From Visit to Visit: Information needs of primary care physicians providing continuity of care

Boaz GurdinMaster’s Thesis DefenseJuly 25, 2012

2

Welcome to Primary Care

• Doctors provide care for patients• Patients keep coming back• How do doctors pick up where they left off?

…and where the patient’s other doctors left off?…on each of the patient’s multiple health issues?

“Continuity of Care”

3

Continuity of Care

Patient X

Time

Hea

lth Is

sues

?

Visit Follow-up Visit

high blood pressure

rash

diabetes

sprained ankle

4

Coordination Across Visits

Visit n Visit n+1

Exam Note

5

Problem-Oriented Medical Records

Problem-oriented medical records (Weed 1968) organize information by health problem

Problem List Exam Note

Patient: ______________ Date: _____Reason for Visit: __________________

Subjective (S): ____________________________________________________________________________________________________________________Objective (O): ____________________________________________________________________________________________________________________Assessment/Plan (A/P): _____________Problem1 – work done at visit; plan___Problem2 – work done at visit; plan___Problem3 – work done at visit; plan__

Health Problem 1Health Problem 2…Health Problem N

6

Exam Note

Coordination Across Visits

Visit n Visit n+1

Exam Note

7

Research QuestionHow can electronic medical records (EMRs) help primary care physicians (PCPs) provide more efficient and effective continuity of care?

Visit n Visit n+1

?

What are their current practices for reading and writing the information?

What are their information needs?

8

Research Goal

Visit n + 2 Visit n + 3Visit n Visit n + 1

Improved EMRs Improved Work Practices Improved Continuity of Care

9

Findings

1. Illness and wellness trajectories across visits2. Mapping trajectories to visits3. Information needs for mapping trajectories

to visits

10

Research Methods and Setting

• >50 hours of observation• 68 patient-visits• 6 primary care physicians + 2 medical students• 2 primary care clinics associated with the

same university hospital healthcare system (Campus Clinic and Low-Income Clinic)

• Mix of paper and electronic medical records

11

Data Collection and Analysis

• Fieldnotes (including dialog and physical interactions, use of technology and space)

• Grounded theory coding (Strauss and Corbin 1998)

• Taxonomic grouping of codes (Lofland et al. 2005)

• Grouping patterns of visits• Information needs analysis of fieldnotes• Design brainstorming reframed as breakdowns• Writing, presenting, and feedback cycles

12

Scope

• Small sample, one hospital system• Lack of design prototyping and evaluation• Not all aspects of continuity of care– Focused on needs of primary care physicians not

coordination across specialties– Focused on continuity of care in agenda-setting

not in clinical decision-making– Focused on continuity of care at visits not

between visits

13

Findings

1. Illness and wellness trajectories across visits2. Mapping trajectories to visits3. Information needs for mapping trajectories

to visits

14

Illness and Wellness Trajectories

Patient X

Time

Hea

lth Is

sues

Illness trajectories (Strauss et al. 1985)

Illness and Wellness Trajectories

15

1. Discovery phase Scheduling a visit Health maintenance screenings Comprehensive history and physical exam Patient questions during visit

2. Diagnosis phase Differential diagnosis Labs to “work up” diagnosis Updating the problem list

3. Treatment phase Negotiating plan Researching treatment options Writing medication prescriptions, referrals to specialists, lab orders Counseling Scheduling follow-up

4. Monitoring phase Review changes since the last visit (symptoms, medications, labs, consults) Adjust the plan or refill without change Schedule follow-up Chart Evaluate labs in inbox

16

Sequences of Visits

Patient X

Time

Hea

lth Is

sues

Visit n Visit n+1

? ? ? ?

17

Findings

1. Illness and wellness trajectories across visits2. Mapping trajectories to visits3. Information needs for mapping trajectories

to visits

18

Day in the Life9am

5pm

12pmExam notes

PaperworkPreparationChartingInbox

VisitsAcute

Physical – adult

Follow-up – generalFollow-up on a chronic health issueFollow-up on an acute issue

Follow-up on lab results

Physical – new patient

Physical – well child

Referral request / rx refill request

19

Visit Agendas

History-taking: recent acute issue

History-taking: reason for visit

Review medication regimen: all health issues

History-taking: chronic health issue

0 min

20 min

Physical examination: all health issues

Inform patient of lab results: all health issues

Negotiate plans: each health issue

“Anything else?” Patient requests and concerns

recently fell and injured ribs

referral to ophthalmology

meds for BP, diabetes, injury pain

labs for diabetes

symptoms and lifestyle for diabetes

physical exam of ribs, eyes, general

plan for ribs, BP, diabetes, eyes

patient concerned about heartburn

20

Planning What to Work On9am

5pm

12pm

VisitsExam note(old)

