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Integrating QI into Dermatology Practice
Cort McCaughey, MD, FAAD
Intermountain Healthcare
Logan, Utah
Steps in Quality Improvement
• Identifying a problem or process that needs improving
• Implementing change
• Measuring that change (# patient visits, revenue, your happiness, etc)
• Making additional changes and/or disseminating a process that works to other clinics
Identifying a Problem
• Maximize my face-to-face time with patients
• Minimize time spent at the computer/EMR
• Implement a safe and efficient process that allowed me to accomplish these goals
Identifying a Problem
• How do I maintain safe high quality care (meaningful use, PQRS, value based modifiers, etc)?
• Is my current process effective?
• Can I still practice patient centered care with my current EMR?
• Are my patients being triaged and treated in a timely manner?
• How do I maintain efficiency (appropriate levels of staff, appropriate use of staff, office layout/design)?
• Are there processes I can put in place to help prevent burnout and allow me to continue to have high job satisfaction?
Prior to Implementation of Change• One patient every 15 minutes
• 15 minutes per patient• 9 minutes in the room with the patient• 6 minutes of paperwork (documentation, billing, med rec, patient education, etc)
• Utilizing 2 MA’s• 30 minutes per patient• 5-10 minutes were spent rooming, pregnancy tests, initial documentation, etc• MA would leave the room after their initial intake tasks were complete and would only return if
needed for procedures
• Problems with this system• Each patient received only 15-20 minutes of face-to-face time. Lower patient satisfaction• A lot of down time for MA’s• Loss in revenue• 3 hours of documentation when seeing 30 patients/day• Lower job satisfaction due to EMR burdens
• The change I wanted to implement would hopefully eliminate these problems
• Solution• Use of MA’s as scribes
Implementing Change
• Using a scribe model effectively• Evaluation of staffing
• More MA’s
• Change the way MA’s were being utilized
• Clinic setup would need to be safe and efficient• Computer placement
• Lighting
• Tray setup
• Processing specimens
• Eliminate the use of a central scheduler • Patients placed in appropriate time slots
Implementing Change
• 1 MA per patient room (3 patient rooms)
• With 10 minute appointments, the MA once again has 30 minutes for each patient• 10 minutes for rooming, pregnancy tests, initial documentation• 10 minutes in the room with me (scribing, assisting with procedures, orders)• 10 minutes to process specimens, counsel on isotretinoin, schedule f/u, etc
• Minimize errors by allowing MA to focus 100% of their attention on one patient for 30 minutes
• Elimination of wasted MA time
• Increases patient satisfaction • At least 20-30 minutes spent directly with patient
• Allows me to focus on patients, and minimize the time spent at the computer/EMR
Implementing Change
• Rebuilt and simplified all note templates
• Before I enter the patient room• MA rooms patients and records allergies, reviews medications, ensures intake
sheet is filled out
• MA records a detailed history using a specific template (ie new rash, f/u lesion, new isotretinoin, f/u hair loss, new wart, etc)
• MA reports history to me and provides me patient intake sheet which I sign once I have reviewed
• MA presents pertinent information, we review the chart, and we enter the patient room together
Initial Template• Consultation: _
Chief complaint: _
History of present illness:Location of concern: _Duration: _Persistent/Intermittent/Other: _Associated signs/symptoms (ie itch, burn, sting, pain) include: _Treatments tried (ie OTC's, Rx) include: _Anything that makes it worse: _Anything that makes it better: _
Other concerns aside from chief complaint: _
Past skin history (ie eczema, asthma, allergies, psoriasis, contact dermatitis): _ (see intake sheet)
Family skin history: (ie eczema, asthma, allergies, psoriasis, contact dermatitis): _ (see intake sheet)
Social History: _ (see intake sheet)
ROS: Pertinent negatives: No wt loss, fever, chills, adenopathy. All 12 systems were reviewed and included on intake sheet with no other pertinent findings aside from information included in HPI
Physical Exam:Patient is pleasant, alert and oriented, and in no acute distress
[_] Full body skin exam including scalp, face, neck, bilateral upper and lower extremities, chest, abdomen, back, lips, oropharynx, groin and/or buttocks, eyelids[_] Upper body skin exam including scalp, face, neck, upper extremities, chest, abdomen, back, lips, oropharynx, eyelids. Patient declined full skin check[_] Lower body skin exam including lower extremities, feet, nails[_] Exam of groin, genital skin, buttocks. Patient declined full skin check[_] Focused skin exam of _. Patient declined full skin check --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Entering Diagnoses• I built all templates to combine the objective with the assessment and plan, which
minimizes documentation time (see example below)
• O: Round, red, dome shaped papule(s) involving typical location(s) including trunk and/or extremities A/P: Cherry Angioma(s) (I78.1) - Discussed that these lesions are benign - Lesions have a tendency to increase in number over time - There are cosmetic treatments available for these lesions if desired--------------------------------------------------------------------------------------------
• All diagnoses have an abbreviated code which I give the MA while I am examining the patient (ie cherry)
• They enter these templates and fill in any unknown fields
• After each template is entered, the MA enters the code into the problem list
• All templates have the ICD10 code next to them
• All templates are formatted the same to make it very easy for MA to enter templates
Entering Diagnoses
