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Service Delivery Innovation Profile

Care Management Protocols and User-Friendly Forms Embedded in Electronic Medical Record Improve Documentation, Coding Accuracy, and Readability of Visit Notes


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Snapshot

Summary

All Air Force and many Army and Navy health care facilities have adopted the Tri-Service Workflow program, which consists of protocol-based care management tools and simplified documentation forms embedded in the electronic medical record that make it easy for military clinicians to provide, document, and accurately code evidence-based care tailored to the patient's condition. The program has improved documentation, the readability of notes, and coding accuracy, and has generated incremental revenues and high levels of satisfaction among clinicians.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of performance in several areas between clinicians who used the system and similar clinicians not using it, including metrics related to the completeness of documentation, the accuracy of coding, and the readability of notes; other evidence includes anecdotal feedback from users of the system.
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Developing Organizations

U.S. Air Force Medical Service
The Tri-Service Workflow was developed by the Division of Workflow Management and Business Process Reengineering, a division of the Air Force Medical Support Agency of the U.S. Air Force Medical Service.end do

Date First Implemented

2011
January

Problem Addressed

Providers often underuse electronic medical records (EMRs) due to poorly designed user interfaces and the failure to integrate EMR-related processes into existing workflow. Such underuse often leads to wide variability in the way providers document care, which in turn can cause problems with communication among providers and other inefficiencies. 
  • Underuse of EMRs due to poor interfaces, workflow issues: Difficulties in using EMRs, including cumbersome navigation and complex documentation processes, are common, leading many providers to underuse the systems.1,2 In 2010, 48.3 percent of office-based physicians reported using EMRs; yet, only 21.8 percent did so in a meaningful way.3 Common reasons for underuse include difficulties viewing and entering patient information and a need to check multiple places to get a complete view of the patient's record.4 
  • Leading to poor documentation: Frustrated with poorly-designed user interfaces, providers often turn to free-text boxes for documentation, leading to high variability in documentation across providers and patients.4
  • Same problems in military settings: These problems occur not only in civilian health settings, but in the military as well. Before implementation of this program, military providers often found the military EMR (known as the Armed Forces Health Longitudinal Technology Application or AHLTA) to be slow, unreliable, and difficult to integrate into the existing workflow. Many providers used it only minimally or avoided it altogether. In fact, exit interviews with providers leaving the military found the EMR to be the third biggest reason for departure.5 As in civilian settings, those providers using the system developed a variety of personalized methods to document patient encounters (including use of long, difficult-to-search notes in free-text boxes), leading to poor communication among providers and other inefficiencies.5

What They Did

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Description of the Innovative Activity

All Air Force, 75 percent of Army health care facilities, and over 55 Army medical home clinics have adopted the Tri-Service Workflow program, which consists of protocol-based care management tools and simplified documentation forms embedded in the EMR that make it easy for military clinicians to provide, document, and accurately code evidence-based care tailored to the patient's condition. Key program elements include the following:
  • Patient completion of paper-based personal history: Upon arriving at the clinic, patients complete the front side of a paper worksheet (called the "Encounter Worksheet") that collects a standardized, detailed patient history. Information covers two main areas. The first relates to the current visit, including reason(s) for the visit, how long the problem or problems have existed, and a self-rated pain level. The form also asks for standard information related to medical history, including (but not limited to) current and previous medical conditions, surgeries, and medications; family history; allergies; tobacco and alcohol use; exercise habits; signs of depression; preferred method of learning; and other general health topics. Individual facilities can choose to include additional site-specific questions.
  • Medical assistant review and entry into EMR: Before seeing the clinician, the patient meets with a medical assistant who references the worksheet to ask clarifying questions and/or identify any services needed (e.g., screening tests). The medical assistant enters all information into the EMR. 
  • Easy-to-use electronic documentation: During the visit, the physician or nurse practitioner completes an electronic template, known as the "Alternate Input Method" or AIM form, that documents all care provided or ordered. The form follows the same chronological flow as the Encounter Worksheet. Providers select from several versions of the AIM form depending on the patient's clinical circumstances; current forms cover adult primary care, pediatric care (four forms), behavioral health, and low back pain, with a form for metabolic syndrome under development. What follows is a description of the adult primary care form, which is organized into several electronic screens: 
    • History of present illness: The first screen allows documentation of the history of the present illness, with check boxes and free-text boxes that cover tobacco and alcohol use, exercise habits, depression screening results, and the patient's self-report on general overall health. 
    • Physical examination: The second screen documents the results of the physical examination through standard check boxes, thus allowing providers to readily identify abnormal findings as compared to the prior visit. 
    • Preventive care processes: The third screen allows for documentation of all preventive care processes delivered or ordered during the visit, such as immunizations and tests to screen for high cholesterol or various types of cancer (e.g., colorectal, breast, cervical, prostate). 
    • Disease-specific care processes: The fourth screen allows for documentation of disease-specific care processes. The screen covers recommended care processes for eight clusters of diseases that cause the overwhelming majority of morbidity and mortality in military personnel (e.g., metabolic syndromes, cardiovascular disease, pulmonary disease, behavioral health problems, substance abuse disorders, and chronic pain). The screen also includes a box that allows the provider to track other conditions not specifically listed.
  • Care based on standardized protocols embedded in EMR: During the visit, the physician or nurse practitioner determines care needs based on standardized protocols within the EMR that are linked with various care management tools, such as assessment and screening questionnaires, order sets, and provider referral forms. These tools help to ensure the patient receives all appropriate care and services based on his or her needs. At present, protocol-based tools have been developed for adult primary care, pediatric care, and behavioral health, with tools for obstetrics/gynecology and case management currently under development.
  • Simplified coding guidance: In the military, providers assign the evaluation and management (E&M) codes required for reimbursement. To make the coding process as easy as possible, the AIM form provides a simple checklist with five questions that help determine the appropriate code (e.g., "does the patient have a new problem requiring a prescription?"). Answers to the questions indicate the code that providers should use; providers then simply enter the code into the AIM form.
  • Back-up paper system if EMR unavailable: If the EMR is unavailable during the visit (e.g., due to technical problems), the reverse side of the Encounter Worksheet can be used by providers to document the visit. This sheet can then be scanned into the patient’s record once the EMR becomes available.

