|
|
OpenDoorDocs.org |
|
"ODC-Out" Archived Messages |
2007-03-07 |
|
| Move: The excitement and dread of dislocation is upon us. The countdown to our installation in the new location is quite audible throughout the Urban Ministries site, and Pablo Escobar (Dir. Operations) is more than simply advisory: He’s engaged in every detail of the relocation of materiel, personnel, services and utilities. (eg: Which wall is the data port for both pt-education rooms?) Our new address: Map showing the short distance and directions from the current site: http://tinyurl.com/2f2zpa Narrated Directions From North: – Take Capital Blvd. South from the Beltline (I-440). – Go past the Wake Forest/Atlantic Avenue exit. – Pull over at the next left-turn lane, no traffic signal there. Your landmark is the Public Storage "lighthouse". – Turn into the Public Storage entrance and drive around to the right, to the building just south of the Public Storage facility. – Follow signs for Urban Ministries. From South: – Take McDowell Street north out of Downtown Raleigh. – McDowell becomes Capital Blvd. Stay on Capital past the Wade Avenue exit. – Look for the Urban Ministries building on your right. – Turn right into the Public Storage Warehouse entrance and drive around to the right, to the building just south of the Public Storage facility. – Follow signs for Urban Ministries. Dates Physical move: 3/22-26 Last day of clinic: Wed. Mar 21 evening Days when patients would be expected to miss refill opportunities, so got 2 months of meds: Feb 22-28 First evening clinic in new facility: Wed Mar 28 Much of the move will be achieved by staff, but over the weekend, Pablo has several teams of energetic young volunteers (with strong backs) to relocate all of the clinic’s materials and even the food pantry’s contents. If you have ideas how to help, you can reach him at 832-0820,*819 or PEscobar@urbanmin.org = — = — = — = — = — = — Before the end of April, we hope to aggressively ramping up our daytime care sessions. That means we REALLY need help from volunteers of all types, so the new facility (& my clinical availability) can be fully utilized. So, please look around in your own circle of personal and professional contacts for folks who can serve our new DAYtime clinical sessions: Every week Thur PM (up from 2x/mo) Every week Wed AM (up from 2x/mo) Every week Mon PM (new!!) Every week Tur AM (new) We’re interested in help regarding these categories: – Nurses – Pharmacists and pharm-techs – Lab / Phlebotomy tech – Interpreters – Eligibility helpers – Reception – Clinicians (MD’s , PA’s , FNP’s) = — = — = — = — = — = — Doctors’ Work Station Reorganization: At the current site, Barbara created a central repository for all necessary clinical forms. Inside a specially marked looseleaf binder ("Forms"), you’ll find: – Progress Note forms for Acute patients (holes at the top, no dates along bottom) – Progress Note forms for Chronic night patients – Referral forms for specialty care and routine radiology – Mammogram request forms – Letterhead for simple doctor-notes Since the resources are collected together, it’ll be easier for clinicians to find and for staff to re-fill. Let us know if there’re other paper resources that might make your night easier. We discussed including prescription blanks, but there’s good reason for a discussion whenever these might be used and so the pharmacist will help you with these recognized situations: – patients leaving the practice because they have MCR, MCD or moving – drugs that aren’t available and a FIGS [=Filling In the Gaps] voucher will be needed. Once we move, the doctors’ station will be much more computer-centered. We’ll have to develop a clinicians’ virtual desktop in the new PC, with links to the best available clinical references. I’m glad to abuse my own academic access to both Duke & UNC medical libraries to make available Harrisons, UpToDate, Ovid, MD-Consult, ePocrates-Online, etc. Please let me know if there’s other online tools that might help. We’ll also have a publicly available WiFi network, so clinicians who like to round with laptops _will_ have ‘net access. I hope that I’m not our only white-coated geek. One real advantage will be the use of rapidly found printable patient education materials, in English & Spanish. We may even bring in some common topics to rest directly on the local PC desktop. Again, your ideas are welcome. = — = — = — = — = — = — Personnel Biographies: Welcome! to Rosemary ("Posie") Belden, MSN, FNP-C Posie has agreed to become our clinic’s Administrative Director and to start the first week of April. Many may already know her from her steady volunteering as a nurse in our 4th Wednesday clinic (since 1999!). Her nursing career included considerable management responsibility, including dozens of advisory / utilization nurses at United Healthgroup/MAMSI Health Plans, and the entire outpatient clinical functions for the faculty practice at Univ-W.Va. She completed her supplemental training to become certified as a Nurse Practitioner in May 2006, and has recently been working with the Duke Endocrine group’s in-patient diabetes program at Durham Regional Hospital. She’s joining us because she knows how much more FUN she’ll have. Posie’s responsibilities will be to manage the Clinic’s operations, including appointments, records, pharmacy, nursing, educational and logistics (ie, all but the providers). Though the job description she applied to does not include hands-on care, we expect that once volume grows, that we’ll be delighted to have her pitch in occasionally, at least enough to retain her FNP-C licensure. Every reference and each interview confirmed that Posie is a dynamic, collaborative and idea-originating powerhouse… and we’re all excited that she’s moving into our staff-side of the clinic. Please make sure to meet her once she starts in April. Thanks again for your energetic support and quality efforts for our patients. – Gary — Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList |
