TSWF Long-Term Opioid Therapy CPG AIM Form User Guide January 2019 0 Form Version: Jan-Apr 2019 Form Version
Table of Contents Long-term Opioid Therapy (LOT) CPG AIM form Introduction..2 General Information....3 Best Practice Procedures and Workflows...4 Form Tabs HPI/PFSH...5 ROS/PE...8 Exit/CCP 9 Patients Currently on OT.10 Appropriateness for OT...12 Treatment with OT....13 Tapering or Discontinuation of OT 14 Medication Guidance 15 Drug Interactions...16 Adding Form to Favorites Instructions..17 Copy Forward Instructions 20 AHLTA Options...24 1
Intro to Long-term Opioid Therapy (LOT) CPG AIM Form Background/History: The Tri-Service Workflow (TSWF) Team has created AIM forms to bring team care to MTF workflow, save provider and staff time through standardization of AHLTA templates, and enhance documentation of the patient encounter. The focus of TSWF activities is to facilitate improvements by evaluating clinical workflows and creating standardized structured documentation tools that mirror clinical processes. This is done through the use of AIM (Alternate Input Method) forms with the goal of improving care and documentation in AHLTA and not just the use of a form for its own sake. The LOT CPG AIM form is used in Primary Care and can be used alone or in conjunction with the CORE form during an encounter. In fact, all of the TSWF CPG AIM forms are compatible with each other and the CORE form and can be used interchangeably, either within an encounter or for different encounters. Who is this form made for? The TSWF LOT CPG AIM form was developed to provide standardized clinical documentation for the management and adherence of long-term opioid therapy patients. Utilizing this form can support your evaluation, documentation, and management of patients undergoing this type of care. Keep in mind that the form is used to manage the patient s opioid use for their chronic pain, not to manage the source of their chronic pain. The goal of managing these patients is to get them to be able to perform their daily duties in a safe and consistent manner. The form contains key elements from the January 2017 Opioid Therapy VA/DoD Clinical Practice Guideline, resulting in documentation that supports adherence to the guidelines. The form also contains and provides easy access to clinical decision-making resources. Like the other TSWF CPG AIM forms, the LOT CPG AIM form is largely similar to the TSWF CORE form in layout, function, and appearance. Therefore, this guide will primarily highlight the differences between the two. For full details about the use of the CORE AIM form, please reference the CORE User Guide. Why would I want to use this form for my notes? This form and associated workflow was designed to standardize health documentation practices in the MHS. Standardization of documentation can result in the following: Integrating clinical support staff into the care of patients Obtaining more thorough and better documentation Guiding providers toward using evidence-based care Standardizing suicide and safety evaluations Improving the speed and efficiency of documentation Improving coding accuracy Building in items required for inspection Features of the Tri-Service Workflow AIM forms and associated workflows: The copy-forward process (see instructions on p20 of this Guide): o Maintains continuity of clinical information o Carries forward treatment planning and ongoing course of care o Improves note writing efficiency The forms include clinical clues and reminders VA/DoD CPG decision support is available right at the point of care This user guide is a comprehensive AIM form reference that walks through the tabs on the TSWF LOT CPG AIM form. If you need initial training on the use of AIM forms, please contact your clinical systems trainers. Training is also available at: www.tswf-mhs.com If you have questions or feedback about this User Guide, please contact us via the following link on Milsuite: https://www.milsuite.mil/book/groups/tswf. 2
General Information on Form Use ------------------------- (Sequence of Clinical Workflow) -------------------------- Form Structure: - Mirrors clinical workflow (from left to right: intake, screening, ROS, PE, and care plan documentation) - Facilitates use of clinical support staff (technicians, medics, corpsman, etc.) for screening and intake documentation - Provides decision support from VA/DoD CPGs and other national level recommendations - Improves documentation efficiency - Carries important information forward from one appointment to the next via the copy-forward process (REMINDER: any information you want carried into subsequent notes must be placed into the yellow fields as these are the only fields that copy-forward!!) - Contains reference only tabs ( ) outlining reference material specific to the CPG covered in the form Form Basics: MilSuite link AHLTA users can ask questions, provide input, and obtain training materials. Access any TSWF form from the Navigator via this link. Do NOT delete the TSWF AIM form identifier (integral to the copy-forward process). Start the note below this text. Labeled buttons throughout the form are links to supporting documentation or information. Clinical clues are found throughout and give relevant information. A red X indicates this section will be included in the note. AHLTA automatically marks this X after text has been entered. Clicking on the X after typing in the box will reset the box to its default text by erasing what has been entered. The Undo button (at the top of the screen) can be clicked if this was done accidentally. 3
Recommended Documentation Workflow a. Clinical support staff (CSS): copy-forward PMH from previous encounter (highlighted in yellow on the AIM forms); consider Open, Not Checked-In up to a week prior to the visit for clinical review of information. b. CSS: at the time of the encounter, perform Screening (2 nd tab on the form), Past History, etc. as directed by clinic leadership and workflow. The CSS should also verify all the copy-forward information with the patient. They then close (not sign) note. c. Provider takes ownership of the note, i.e. edits S/O portion of note. Provider reviews the existing documentation, edits as needed, and proceeds with documentation of additional history, physical exam in the AIM form. d. Provider reviews CPG AIM form reference material as desired. e. Provider updates the CCP as desired. f. Provider completes A/P, disposition, and signs the encounter note. Why Copy-Forward? Copy-forward supports continuity of care by allowing staff to bring forward all of the past medical history and chronic care planning into the current encounter to be reviewed and updated (only elements placed in yellow fields will copy-forward). In addition to this being best practice, performing a copyforward is a significant time-saver as well. The TSWF repository for training/educational materials and updates: www.tswf-mhs.com PLEASE NOTE: A comprehensive visual change log has been created to assist users in identifying the 4 changes made with each version s update. Click here to access this presentation.
