PPRNET and the AATRIP
Study
Lessons in how to improve use of the
AUDIT-C in patients who have Hypertension
This document is to explain
several processes which are examples in how you can do population based
medicine using an EMR. Specifically, we
participate with PPRNET which is a research organization which is a consortium
of over 100 practices which use an EMR (Practice Partner). What is explained
below are processes which:
Now, it must be stated that
there are many physicians, medical staff and IT folks who could create a much
more efficient process for doing these steps that will be mentions. This documents is to
show but one way of attacking a population based process in health care. Further, this document shows how we recently
revised our process to improve our asking the AUDIT-C (and other questions) in
patients with a diagnosis of hypertension) and give you the conditional logic
and quicktext to easily add into the notes. We currently (3/2006) parcticpate with 19
other practices in PPRNET for the AA-TRIP study. AA-TRIP is a study looking at how using the
EMR to query patients with hypertension may lead to improvements in care
particularly when they learn that alcohol may be affecting their
hypertension.
Software Used:
Partice Partner Patient Records version 8.2.2
Office XP – (Word and EXCEL)
How we improved the
process:
We have a “HMaintenance” lab table that has certain diagnoses which
have been designated as “Y” if they have it. If the patient has
Hypertension, there is a lab value (“HTN”) as “Y” ,
Using lab values (“HTN” = Y) will allow for Conditional logic to kick in.
Conditional logic has been added to the general progress notes, NOV BP visits
and other templates that include the diagnosis of hypertension. There is
other conditional logic to populate the problem list correctly also. When
the patient doesn’t have the diagnosis of hypertension (Lab value: HTN is
blank) the Audit-C questions are not even presented. When the patient
does have the diagnosis of hypertension (Lab value: HTN is “Y”)
Preparing the database
for use of CONDITIONAL LOGIC, requires a lab value:
Since you can’t use a
problem list item (“HYPERTENSION”) in conditional logic, you need to create a
lab value. Populating the LAB TEMPLATE “HMaintenance”
with “Y” with for the lab value “HTN” wasn’t too hard and only required me to
do an inquiry with the DX = to HYPERTENSION. Then I had a list of
patients with the diagnosis of hypertension to start creating a file for
importing the “Y” value to all the patients with the diagnosis of hypertension
in our practice. (I haven’t mentioned how to create LAB TEST NAMES and
LAB TABLES – but this is in your documentation)
This text file was culled
from the Patient Records inquiry (DIAGNOSIS = HYPERTENSION):
Report Selection Criterion - Generated
1197
patients (10%) out of 11079 met selection criterion.
Name: Auntie
J Adams ID: 14636
Phone: (540) 688-6803
AND SO ON
Once I had the patient list
(in text format), all I had to do was to import this into Excel.
Excel is pretty intuitive when it comes to importing tab delimited
files. It wasn’t too hard to correct the entire list in excel and then
strip the extraneous columns like “NAME:”, Middle
initial, “PHONE:”, and the phone numbers. Then I moved the column of the
last name before the first name (using Excel) to prepare it for the lab import.
|
.D: |
|
, |
Auntie |
: |
14636 |
AND SO ON
So the first column has to
add the correct .D code and the other columns (comma and colon) were added to
prepare for export to the WORD file (a text file). Of course, if you used
MACRO Express, you could probably do the .L: HTN: Y add right in EXCEL
but I chose to then save it in TXT format and import it back into WORD to do
the MACRO (in WORD) to add the .L line after each patient
Exporting this list of
patients to WORD wasn’t too hard and neither was creating a macro in Word to
add the .L: HTN: Y line to each patient so that this would load the “Y” value
into each patients chart. It looked a little like this:
.D:
.L: HTN: Y
The next name AND SO
ON
Then using the LABORATORY
DATA LOADER on the above text file, all of our patients were loaded. That
is, any patient who had the diagnosis of Hypertension in their problem list now
had a LAB ITEM of “HTN” in the HMaintenance table
with the value of “Y”. There were still (despite my trying to correct any
potential lab load errors) about 6 patients but all I had to do was look at the
Printed LABORATORY DATA LOADER ERROR FILE and add them individually.
