My Process for Meaningful Use & Chronic Care Management

What is actually involved, in providing good ongoing medical care to a frail older adult who is medically complex?

I’ve been thinking more about this, since earlier this week I attended a Code for America event about meaningful use. And in an interesting coincidence, Christopher Langston of the J. Hartford foundation published a blog post yesterday titled “Making Electronic Health Records Responsive to Needs of Older Adults (Really Meaningful Use).”

Now, since my consultative geriatrics practice is direct-pay and I’ve opted-out of Medicare, I don’t have to use a certified EHR that is going to help me attest to meaningful use.

Nor do I have to figure out how to qualify for the new chronic care management (CCM) payment.

But of course I use my EHR (MD-HQ) very meaningfully. And the clinical work I do meets the 99490 criteria:

  • Multiple (two or more) chronic conditions expected to last at
    least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death,
    acute exacerbation/decompensation, or functional decline,
  • Comprehensive care plan established, implemented, revised,
    or monitored.

(The one criteria I don’t meet is that I don’t provide 24/7 access to my services, although all my patients can access their clinical information — including detailed clinical notes — via my patient portal. Because my practice is small, solo, and consultative, everyone has to have a PCP and that’s who they can call after hours or on weekends. It’s not ideal but oh well.)

Helping an older person with health is like managing a complex ongoing project

One could write a long book listing everything that goes into providing ongoing health help to an older adult.  Especially since this usually means also helping family, as well as the paid individuals providing assistance.For an older adult with functional impairments, it’s easy to have a very large number of people involved, when you consider specialists, home health, family, residential facility staff, paid in-home caregivers, geriatric care managers, etc. And usually we have lots of ongoing health issues to collectively address.

So those are the circumstances in which I usually do my doctoring. In this post, I’m going to focus on what I’ve noticed when it comes to what I need from my EHR, and my personal clinical workflow.

First of all, it’s important to have a way to capture and store all the relevant data that emerges between face-to-face visits. This includes things like:

  • Test and study results, such as lab results or imaging reports, whether ordered by me (in which case they get faxed to me) or ordered by another provider (in which case I might have to request a copy)
  • Clinical notes from other healthcare professionals, either outpatient or inpatient (ED notes and hospital discharge summaries are extremely important, and usually a hassle for me to obtain)
  • Information from the living facility and/or paid caregivers
  • Vitals or other data collected where the patient is (just who gathers this and transmits to me is always its own small project to work out)

I also need a way to capture and store a record of the communications and conversations that I have with everyone involved in the patient’s care, whether that’s the patient, the family, the care manager, another provider, the facility staff, etc. These include:

Notes regarding a phone call or phone message. This needs to include what each party said, and what was decided or suggested as next steps and plan for follow-up.

  • Written exchanges, such as that within secure messaging or even short text messages
  • Faxed exchanges: it’s quite common for entities such as pharmacies, residential facilities, and home health agencies to communicate their questions by fax. And I fax back, because that’s what’s fastest.

I have even occasionally had to figure out what to do with the communication embedded within a secure “doctor-to-doctor”platform like Doximity, which I’ve occasionally used to communicate with a patient’s PCP.

Capturing and storing data can be a bit of a hassle. You also need to make sure all this data can be accessed or shared with everyone else who needs it. (Someone else might want to know what I said to the patient’s family.) But in many ways, it’s not much effort compared to what really matters: making sense of it all.

Why make sense of it all? Well, the whole point of ongoing outpatient healthcare is to have a meaningful collaboration with a patient and care circle, in order to help the patient move forward towards his or her health goals.

So when we think about meaningful use, and paying for chronic care management, we shouldn’t just ask ourself what does the doctor need to check, document, and share. We need to also ask ourselves:

“What does it take to collaborate long-term on a complex endeavor that involves lots of data, lots of people, and is constantly generating interdependent to-do items?”