HPI/PFSH Tab At the very top of the first tab you will find the CPG recommendations for patients requiring increased monitoring while on long-term opioid therapy (LOT). At the top right are the CPG recommendations for increased monitoring methods. Website for TSWF training, contacting the TSWF team, and many other resources. A high percentage of patients discontinue therapies due to medication side effects. The LOT form allows for documentation of these adverse effects at every visit. Patients with contraindications are NOT candidates for Opioid Therapy and should be referred for alternate pain management. These should be reviewed with the patient EVERY visit. The DoD/VA Pain Rating Scale (DVPRS) allows you to document and follow the patient s pain management by understanding how their pain has affected: mood, stress, sleep and activity in the last 24 hours. The past pain treatment history is crucial in understanding the patient s chronic pain management history. Use this field to document such information. 5
HPI/PFSH Tab, cont Medication restriction program links allow providers to limit opioid and other prescriptions to a single provider/pharmacy linked to the patient s Tricare benefits. LOT Informed Consent is an annual requirement for all LOT patients. This form allows for the documentation of the presence and location of that informed consent, and the name of the primary opioid provider as well as a link to an approved informed consent word document ready for download. Links to multiple supporting websites are provided as are clinical cues for comanaging consultants and a legend of the numerous acronyms used on this form. Opioid risk assessments should be completed: -at the initial visit with a new provider -when changing dosages or type of opioid -when clinically indicated The Chronic Pain Care Plan is prepopulated with the pertinent information needed to manage the LOT patient. It takes the place of the assessment and plan traditionally placed in the note and copies forward making it an evolving care plan. Besides the metrics seen, it also includes a place to document: -GOALS -ACTIONABLE DATA -PATIENT RESPONSIBILITIES/ INTERVENTIONS -BARRIERS TO ACHIEVING GOALS -COMANAGING TEAM/ CONSULTANTS -FOLLOW UP PLAN Use the AHLTA allergies module to document pharmaceutical allergies. 6
HPI/PFSH Tab, cont. All the yellow elements will copy-forward from visit to visit. When documenting chronic care, be sure to include date of occurrence, diagnosis if applicable, current treatment and/or resolution. Double arrow will expand and collapse ribbons. 7
ROS/PE Tab Depending on your clinic, either the support staff or the provider might be responsible for completing the ROS portion of this tab. A comprehensive review of systems covering the majority of systems is found in the top left grey box. Select All Normal and either deselect or change N to Y as appropriate. Free text option for documenting ROS. To the right of the ROS button is a button with a square in it. That s an area where you can add free-text to expound upon an entry if needed. And once there is text in that box, you ll see the icon change to look like this: By clicking on this button you can see what was written, and either add/edit or delete the text as appropriate. These free-text boxes are found throughout the form. PE features the auto-normal button which will select those elements to the left of the bar that are not italicized. Italics is used for items to the right of the bar and represent exams not routinely performed; these are not selected when the Normal button is used, and must be marked manually. 8
Exit/CCP Tab Several accreditation agency expectations (such as patient handouts and selfmanagement assessments) are on the Exit/CCP tab. This tab also contains comprehensive care plans (CCP) for a large number of chronic clinical conditions. These include many aspects of the patient s care plan: goals, test results, etc. Although this is a lot of data, it only has to be filled out once to then be copy forwarded. Once it s been started, it s relatively easy to update. Clinical support staff can update a lot of this information when they do the Open, Not Checked-In scrub of the record. 9
Patients Currently on OT Tab The remainder of the tabs on the LOT CPG AIM form are for reference only- no patient data or information is recorded on them. The three ribbons at the top of each tab are the samecontaining lists of significant risk factors, aberrant behaviors, and definitions regarding addiction, tolerance etc. Below the Definitions ribbon is the corresponding algorithm for that specific tab. The algorithms and accompanying links are taken from the January 2017 VA/DoD CPG and are designed to guide providers through LOT patient management. 10
Patients Currently on OT Tab, cont. 11
Appropriateness for OT Tab 12
Treatment with OT Tab 13
Tapering or Discontinuation of OT Tab 14
