Improved Visit Planning: Can It Lead To A Higher Level Of Quality Care?

By Barbara Aung, DPM and Kim Jungkind, MPH, RN, CCM

   Podiatric medical practices strive to provide patients with high quality care. Patients with diabetes pose an added challenge due to the comprehensive nature of the condition and resulting complications. In a proactive effort to improve visit planning and improve the care of these patients, podiatrists may want to consider the use of software decision support and tracking tools to assist them in delivering needs-based care to their patients.    We have found success with a simple, practical registry, decision support and tracking system. As a “connected health record,” the DocSite PatientPlanner incorporates evidence-based guidelines at the point of care for patients with diabetes. The approach has general applicability for fostering best clinical practices.    Last year, we took a closer look at the impact of using this software decision support package in an Arizona-based podiatry practice. Going into this project, we believed that improving the efficiency and effectiveness of the practice could help facilitate a higher standard of care for patients with diabetes.    The staff implemented the decision support and tracking tool as they scheduled routine office visits for patients with diabetes. The office made a clear decision to enroll patients in the system as they came through the office as opposed to enrolling via a retrospective chart review. By enrolling prospectively, it was not necessary to garner resources outside of the day-to-day office flow.    Planning seemed to be the key word as educational efforts and an expanded patient assessment became the new objectives for this podiatric medical practice. The expanded assessment addressed several areas including diabetic shoes, diabetic inserts, dilated eye exams, lab testing and a review of current patient medications. The results included opportunities to improve care and to enhance service delivery from the practice.

How Visit Planning Helps You Meet Patient Needs

   The software tool assists the podiatrist and the office staff in the areas of visit planning, scheduling follow-up visits and analyzing practice effectiveness. The program supplies not only specific details related to the care the given patient will need at that visit, it also creates a method for bringing patients back for appropriate follow-up. Additionally, the program provides a reminder approach to managing patients.    The “Visit Planner,” or encounter form summary sheet, tracks all of the patients’ clinical management needs, providing an easy way to incorporate clinical guidelines and evidence-based care delivery that is based around the patient’s needs.    At the beginning of the day, the staff prints out the Visit Planner for each patient with diabetes. They place this sheet on the patients’ charts and it serves as the summary of all clinical activities and follow-up needs for the patient. The Visit Planner can include lab results, demographic data, pharmaceutical agents, allergies, etc. The DPM uses the Visit Planner during the direct patient assessment. The planner documents changes in the treatment, meds or other follow-up needs.    After the visit is complete, staff members use the Visit Planner and the chart for updating in the computer through Web-based access. Updating the online patient information takes less than one minute.    In addition, the system tracks several measures of diabetes. These include A1C, type of diabetes, smoking status, capillary refill, DP and PT pulses, protective sensation, fungal nails, foot risk assessment (low and high), diabetic shoes, diabetic insoles and lower extremity orthotics.

Emphasizing Easy Access And Use Of Software

   The program requires only a single computer at the front desk and a Web connection to work. There is no need to outfit the whole clinic with computers. The podiatrist typically does not need to touch the computer. Accordingly, he or she doesn’t have to worry about data entry tasks slowing him or her down during patient visits.    However, for offices with computers in the exam room, physicians can access the Visit Planner online during the visit. Web access allows physicians in the individual patient exam room to document the changes. Some clinicians find the computer tablet easy to use and update the patient’s progress but for others, it may be a barrier to the patient exam.    With the system that we utilized in the Arizona-based practice, there is no need for additional equipment and expertise such as computer servers and back-up methodologies.    Some practices may use a Microsoft Access database system to monitor patients. While this approach is sometimes satisfactory, it may require local information technology management and back-up capabilities. Additionally, accessing records from multiple offices is problematic. Many systems require constant programmatic fixes and updates, a process that can be difficult to manage. Deploying this kind of registry can require resources that are unavailable and it is typically not as flexible as a Web-based interactive tool.

Promoting Quality Care, Better Documentation And Improved Office Morale

   Patients with diabetes are particularly challenging to treat and need comprehensive care. Improved visit planning can enhance a practitioner’s ability to deliver care that specifically addresses the patient’s needs during a particular visit. The improved efficiency also allows podiatrists to address more of the patient’s comprehensive care needs and facilitate appropriate referral recommendations if necessary.    Employers, managed care plans and “pay for performance” initiatives are becoming more popular for documenting quality care for patients. PatientPlanner can help podiatric practices meet the emerging documentation and reporting challenges. Indeed, improved documentation may facilitate increased reimbursement.    We also found that implementing this software decision support package improved the performance of the office staff. We saw increased job satisfaction among the staff as they took on more of a role in the care of a patient.    In terms of emerging and future trends, communication through a HIPAA compliant and secure exchange of information is certainly part of the medical communications landscape throughout the United States. It is also important to keep in mind that patient messaging with the podiatric physician may be more commonplace in the future. This information may include patient risk assessments and patient education.    In contrast, retrospective chart review will become a thing of the past. It is time consuming, costly and may not have updated information. Physicians may also be reluctant to participate in voluntary chart reviews.

In Conclusion

   Since the aforementioned podiatric practice implemented the software decision support and tracking package, there has been improved office efficiency and it has noticeably bolstered patient follow-up efforts. The staff is more attentive to details as they have become more aware of patient needs and their role in improving patient outcomes. Granted, there was some initial awkwardness at first, which one can expect with a rethinking of office flow and roles within that office dynamic, but as the office became more oriented to this approach to visit planning, staffers tended to embrace the system wholeheartedly.    A more formal evaluation of the information technology and clinical outcomes has not yet been summarized. However, the initial findings show a positive impact on practice and more opportunity for teaching within the office. An increase in “teachable moments,” when a patient demonstrates a vested interest in his or her care, has been an unexpected and welcome finding. Patients are more engaged in their care and have a greater understanding of their needs.    In summary, we found that using this software decision support and tracking package met the expectations of sustaining improvements in high quality podiatric care for patients with diabetes. Dr. Aung currently serves as a member of the PPOD (podiatry, pharmacy, optometry, dental) Workgroup Member for the CDC-NIH National Diabetes Education Program. She is also the principal investigator for the Amputation Risk Project. Dr. Aung is in private practice in Tuscon, Ariz. and is Co-Director of the Wound Center at Carondelet St. Joseph’s Hospital. Yungkind is employed as a Senior Program Manager at McKesson Health Solutions in Broomfield, Col. She has been involved with national and regional initiatives that incorporate evidence-based clinical guidelines. She has authored and lectured on disease management, clinical and quality topics.

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