharmacist will look at the last lipid profile. If the LDL is above goal, AND lipids were done a year ago or less, AND the patient has no contra-indications to increased dosage (SGOT or SGPT is less than twice normal; patient is not complaining of statin-related myalgias), then:

If the patient is on a Statin, the pharmacist is authorized to increase the dose of the statin to a maximum of:

  • Rosuvastatin (Crestor): 40 mg PO od
  • Atorvastatin (Lipitor): 80 mg PO od
  • Simvastatin (Zocor): 80 mg PO od
  • Lovastatin (Mevacor): 80 mg PO od
  • Pravastatin (Pravachol): 80 mg PO od
  • Fluvastatin (Lescol): 80 mg PO od

The pharmacist is authorized to request cholesterol/SGOT retesting, using the physician’s lab requisition (with CK testing at pharmacist discretion, if there is concern about myopathy) for follow up of the changed dosage. The patient will be asked to retest blood a month after medication change, with result forwarded to the patient’s family physician.

The pharmacist is authorized to request lipid profile (total cholesterol, LDL, HDL, triglycerides, total cholesterol: HDL) testing (using the physician’s lab requisition) if this has not been done in the last 12 months, and the patient is not booked to see their family physician for an annual review in the next 3 months.

If we're going to do Team-based care, we have to have clear, common goals, based on solid evidence. We also have to have really good communication within the team. I think the EMR will help us do that. I wish we could have patient access to the chart; after all, they are at the very center of the Team.



Anonymous said...

Is there a billing code for blogging?

Michelle Greiver said...

No, but feeling somewhat useful counts as payment. I look at the extensive amount of unpaid work that my colleague, Dr Brookstone, has done on CanadianEMR (which I follow regularly); his work is useful to me. I feel that I'm paying forward by following in his footsteps.


Anonymous said...

Your comments are the most useful I have found on the net. That's because you give practical examples and you explain everything so well. It is obvious that you want to help all of us - your colleagues. I have learnt so much from you.

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