Time for a Dive in Ocean?

I’ve recently downloaded my Concordia Portland capstone project, my action research, my first Quality Improvement Project (QIP). I did this late 2013. I struggled to use the PS Suite EMR to more advantage, pressed into service tablets and the Kavanagh’s “Ocean” program. It truly felt like it. A “Dive in the Ocean.”

Geronimo Dive in Ocean Brett Davies via Compfight

This project took a lot of effort. Months have passed. I sat with a coffee this morning and considered where I am now, what has happened, trying to take stock of what this QIP has actually left me with.


During the QIP implementation phase, I slavishly adhered to the principle of using templates with each and every clinical interaction, be the template only, “SOAP”. Frankly, it was a pain. And, frankly, I’ve stopped doing it.


Over the 27 years I’ve been in practice, I’ve developed, or perhaps the better descriptor is “fallen into” using what the psychiatrists would probably call process notes. I try to start typing as soon as we engage, try to get the problem down as it comes out of the patient’s mouth. I then follow this with an appropriate exam (usually), an assessment and a plan. I confess I don’t label them as such.


During the QIP, I made a couple of discoveries. Using “SOAP” forced me to include some physical exam that I normally wouldn’t. GULP. Quite a confession. I found I needed to “fill up” that spot on the template. Right there was a HUGE realization. I could stand outside myself, and look at my performance, critically.


Previously, often my assessment was inferred. You know, “red ear, antibiotics.” (I’m exaggerating; that’s a kind of note from the “recipe card” histories they had 30 years ago.) Reading the note, I’d know it was OM, but I didn’t say so.


I still use the DM templates. That’s an easy one, we get paid for it. I use the smoking templates. Ditto. Annual physicals, well child templates. HAMD7, GAD7, and patient generated (tablet) templates for mood (PHQ9), new contacts, fibromyalgia severity scores, and a few other things, like smoking templates. I look over my schedule before it starts, and pick the patient where a template might help. Most don’t fit that description. And that’s about it.


I really don’t need a “sore throat template”. I know how to treat a sore throat.


The back pain template, however, when I forced myself to use it last year, taught me something. That’s what’s niggling at my brain. I graduated in 1986, and had never even heard of the Canadian Back Institute, never mind their classification of back pain. There I had a patient, during my implementation period, that had back pain. I plugged in the template, and sat there, agog. What were they talking about, class 1-4 CBI back pains??


Without that slavish commitment to check the template, I wouldn’t have learned this system, and the accompanying therapeutic exercises. This discovery has really helped my patients. So what else am I missing?


It just takes so long. We are truly a transition generation. The patient volume is high. We don’t have the extra minutes it takes to search appropriate templates. More automation is coming, I’m told. Perhaps a way where we could double click on “diarrhea” in our symptom list, and get reminders to use florestore and Zinc. The way the system sits now, you basically have to do the traditional assessment, then pop the template in. There must be a way to use a template, benefit from reminders (and learn new things!), without it getting in the way of a traditional physician assessment.


The closest thing I’ve seen yet is with our “Ocean” program with PS Suite, the EMR our clinic uses. This isn’t a commercial. Here, the patient works with a tablet, filling out the appropriate form, in essence prepopulating your screen before you see him. On more than one occasion, I’ve had a non borderline patient tell me they’re suicidal on the tablet, and deny it face to face. On challenging them, they did confess this symptom.


This tablet system could have saved lives here. Maybe hyperbole.


Maybe not.


I wonder if there’s a different way to use it. Currently, we have to pick the template, then give the tablet to the patient to work on it.


I wonder if the patient could pick the template?


At least the template could address their presenting symptom, what they were most concerned about. Every patient could get a tablet, then they pick the symptom, go through some kind of hierarchical decision tree to get the right template.


Wow. Think of that expense. Think of the work to get a system like that going. Ugh! Everybody getting a tablet? Maybe one assigned per exam room…


More work for the Kavanagh’s! (And clearly more expense, as they’d have to give tablets to all those brave enough to embark on such a voyage…)


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