Context of the Innovation

The various branches of the U.S. military serve 9 million individuals in hospitals, clinics, and other treatment settings across the United States and abroad; the U.S. Air Force has 74 facilities, while the Army and Navy have more than 60 facilities each. In 2005, the U.S. military deployed an EMR in rapid fashion, after which many providers quickly became dissatisfied with this system. To address this issue, the Air Force Medical Support Agency sent two physician staff from its Division of Workflow Management and Business Process Reengineering (which helps integrate information technology into the military's clinical settings) to provide training and mentoring to individual providers on the use of the EMR. Based on their interactions with clinicians, these physicians felt the Air Force could improve clinician efficiency, documentation and coding accuracy, and overall satisfaction with the EMR through the creation of simple tools that help to standardized workflows across all members of the provider team.

Did It Work?

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Results

The program has improved documentation, the readability of notes, and coding accuracy, and has generated incremental revenues and high levels of satisfaction among clinicians.
  • Better documentation: A retrospective medical chart review found that staff at one base using the Tri-Service Workflow program achieved significantly better adherence to the documentation requirements of the Joint Commission and Health Services Inspection (the Air Force Inspection Agency performs Health Services Inspections of all active duty Air Force Reserve and Air National Guard medical units in partnership with the Joint Commission) than did those at a second, similar base where the program had not been implemented. Overall adherence averaged 89 percent at the base using the program, compared to 70 percent at the other base. The base using the program tended to have better adherence in most specific areas of documentation, including pain levels (100 percent vs. 84 percent), alcohol use (100 vs. 78), tobacco use (100 vs. 80), medications (100 vs. 96), allergies (98 vs. 73), family history (100 vs. 70), surgical history (77 vs. 59), learning disabilities (91 vs. 63), and depression symptoms (94 vs. 66).
  • More readable notes: Experienced family practice physicians who used the program reported better readability of other providers' notes than those not using it, including how well organized the notes were (4 vs. 3.3 on a 5-point Likert scale), ability to identify the chief complaint (3.9 vs. 2.9), and predictability of the notes (3.9 vs. 3.4). Similar findings occurred with physicians and nurses who had been practicing for a year or less. 
  • More accurate coding, translating into higher reimbursement: Experienced physicians using the process achieved an E&M coding accuracy rate of 64 percent, well above the 49-percent rate for non-users. New physicians and nurses using the process did even better, with a coding accuracy of 73 percent, nearly triple the 27-percent rate among inexperienced clinicians who did not use it. Greater accuracy in coding resulted in a higher number of relative value units per encounter among those using the system, which in turn led to higher reimbursement for physician services. 
  • Positive reports from system users: Providers in clinics adopting the program report being more satisfied with the EMR and clinic workflows and spending less time auditing codes and reviewing the charts of peers. In particular, they highlight the system's ability to make better use of medical assistants (including eliminating their need to memorize what individual providers want in their notes), reduce variation in documentation, preserve workflow even when the EMR is unavailable, track health indicators over time, improve the accuracy of medication and problem lists, facilitate the training of new providers and clinic-to-clinic transfers of medical assistants (because workflows are now standardized), and improve communication and continuity of care across providers and care sites.