|
2007-03-04 |
|
|
Updates: Med Profiles, Next-Day Follow-up, Personnel! 1) In a previous distribution, I described that we now had access to the Open Door Clinic Pharmacy’s database of dispensed medications. At that time, its only use was to make a G-I-A-N-T database available to prescribers to assess what their patients were getting, and to consider how compliant each was regarding their refill frequency and reliability. We have now taken up a MUCH more practical approach to these data. At each patient’s visit (whether for chronic or ‘acute’ clinic nights), their med-profile page is printed out and included in the patient’s chart. By allowing this page to provide a template for the medication ORDER, it seems much more practical. a) Docs no longer have to write down *any* of the renewal medications. In fact, there’s a designated check-box next to each drug and a blank at the top of the page to indicate how many months are being approved globally. b) Since the page is printed, clinicians can review their findings face-to-face with the patient. Our less, um, dependable patients can see that we know the date for their last 3 refills of each med, and we can discuss the need for maintaining control of their chronic conditions. c) Surprise findings (or residual meds from past care) can be explicitly crossed out. Often patients have to be moved into combo-drugs (eg containing HCTZ) in order to obtain them through the Pharma Pt-Ass’t-Prg mechanism. The residual indiv. Rx for (eg) HCTZ is now redundant, and can be explicitly cancelled. d) Eventually, we’ll try to keep the medical record out of the pharmacy. If medication history and orders are provided as the order-sheet, we can begin to simplify the current program where the chart visits the pharmacy for each Rx (& again for each refill). You can guess how painful it is for charts to migrate in our clinic, and then to search for them in the nursing desk, the lab-pile, the pharmacy, the social-work or eligibility office, the diabetes program, etc. We’ve used this page for the last weeks of Feb., and we’ve already modified the system. Docs found that 13 months of data was too distracting and contradictory, so now the pages just show 6 months of information. As before, just the single most recent SIG is shown for each drug, and just the most recent 3 refill dates are seen. We’ve also worked to clarify the instructions that’re printed at the top of each page. I encourage your feedback so this might be even more useful and easy. = — = — = — = — = — = — 2) Critical Follow-up Opportunities With the hire of new staff clinicians (that’s to say me), there’s an opportunity to provide much more dynamic follow-up for patients in unusually risky situations. In the Dr. work-room, there’s a loose-leaf notebook with a horrifying green paper cover and spine. The contents are similarly green, labeled as "Clinical Continuity Communication". The idea is that whenever you see a patient where something needs extraordinary attention, on the next business day, that you can request me to look into the issue. The green page is to be attached to the chart (so you don’t have to write anything twice about your findings, ideas or actions), but so you can draw me into the patient’s care for any of these activities: – Contact patient by phone regarding well-being or improvement – Check lab result or radiology result – Be sure patient is set with a follow-up visit at ODC – Contact patient’s prior care for baseline or prev status – Contact a consultant about the patient’s situation (to get their findings, recommendations or even to just alert them that the patient is coming & why). We’ll act on these requests, and then remove the page from the chart (so it’s not part of the medical record), returning it back to the rear of the same binder. On your next visit, you can see what we did or found noted on the same page (or just use the page to recall the pt’s particulars and ask for the chart, to see what I’ve noted & what happened next). Hopefully, this will allow us to find out what the ER did with urgent transfers, and permit more effective referrals to specialists based on my own daytime shepherding. Again, if you see a way to improve this process, let me know. = — = — = — = — = — = — 3) Barbara Hancock: background. I remember last year when I was a monthly volunteer, I recognized it to be hard to learn the names and stories of the folks who really run the clinic. I decided that we could use the technology of ODC-Out to give background stories about the staff you count on for your patients’ help and for each visit’s success. Here’s