Medication Guidance Tab The Medication Guidance Tab offers references and conversion charts and a link to a morphine equivalent calculator to assist in determining appropriate opioids for use with different types of pain. 15
Drug Interactions Tab The Drug Interaction tab includes aids in identifying the numerous possible interactions between opioids and other medications. 16
TSWF LOT CPG AIM Form: Adding Form to Favorites Instructions 17
The preferred method of accessing TSWF AIM forms is to have the Navigator in your Favorites. Loading from the Navigator will take you to the most current version of the form. Alternate Method: Add the specific TSWF AIM form to your Favorites 1. Open Tools 2. Select Template Management 3. Click Expanded Search to locate TSWF AIM forms 4. In Template Name line type TSWF 5. From Owner Type dropdown list select Enterprise 6. Click Search button 18
7. In the Search Results list: Right click on the TSWF- LOT CPG- (Department of Defense) AIM form 8. Select Add Favorite (Do not use Save As, as the form will not get updated properly see below) Do not use Save As when adding this template to your favorites list. Do not set this form as your default encounter template unless you have specific instructions on how to do it from your local clinical systems trainer. Save As will break the link to the Enterprise and keep the form from updating properly; setting as a default will also break the link if not done properly. We suggest cleaning out old and un-used templates from your favorites to help you quickly find the ones you most often use. 19
TSWF LOT CPG AIM Form: Copy-Forward Instructions 20
Copy-Forward Instructions 1. In Appointments view; Double-Click on the Patient. (This takes you to this Current Encounter view.) DO NOT OPEN S/O The copy-forward process is integral to the Tri-Service Workflow. Following these steps will ensure that the appropriate data you enter in today gets reused as efficiently as possible. REMINDER: only information placed in the yellow fields throughout the form will copy-forward!! 2. Select the Previous Encounter module from the Folder List. Consider including cancelled/lwobs visits when reviewing this module. 3. Click on the most recent and compatible TSWF encounter listed (e.g., includes <<Note accomplished in TSWF- >> in the HPI section). 4. Click the Copy-Forward icon on the tool bar. 21
AHLTA returns to the Current Encounter 5. Select S/O DO NOT MAKE ANY EDITS WITHIN THE COPY-FORWARD TEMPLATE! - If the Copy-Forward Template is not automatically loaded; select it from the Template drop down menu. 6. Select PMH tab to copy-forward. 7. Click AutoEnter. TSWF Copy-Forward process All copy-forward items are located on the PMH tab in this view, and are ONLY in the yellow colored fields throughout the AIM form. Critical Assumptions You MUST complete copy-forward and open the TSWF AIM form before editing the content. You MUST copy-forward from a TSWF standard primary care AIM form (CORE or any CPG AIM). 22
8. Select TSWF-LOT CPG AIM Form 9. Once in the encounter, go to the Obsolete Terms tab. Click the uncheck ALL the items below button to deselect any term found on this page as they are no longer used on TSWF forms. You will not see these terms in the form view but they would show up on the Note View. This should be your final step in the copy-forward process. 23
AHLTA Options Access by opening up any clinical encounter or tel-con to this screen. Click on the OPTIONS tab. Line 1- will default to your name Line 2- as directed by your MTF-in the LIVE system, AHLTA s default is PHYSICIAN/WORKSTATION Line 3- as directed by your MTF Co-signer- as directed by your MTF AUTO CITES- recommend checking Allergies and Questionnaires (if used). Uncheck anything else. VITALS/LABS/RADS- this will automatically place ANY vitals/results in your note for the time period you selected- i.e. for the last 7 days. We recommend leaving all these unchecked. WARNING-THIS FUNCTION WILL AUTOMATICALLY PLACE INFORMATION IN YOUR NOTE REGARDLESS OF WHO ORDERS THE LABS. Individual labs/rads can be added to the encounter when viewing those results. A/P Active Order Default: recommend checking all the boxes 24
S/O Default- We recommend unchecking both of these boxes. They used to make a lot more sense in one of the older ways we used to teach how document but now having them checked doesn t work well with the TSWF forms. Disposition Follow Up Discussed with Default: Defaults to Patient. Option to override for exceptions is located in the DISPOSITION tab E&M Calculator Defaults: Setting: Outpatient; Service Type: Outpatient Visit; Exam type: General Multi-System Do NOT check AUTO PRINT or SENSITIVE Include ICDCM/DoD Unique/CPT4/HCPCS codes in encounter note- check this box. This will place the codes on the signed encounter. No action required by user. Warn me if no procedure documented- for primary care, do not check this box. Auto Save- recommend unchecking this box. This used to be helpful but auto-saving freezes up AHLTA for a moment and it s really just not needed. 25