CONDITIONAL LOGIC was
created to use the LAB TABLE item “HTN”:
Using conditional logic
(many other end users are experts with this) in progress note templates and quicktext allows for conditions to be checked and then
actions taken as will be noted below:
================CONDITIONAL
LOGIC EXAMPLE======================
|| IF
LAB<HTN> = "Y" {} ELSE {.L: HTN:
Y «...This is to LOAD DX
into lab tables...»
} ||
|| IF
LAB<HTN> <> "Y" {.MP: HYPERTENSION: 401.9 «*...This is to update MP Table...»} ELSE {} ||
|| IF
LAB<ASPIRIN> = "" AND PAT_AGE
> "40" {«...ADD/INSTRUCT
on use of ASPIRIN and add dose!...» «
«*WARNING - If
on COUMADIN or allergic to Aspirin -- Don't advise and skip....» «
«REQ» «*RX-ASPIRIN...» «<==You must
choose which dose they're taking. If none, 81mg...»
}
ELSE {}
||
|| IF
LAB<AUDIT-C Q1 FREQ> = "" {«***You must do AUDIT-C - entirely if
need be...» «
«REQ» «AUDIT-C1-FIRST» «<--Click on Quicktext
and finish...»
}
ELSE {«**Check Last AUDIT-C date...»} ||
==============END of
CONDITIONAL LOGIC====don’t put these lines in============
QUICKTEXT instead of the
TEMPLATE:
You can see that the naming
to the QT is such that beyond the AUDIT-C1-FIRST, none of those are triggered
since in most cases our patients don’t score above 3. When they do score
above 3, the pick list (in the AUDIT-C1-FIRST) can easily drop all of the
questions into the note. As a sidebar, PPRNET had use create lab test
names (which you will see below) and again, this process is not
explained. If questions on any aspect of the AUDIT-C and the AA-TRIP
study, I would refer you to the PPRNET website found at:
Why not use the template
suggested (in our setup for the AATRIP prep)? We found that you have to
actually think to do this (that is, add a template)! Therefore, folks
were occasionally leaving it out the AUDIT-C template. By using the
conditional logic, the nurse (or doc) is “forced” to address the AUDIT-C (and
we added the ASPIRIN also). I am sure there are bugs in my logic of this
process but so far this has worked pretty well. I, again, want to thank
Don Stewart for the ideas of creating “LABEL” using the red pick list and of
course his good document on conditional logic. Below is the quicktext. Due to limitations with the number of
characters allowed in quicktext, the AUDIC-C Alcohol
Screening template had to be broken into smaller pieces. Also, templates
can’t be “called” in conditional logic but quicktext
can. Please remember that you should setup your lab tables as previously
recommended and realize that you are welcome to cut-past the logic and quicktext but remember you have to go back and recreate the
labels/quicktext as you normally would de novo.
Also, go to:
http://skylinefamilypractice.net/EMR/EMRIndex.htm
to get DON Stewarts Conditional logic document.
==========QT NAME –
AUDIT-C1-FIRST===============================
ALCOHOL SCREENING:
ASK: AUDIT-C Questions
A drink is defined as a
12-ounce bottle of beer or wine cooler, a 5-ounce glass of wine, or 1.5 ounces
of 80- proof distilled spirits.
1) How often did you drink
in the past year? (Score as follows: Never="0"; monthly or
less='"1"; 2-4 times a month="2"; 2-3 times a
week="3"; 4-5 times or more a week="4")
.L: AUDIT-C Q1 FREQ: «REQ»
2) About how many drinks did
you usually drink on the days you drank in the past year? (Score as follows: 1-
2="0"; 3-4='"1"; 5- 6="2"; 7-9="3"; 10
or more="4")
.L: AUDIT-C Q2 QUANT: «REQ»
3) About how often did you
have 5 or more drinks on any 1 occasion in the past year? (Score as follows:
Never="0"; monthly or less='"1"; monthly="2";
weekly="3"; daily or almost daily="4")
.L: AUDIT-C Q3 BINGE: «REQ»
«ADD scores for questions
1-3 above to compute AUDIT-C SCORE» «
.L: AUDIT-C SCORE: «REQ»
«Go on to "ASSESS"
For patients with AUDIT-C score of 4 or above, or 5 or more drinks on any
occasion in the past year, otherwise stop and delete remainder of template.»