What it takes, in my experience, is being able to successfully toggle between all the little tactical things and also the big picture strategy and trajectory. While not losing track of anything important but not super urgent (like discussing prognosis).How can EHR regulations and CCM payments support that? This is what we need to figure out.

Why I’ve found that face-to-face visits are very important, and also hard

I created my practice in part to escape the tyranny of relying on face-to-face visits. I wanted to be in touch with patients and others more often…as often as necessary, really.

Also I wanted to figure out how to work well with their care circle, and with any technology we might be able to leverage in their homes. (Blood pressure cuffs that send their data to the cloud are great! But I can hardly get anyone to use them.)

So in my practice I charge for time, no matter what I’m doing. Most of the time spent on my practice does not involve face-to-face visits.

But, after doing this for 2.5 years, I’ve found that face-to-face visits — which for me are always housecalls — remain essential. Because right now they are the catalyst for three very important processes.

Important Process #1:
First of all, preparing for the face-to-face is when I go back and review all the little bits of data that have come in since the last visit. I do this because I feel I need to summarize the key points in my housecalls note.

And I want to summarize them in my housecalls note for two main reasons. I need to make sure that I know what is really going on, and without going through a process of cognitive synthesis, I’ll just remain buried in a bazillion details.

Obviously, I have to think and take action every time some little piece of data comes in. However, especially when lots of little things keep happening, I’ve found it’s easy to get buried in details and short-term issues. To properly help an older person, one needs a way to keep coming back to the big picture of things and the most important things to do next. Taking time to sit back, synthesize, and summarize helps achieve this.

The other value in documenting one’s synthesizing process is that I see my housecalls note as a useful summary to be used as a reference in the future. I’ll certainly look at it when preparing for the next housecall. And I’d like for it to be useful to the other providers and entities involved in the patients care. (Including the family or conservator.)

Important Process #2:
Now for the second important process that happens during a face-to-face. I have noticed that an in-person conversation is by far the most conducive environment for reviewing the overall plan of care and hashing out next steps — especially the big challenging ones — with the patient and family.
Next best is phone. Email, on the other hand, is terrible for this purpose. It’s basically hard to get people to do something cognitively demanding (like synthesizing a situation, weighing benefits/burdens and deciding which course to try) over email.

Also, addressing fears and emotions, and leveraging the patient/family-clinician relationship are important aspects of collaborating with patients. It’s very hard to do this without at least being in conversation, and it works even better when you are face-to-face.(Hence I’m always skeptical when I hear about email visits. I’ve found they are useful for small things, useless for important things. Other than saying “we need to talk and here’s what we should talk about,” which IS useful.)

Important Process #3:
After going through a synthesis of information, a review of everything going on, and then having a productive encounter in which we decide what we’re doing next, I move on to the third process: carefully documenting the problem list, what we discussed in the visit and decided, and the plan for each item on the problem list.

I do this by writing out a pretty extensive assessment and plan, and also by creating a related — but simpler — list of next steps which I send to the family or whomever is the patient’s point person.

What I need from my EHR

Well, in brief, what I need from my EHR is for it to be easier to do what I just described. This means:

  • Capturing and storing of all the relevant data and communications info.
  • Making it easy for me — and also the patient, while we’re at it — to go through a periodic process of synthesis, recap, and review.
  • Making it easy for us to document an update and plan of action for everything on the problem list — even if we didn’t address it during a given face-to-face visit — along with next steps.
  • Making it easy to share all the above with everyone else who is involved or needs to access this information.

It  seems to me that it’s a pretty tall order, especially if you throw in the need to accomodate billing and admin needs. Especially since healthcare workflows were essentially designed to accommodate short discrete encounters, rather than the ongoing management of the very complex and often changing health needs of an older adult.

But this is a key part of what I need to meaningfully help my patients and synergize with others helping my patients. Yes, I’m direct-pay, but for the most part I am doing what we’ll need primary care doctors to do for complex aging patients.So I hope the next generation of EHRs and payment mechanisms makes all this easier.

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