the information I got with her permission. Our staff nurse Barbara graduated from the U-Va with a BSN (date not provided, but I suspect it was during the Johnson Admin), and worked in the university hospital for a few years (including as a ward nurse with managerial responsibilities). However, most of her 30-yr. career was in Virgina’s Public Health system, including opening U.Va.’s Homecare network. She ‘retired’ in Virginia in 1999 and moved to NC, where she then worked for just a year in a homecare agency while volunteering evenings at Open Door. When the staff nursing job here at U-M was available, she started, working the odd schedule of 1PM-9PM x 4 days (& a normal 9-5 on Fri) in Feb. 2000. Almost 2 years ago, she remarried her previously-ex-husband (to the amazement of her 2 kids). Their ceremony was on the beach at dawn. (Dawn was his idea, the beginning of God’s new day). She has 2 children, and her daughter is a physician, presently training in anesthesiology in Hershey, PA. Her son is area director for Younglife in Goldsboro, NC. She has 5 grandchildren from 5 months to 4 years old. In recent years (because her husband is more available in the evenings), the U-M mgmt has allowed her a slightly less-weird schedule and you may have found her occasionally ‘missing’ from evening clinic. Hopefully, as we expand, there’ll be a range of staff who might grow to know as many of the needed answers as Barbara does. Let’s cross our fingers! We on the U-M staff continue to appreciate you all for your energetic and reliable presence in our clinics and for your outreach efforts. Please do provide feedback about how we might improve our care and clinical operations, and about new opportunities for better process. We have several additional announcements, so (please!) keep opening and reading these msgs . Thanks, — Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList |
|
2007-02-17 |
|
|
Most practitioners agree that the first page in a medical chart needs to be a Problem List, with the agenda of the patient’s status displayed in an organized fashion, in a format that allows brief recognition of current and significant past events. I must admit that the Open Door’s current pink page, encased in a plastic sleeve, does not meet my own needs, and I know that several among us have expressed agreement. Just for starters, there’s too much overlap between family & personal history, the diagnoses are only available in the form’s boilerplate wording, and most importantly, there’s no easy way to add new information. I have now been soliciting opinions from staff and volunteers about a proposed replacement for this front sheet. I believe it represents a reasonable change for the chart’s format, and has several carefully arranged and (repeatedly!) discussed aspects. Before reviewing this, please understand: This form is NOT a questionnaire for the patient to complete, and may only get the nurses’ input the first it’s used. We’ll need some effort by all of us to collect the information that’s often scattered throughout the chart, but the effort at organization should be worth it. I posted a pdf version of this draft at the http://www.OpenDoorDocs.org website: This URL will open it directly: http://occhealthnews.net/OpenDoor/ProbList.pdf Once all suggestions are discussed, we’ll print it on card-stock, punch holes and add it above the current form. I guess a pink color is part of our local culture. Here’s an explanation of the features: 1) There’s more room for free-text problems. 2) Significant, permanent or past problems are listed, but separately. 3) Medications are NOT included here (profiles are being printed for practitioners’ use at each visit, and will become part of the chart after the visit). Meds change too often and are hard to track 4) Family History is very limited, to 1st-degree relatives and just a few illnesses. Age for these is requested (obviously especially for CAD, CVA, CA). There’s still 2 lines for important additions (eg Huntington’s!) 5) Many social factors, including if an interpreter is required are now combined. EtOH is asked both as Y/N and for clinician’s concerns. The tobacco question provides for non-smoking and for quit-date. "Home / housing safety issues" means both whether the pt is homeless or facing abuse at home. I think it’s a good idea to know what are patients do at work, and if the activities there are dangerous. 6) There’s a place to indicate that the pt’s care isn’t only at ODC. Some of our patients get psych care or GYN/Contraception at the County Mental or Public Health Clinic. Obviously, others are involved in Project Access care with outside specialists. This makes such collaboration more evident & routine. 7) Vaccination information is assembled together. Surprising content includes HepA & HepB, because it sounds like the clinic might be provided with a steady supply of TwinRx. Remember, both vaccines are recommended for patients in these categories: · Ongoing liver injury (Hep C or EtOH) · Multiple sexual partners (Hep B for all, Hep A as well if gay men) Patients less than 30 may have had the Hep B series as teenagers, and over time, the current Hep B childhood immunizations will likely take this off our adult-care list. Additionally, I’m hoping we might get the Tdap vaccine (tet, diphth, acellular pertussis). This is now recommended for adults 19 -64 y/o to replace their next (1x only) booster dose of Td. 8) Cancer screening is currently an uneven program in our program. We’re great at Pap’s & mammograms, but we don’t have sure referral support to do programmatic screening with DRE’s, hemoccults, PSA’s (or colonoscopies!) for prostate & colon CA. I hope we’ll get that established soon, and the form should prepare for it. The surprising "hght" on the mammography line is because the mammogram order form requires a calculated BMI, and we don’t routinely measure height at pt’s visits. 