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of performance in several areas between clinicians who used the system and similar clinicians not using it, including metrics related to the completeness of documentation, the accuracy of coding, and the readability of notes; other evidence includes anecdotal feedback from users of the system.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Observing  process: The two physicians observed work processes in a clinic for 2 weeks to develop ideas for how to better incorporate the EMR into the clinic's workflow.
  • Developing and testing system: The two physicians developed the new processes (and associated forms) and asked clinic providers to try them. After some success, the physicians introduced the new process into several other clinics and refined the process based on feedback. 
  • Spreading the process: The process was rolled out in several Air Force clinics. After the two physicians demonstrated the process to the Air Force's Surgeon General, the process (initially named Compass) was rolled out across all Air Force medical facilities.
  • Training providers: The two physicians visited 25 Air Force bases to train providers on the new process. Subsequently, they obtained funding to hire contract trainers to help manage the roll out to all 74 Air Force facilities.
  • Rolling out to other branches: Based on interest from other branches of the military, the process has been adapted and renamed the Tri-Service Workflow. It is currently being rolled out across Army and Navy health care facilities.
  • Ongoing development of new functions: Clinical decision support tools and secure messaging capabilities are currently in development. Once completed, they will be integrated into the EMR as part of the Tri-Service Workflow.

Resources Used and Skills Needed

  • Staffing: Existing personnel developed the first iteration of the Tri-Service Workflow as part of their regular duties, and staff in adopting facilities use it in the course of their everyday workflow. Later, the Air Force contracted with 3 trainers to teach clinicians how to use the system as part of the rollout process. At present, 22 full-time and 11 part-time staff are involved in Tri-Service Workflow and EMR enhancements as part of their regular duties; responsibilities include developing standardized workflows, clinical decision support tools, and other new EMR-based functions.
  • Costs: Ongoing costs for staff members (not including contract workers) involved in program enhancement total approximately $5 million annually.
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Funding Sources

U.S. Air Force Medical Service
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Adoption Considerations

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Getting Started with This Innovation

  • Keep it simple: The process should be made as simple as possible for clinicians, even though the behind-the-scenes technology within the EMR may be complex. The goal should be to develop processes geared toward users who are not "tech-savvy."
  • Start with small test, refine based on feedback: The new process should be tested by a small group of providers and then refined based on their feedback, with expansions done on a gradual basis. For example, the program developers began by pilot testing the process at one clinic and expanded it to several other clinics before rolling it out on a larger scale. During this initial testing period, feedback from the clinicians about which elements to include in the forms and how the process was integrated into the clinic workflow and EMR was very informative.
  • Invest in training: Dedicated trainers can help providers understand the system's benefits, answer any questions they may have, and teach them to use it effectively. Trainers who have been through the same medical training may be more effective, as they understand the realities of clinical practice and, as a respected peer, may be better able to convince physicians of the need for this type of culture change.

Sustaining This Innovation

  • Expect to reach a "tipping point": Adoption may start slowly, but then reach a "tipping point" once a critical mass of clinicians begin using the system. Experience suggests that once about 40 percent of clinics adopted the system, other military providers started hearing about its benefits from colleagues and hence no longer needed to be "sold" on the merits of adoption. Program developers note that the tipping point for this innovation was just under a year (roughly 10 months).
  • Consider new functions to enhance value: Clinicians will continue using the system as long as they perceive value in doing so. To maintain momentum and maximize the system's impact, continually explore potential value-enhancing additions to the EMR and workflow processes, such as integrating clinical decision support tools and secure messaging capabilities.

More Information

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Contact the Innovator

Lt. Col. Charles Motsinger, MD
Chief, Division of Workflow Management and Business Process Reengineering
Air Force Medical Support Agency
U.S.  Air Force Medical Service
5201 Leesburg Pike/Skyline 3, Suite 1511
Falls Church, VA  22041
Phone: (202) 255-7619
E-mail: drcharlesmotsinger@gmail.com

References/Related Articles

Motsinger CD, Corcoran TS, McGee L. Effects of COMPASS Workflow on Documentation Quality of Family Medicine Physicians Using the Military Electronic Health Record (AHLTA). Unpublished manuscript provided by project developers.

Footnotes

1 Miller RH, Sim I. Physicians' Use of Electronic Medical Records: Barriers and Solutions. Health Affairs. March 2004. Available at: http://content.healthaffairs.org/content/23/2/116.full
2 AAPC Physician Services. Inefficient EMR documentation processes hinder successful implementations. September 16, 2011. Available at: http://www.aapcps.com/news-articles/Inefficient-EMR-Documentation-Processes-Hinder-Successful-Implementations.aspx
3 Hsiao CJ, Hing ES, Socey TC, et al. Electronic Medical Record/Electronic Health Record Use by Office-Based Physicians: United States, 2009 and Preliminary 2010 State Estimates. Health E-Stats. National Center for Health Statistics. 2010. Available at: http://www.cdc.gov/nchs/data/hestat/emr_ehr_09/emr_ehr_09.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
4 Puffer M, Ferguson J, Wright B, et al. Partnering with clinical providers to enhance the efficiency of an EMR. J Healthc Inf Manag. 2007;21(1):24-32. [PubMed]
5 Motsinger CD, Corcoran TS, McGee L. Effects of COMPASS Workflow on Documentation Quality of Family Medicine Physicians Using the Military Electronic Health Record (AHLTA). Unpublished manuscript provided by project developers.
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Original publication: November 07, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.