«...IF SCORE is 4 or ABOVE - CLICK ON QT BELOW!! CHOOSE ALL!!...»
«AUDIT-C-...»
=======================================================================
Please note that the
LABEL <<AUDIT-C-…>> is a PICK LIST
AND ALL THE BELOW QT IS CHOSEN should the score be 4 and above.
=========QT NAME –
AUDIT-C-2-ASSESS==============================
ASSESS: To determine if patient
is high-risk drinker, alcohol abuser, or alcohol dependent
Weekly average: How many
drinks in a week do you have?
.L: ALCOHOL WK AVERAGE: «REQ»
Daily Maximum: What is the
maximum number of drinks you had on any given day in the past month?
.L: ALCOHOL DAILY MAX: «REQ»
«For men, 15 or
more drinks in a week or 5 or more on any given day in the past month; for
women 8 or more in a week or 4 or more in a day define HIGH RISK DRINKING,
click label below and continue with Abuse and Dependence Questions, otherwise
stop and delete remainder of template.» «
«H-RDRINKER»
«...YOU MUST CLICK all QT BELOW!...»
=====================================================================
==========QT NAME –
AUDIT-C-3-ABUSE===================================
ABUSE QUESTIONS (in the past
year):
1. Did your drinking often
interfere with taking care of your home or family or cause you problems at work
or school? «yes» «no»
2. Did you more than once
get into a situation while drinking or after drinking that increased your
chances of getting hurt – like driving a car or other vehicle or using heavy
machinery after having had too much to drink? «yes» «no»
3. Did you get arrested,
held at a police station or have legal problems because of your drinking? «yes» «no»
4. Did you continue to drink
even though it was causing you trouble with your family or friends? «yes»
«no»
«A yes answer to
1 or more abuse questions=DSM-IV positive for abuse, click label below»
«ALCOHOLAB»
=======================================================================
=================QT NAME –
AUDIT-C-4-DEPENDENCE==================
DEPENDENCE QUESTIONS:
1. Have you found that you
have to drink more than you once did to get the effect you want? «yes» «no»
2. In the past year did you
more than once want to or try to stop or cut down on your drinking, but found
out you couldn’t do it? «yes»
«no»
3. In the past year, did you
end up drinking more or drinking for a longer period than you intended? «yes» «no»
4. In the past year, did you
give up or cut down on activities that were important to you or gave you
pleasure in order to drink? «yes»
«no»
5. When the effects of
alcohol were wearing off, did you experience some of the bad after effects of
drinking – like trouble sleeping, feeling nervous, restless, anxious,
sweating or shaking, or did you have seizures or sense things that weren’t
really there? «yes» «no»
6. In the past year, did you
spend a lot of time drinking or getting over the bad after effects of drinking?
«yes» «no»
7. In the past year, did you
continue to drink even though it was causing you to feel depressed or anxious
or causing a health problem or making one worse? «yes» «no»
«A yes answer to
3 or more abuse questions=DSM-IV positive for alcohol dependence, click label
below»
«ALCOHOLDEP»
=====================================================================================
===============QT NAME –
AUDIT-C-5-ADVISE&ASSIST========================================
ADVISE AND ASSIST:
Patient Education: I
discussed with the patient that most people either abstain from alcohol or
drink within safe limits (<=1-4/week and <=4 drinks/occasion for males,
<=7/weeks and <= 3 drinks/occasion for females) and that the risk for
alcohol disorders and other health effects rises proportionally with the number
of drinks per week and how often a drinker exceeds daily limits.
«High risk
drinkers, those with alcohol abuser, and alcohol dependence should have
"brief intervention", click label below. Those with alcohol
dependence should be referred for additional evaluation and treatment, click
label below»
«BRIEFINTER»
«ALCOHOLREF»
======================================================================================