9) "Allergies" are now specifically Medications, & include non-allergic adverse effects. Clearly several aspects of the new form are cause for apologies, not least of which is that collecting this information will take a lot of effort, and even referring to it will require a new familiarity. I promise to be the most aggressive ProblemList-completer among our providers, but also want to thank all of you who will help, too. But, before we begin, I would be glad to hear ideas and suggestions. Hopefully, once we implement it, this form will NOT change again any time soon. For those who don’t want to type their ideas, you can call me (or the answer machine) at 256-2167. I’ll probably change the website copy if major overhaul is required. Again, I appreciate your attention and ongoing efforts to provide energetic & organized care to our patients. Thanks, – Gary — Gary N. Greenberg, MD MPH Sysop / Moderator Occ-Env-Med-L MailList |
|
2007-02-09 |
|
|
Thanks to all of you who read and commented on the last (actually the first!) outreach by this means. Please encourage your other Open Door clinician colleagues to join (via the website http://www.opendoordocs.org) or by contacting me at this address from their own email. This update is an effort to show a simpler way to manage lab studies for our patients. 1) C-Reactive Protein (CRP) instead of Sedimentation Rates (ESR) Though this common test is so simple some of us remember setting up the tubes ourselves, it has now become an assay with quite demanding parameters. Our laboratory will NOT accept or run a tube that arrives more than 1/2 hr after it is drawn. That means that when any of us orders an ESR, the clinic needs to scramble to find an available courier (usually our beleaguered clinic assistant) to drive the sample over STAT (even though the test isn’t ordered STAT and the result isn’t available any time soon). As you know, the alternative study is C-Reactive Protein (CRP), which can be run long after the blood is clotted, and provides information that’s at least as sensitive, and surely more specific (no effect of nutrition or paraproteinemia). Since the difference in cost is quite small (and our lab costs are generously covered by Duke Health Raleigh), it’s surely worth sparing the unnecessary errand to order the CRP. 2) Direct LDL instead of fasting lipid panel This is another example where we’re valuing expediency (& reliability) over the test’s list price. It’s well known that total cholesterol and HDL are both accurately assessed even non-fasting. The errors associated with evening lipid panels are from erroneously elevated triglycerides (which skew the calculated LDL value). If the need for a fasting lipid panel is to manage statin & hyperlipidemic therapy, it’s vastly simpler to request the lab to perform a direct assay (not a calculated value ) on a sample obtained when the patient is HERE, than to schedule and then cross our fingers that they’ll return for a sample later. Hopefully, with more routine use of direct-LDL, our most common request for fasting lab draws will be hypertriglyceride patients and special endocrine studies. 3) Result turnaround Most of you recognize that we don’t get results for routine lab studies for several days. Mainly for that reason, I’ve applied for hospital priviliges so we can access the secure lab-result online tools to query lab data within 48 hrs. This is not yet in place… but hopefully before the end of the month. 4) Lab results communication In the past week, I have begun generating letters to all patients which includes a description of all the tests performed, and providing a comment on results where more narrative is required. The page is a form (in Spanish if necessary) with check boxes for the common measures, and a place for discussion. For labs where trends are necessary, patients are also told their previous results for (eg) Hgb A1C and LDL. After I’m done with the form, it’s copied to the chart and the letter is sent with the lab page content attached. Obviously, some of these letters will be returned from bad addresses, but hopefully this is a worthwhile activity in patient education and clinical collaboration. I’d be interested in your reaction to seeing these in the medical records at ODC. When you look for the lab page (still filed as previously), you see a stamp that indicates if I sent a letter, called the patient or noted a concern in the chart’s progress notes. That’s it for now… As always, I’m very proud of our collective achievements at Open Door, and appreciate your generous contributions of professional time and ideas. Thanks, – Gary Greenberg |
|
2007-02-06 |
|
|