Exam note(new)

Acute

Physical – adult

Follow-up – generalFollow-up on a chronic health issueFollow-up on an acute issue

Follow-up on lab results

Physical – new patient

Physical – well child

Referral request / rx refill request

Planning What to Work On

21

Visit• Raise issues in priority order*• History-taking*• Clinical reasoning/assessment

(out-of-scope)• Make plans*

Preparation• Review history to plan what to work on• Copy key info to upcoming exam note to

present to patient

Charting• Finish exam note• Fill out forms for referrals, lab orders, billing

Exam note(old)

Exam note(new)

*includes patient interaction

0 min

20 min

22

Findings

1. Illness and wellness trajectories across visits2. Mapping trajectories to visits3. Information needs for mapping trajectories

to visits– Active Issues– History of Present Illness– Health Maintenance History– Work Items

23

Active Issues

Primary Complaint/Reason for Visit

Previous exam notes

Medication list & labs imply health issues

Memory recall What are Active Issues?• Acute issues• Chronic conditions• Patient-raised concerns

Patient or caregiver raises issue during visit

Problem Listactive issues ≠ major issues

Missing n

ew

acute iss

ues

Only one per visit

PCP can’t prepare for these issues before the visit

24

History of Present IllnessWhat is the History of Present Illness?• Recent history (symptoms, labs, medication

regimen, evaluations from specialists)• Long-term history for chronic conditions

Previous exam notes

Only plan is problem-oriented in SOAP notes;missing lab results, etc.

EMR labs, medication list, specialist reports

No unified problem-oriented view

Patient story of symptoms, encounters with specialists

Patient report of medication regimen

Lack of specific information about medication regimen

Paper reports from external labs and specialists

Not integrated with EMR; don’t always arrive

Not available at mobile prep

25

Health Maintenance HistoryWhat is Health Maintenance?• Screenings, vaccines, psycho-social questions• For preventative care and early detection

Patient memory

Labs in the old computer system

Significant Events List in the EMR

Paper chart-flipping

Lack of population-level views or workflows

Missing psycho-social questionsMissing old screenings and vaccinesAbsence of new screenings and vaccines isn’t visible

26

Work Items

What are Work Items?• Health issues discussed in non-

problem-oriented order e.g. review of medication, review of labs

• Work deferred due to lack of time• Work deferred due to patient

preference for fewer shots

Previous exam note

Doctor’s memory

Patient or caregiver’s memory

Single reason for visit doesn’t capture multiple work items, making them more likely to be forgotten

Reason for Visit

Not every deferred work item clearly documented in the exam note

27

Fragmentation

Previous exam note

Doctor’s memory

Patient or caregiver’s memory

Reason for VisitPatient memory

Labs in the old computer system

Significant Events List in the EMR

Paper chart-flipping

Previous exam notes

EMR labs, medication list, specialist reports

Patient story of symptoms, encounters with specialists

Patient report of medication regimen

Paper reports from external labs and specialists

Primary Complaint/Reason for Visit

Previous exam notes

Medication list & labs imply health issues Memory recall

Patient or caregiver raises issue during visit

Problem List

Active Issues

History of Present Illness

Work ItemsHealth Maintenance History

28

Future EMR Design Opportunities

Active Issues

History of Present Illness

Work Items

Health Maintenance History

Active Issues List

To Do List

Problem-oriented view of history including exam notes, labs, medications, reports from specialists

Significant Events List showing missing vaccines and screenings expected for demographic

Prioritize and add items across all types of info to plan visit agenda

Agenda

29

Patient X

Time

Hea

lth Is

sues

Impact

1. Active Issues2. History of Present Illness3. Health Maintenance History4. Work Items

Agenda

Visit

Preparation

Charting

0 min

20 min

Faster and more thorough preparation

0 min

20 min

Better visit agendas(better mapping from illness and wellness trajectories)

More efficient and effective continuity of care

30

Thank You

• To my committee– Gillian Hayes– Yunan Chen– Melissa Mazmanian

• To the doctors who participated in the study• To my professors and fellow graduate students

who have given me advice and feedback

31

Q & A

1. Active Issues2. History of Present Illness3. Health Maintenance History4. Work Items

Agenda

Visit

Preparation

Charting

0 min

20 min

Faster and more thorough preparation

0 min

20 min

Better visit agendas(better mapping from illness and wellness trajectories)

More efficient and effective continuity of care

Patient X

Time

Hea

lth Is

sues