1) Refills Most of the care we deliver at ODC is for disease management/ maintenance, and is effective only as long as we can provide continuous medication to our patients. Patients who are seen only after their supply of medications is used-up (again) make it impossible to ascertain if our medical regimen is adequate (or even excessive), and block any effort to titrate or evaluate these drug programs. I also believe that making sure that their medication is continuously available proves & amplifies the value of the clinical visit by showing that we aren’t providing medication only in direct linkage with appointments, but on a steady basis, to actually help our patients’ well-being. So: a) Please be cautiously aggressive in providing written approval for your patients’ refills. If a patient is due to return in 3 months, then medications for "One month and 3 refills" will ensure that even if logistical issues bar their prompt return, that they still have access to medications for the whole period. We’re also trying to smooth access to approved refills in the pharmacy’s operations, to reduce effort and delay. b) If patients fail to return when recommended, I will almost always extend their medications’ availability for another whole month, if requested when I’m there during the day. I encourage you to be flexible too, at least for the first month after a patient’s med-supply is used up. It seems wrong to extort follow-up by withholding medications. c) Someday in the future, we may be able to provide medications to certain patients for more than a month-at-a-time, but not presently. I’d be interested in some feedback from you-all about this idea. = — = — = — = — = — = — = — = — = — 2) Medication Orders One of the best advantages of having our own pharmacy is that we don’t have to write duplicate medication instructions at each visit, since our clinical note serves as a medical order. It is _also_ perfectly reasonable to demonstrate our confidence in the accuracy of this process by AVOIDING re-writing medications from note to note, or from refill to re-order. I have spoken to nearly all of our pharmacists, and they are all willing to accept medication orders like these: "Refill all medications as previous, one month and 2 refills, but increase metformin to 1000 BID" "Continue meds as previous, but switch Ibuprofen to Celebrex, 200 daily. One month and 3 refills" The advantage here is to avoid all eye-to-hand errors as prescribers try to copy the previous medications into their own note. It also avoids the next-level errors when the pharmacists try heroically to transcribe our hand-writing into a computer order for the medication. Simply re-authorizing the prior meds as already provided allows far less work for all, and much improved accuracy all around. = — = — = — = — = — = — = — = — = — 3) Patients’ Medication Profiles Another bonus associated with having our pharmacy onsite is the availability of comprehensive drug profiles, including a listing of meds provided by any of our providers, a record of the patients’ compliance with refills and an opportunity to be sure that previously prescribed medications have actually been D/C’d. Unfortunately, the information in the Pharmacy’s computer is difficult to obtain during busy clinic sessions, and the impenetrable nature of their software (QS-1, circa 1989) has usually put this information out of clinicians’ reach. Well, that is no longer the case. I have learned some of the dark arts of report-writing for QS-1, and have been able to extract, sort, compile and format the entire list of ODC-authorized medications for each of our patients. While we have not yet decided if there’s enough advantage for each patient’s profile to be printed and filed (and how often we’d do that), a giant text-file of all patients’ medication profiles is now available in the prescribers’ computer at the work-station in the pharmacy. If you simply double-click on the desktop icon, the instructions appear at the top of the report, and by searching (ctrl-F) for your patient, you can see a display like this: DOE, SUSAN; 12/22/1956 Though it’s intended to be self-explanatory, some comments: – Each patient is identified by name & D.O.B. We do have redundant pt-names as you’d guess. – Medications are alphabetized by the pharmacy’s recorded name. Please look for both generic & trade-names. – Each drug is compiled into just 1 line, with the most recent SIG showing in the pharmacy’s internal jargon. The SIG may have recently changed, but just the last one is seen. – The 3 most recent refill dates are shown. When a drug is provided for less than a month, this profile doesn’t reveal it (like the antibiotics here). If you want to print out the list (best for discussing with the patients… since it’s not really needed to re-order the meds, see #2 above!)… then you need to copy the individual patient’s data to a new document before ordering the file to print. This document loads (quickly) into WordPad, which will unfortunately try to print the *whole* document, a 257 page mistake. = — = — = — = — = — = — That’s it for ODC-Out. I appreciate your attention and patience (and of course, your energetic and generous efforts for our patients). Please respond directly to me if you have ideas about these (heck, or any other!) topics. Thanks, – Gary |
|
Back to Open Door Clinic Provider Support & Guidance website.