• O: Verrucous and crusted brown papule(s)/plaque(s) noted on exam in typical location(s) A/P: Seborrheic keratosis (L82.1) - Discussed that lesion(s) are benign, but encouraged to follow up if any changes or symptoms noted - Continue to observe at home and/or in follow up - Discussed treatment options including cryotherapy. Other options include electrodesiccation, curettage, shave removal, etc- Pt elected for observation of asymptomatic lesion(s) ------------------------------------------------------------------
Entering Diagnoses• O: Crusted and hyperkeratotic thin papule(s)/plaque(s) on an erythematous base located
on[_] Areas of head and/or neck (see scanned map for specific locations)[_] Area(s) of trunk, and/or extremitie(s), and/or hand(s) (see scanned map for specific locations) A/P: Actinic Keratosis (L57.0) - Discussed precancerous nature of AKs, and potential risk of transformation into SCC- Stressed importance of avoidance of sun, and at least annual full skin exams- Discussed proper, daily use of sunscreen and clothing to protect from sun and offered handout- Warned of pain, possible blistering, change in pigment, scar after LN2 treatment. Advised to return if not resolved within a few weeks- If an actinic keratosis needs more than two LN2 treatments, it should be biopsied to r/o SCC- In patients with significant AK's, field therapy with 5-FU, efficacy, side effects, and appropriate use of this medication were discussed- Treatment: liquid nitrogen 1 freeze/thaw cycle of 20 seconds for any lesion(s) treated today (see scanned map if treatment performed)- Number of lesions treated: _------------------------------------------------------------------
Entering Diagnoses• O: Round clear papule(s) with central umbilication located on _
A/P: Molluscum contagiosum (B08.1) - Discussed the viral nature of these lesions- Also discussed that the lesions will usually clear over several months to a few years on their own without treatment- Treatment can prevent spread to other family members as well as spread to unaffected skin- Do not share towels or baths with other family members until the molluscum are clear as they can spread very easily- Recent literature does not support use of imiquimod- Discussed treatment options including cantharidin, LN2, extraction, topical tazorac- After thorough discussion of risks and benefits of various treatment options, patient and/or parent elected for:
[_] Cantharidin. Prior to cantharidin application, discussed risks including but not limited to burning, pain, hypopigmentation, hyperpigmentation, scarring, lesion recurrence, failure to improve, infection, blister, and need to soak off in 4 hours after application. After verbal informed consent was obtained from pt and/or parent, lesion(s) was/were treated with cantharidin and covered with spot bandaid(s). The patient and/or family was instructed to wash the treated areas with soapy water in 4 hours via soaking off in a warm bathtub. The patient and or family was advised that the area would likely blister. If blisters get large and uncomfortable, can lance blisters with sterile needle, but leave roof intact. If area becomes irritated, advised to apply Vaseline and a bandage and to wear loose clothing. A total of _ lesion treated at today's visit[_] Extraction. Prior to molluscum viral core extraction, discussed risks including but not limited to pain, hypopigmentation, hyperpigmentation, scarring, lesion recurrence, failure to improve, infection. Following verbal informed consent from pt and/or family, lesions were lightly punctured with a #11 scalpel, followed by gentle removal with a comedone extractor[_] Cryotherapy. Prior to cryotherapy of lesion(s), discussed risks including but not limited to burning, pain, hypopigmentation, hyperpigmentation, scarring, lesion recurrence, failure to improve, infection. Following verbal informed consent from pt and/or family, lesion(s) were treated in a freeze/thaw manner x 1 cycle of 15 seconds each
Benign lesion destruction: Total number of lesions treated at today's visit [_] 15 (see scanned map for treatment site(s) ------------------------------------------------------------------
Entering Diagnoses
• O: _cm erythematous telangiectatic and translucent papule located on _A/P: Neoplasm of unspecified behavior of bone, soft tissue, and skin (D49.2)- Shave Biopsy recommended today
Shave Biopsy NoteR/O: Basal cell carcinomaProcedure: Skin biopsy. Risks including infection, pigment change, scar, bleeding, recurrence and neuropathy discussed. Benefits including; diagnosis, cosmesis, and alternatives including; no treatment also discussed. Written consent signed. Details: alcohol, 0.5% lido/epi + 1/10 sodium bicarbonate, shave biopsy of lesion using curved blade, alum chlor 35% for hemostasis, antibiotic ointment, sterile bandage applied. Pt. without complaints or complications following procedure. Wound care instructions sheet reviewed and given. Specimen to path
Appropriate f/u for discussion of biopsy results was discussed------------------------------------------------------------------------------------------------
Entering Diagnoses
• O: Involving the _ there are light pink, coppery brown macules and patches with fine scale A/P: Tinea versicolor (B36.0) - Discussed the nature of the eruption with the patient- The patient is aware it may take a few months to see complete clearance- This can be a recurrent condition; therefore, over-the-counter shampoos discussed including Nizoral, Selsun, H&S- Recommended these OTC shampoos for use intermittently as a prophylactic treatment- Discussed that pigmentation takes months to years to return to normal after yeast is appropriately treated. Recommended sun protection in affected areas to help mask flares- Discussed potential rxns to topical medications/shampoos not limited to irritation, burning, hypersens, etc- Discussed potential rxns to fluconazole not limited to hypersens, prolonged QT, arrhythmia, CV/Hep/Renal impair, seizure, agran, CBC abnl, angioedema, anaphylaxis, SJS/TEN, Torsades, N/V/D/HA, rash, taste change, ALT/AST elevation, dizziness, preg C, Cr baseline and LFT's- After discussion of risks/benefits of various treatments, pt elected for:
[_] Selenium sulfide 2.5% lotion BID for flares. Tapered to used of OTC shampoos for maintenance. Discussed hypersens, alopecia, preg C[_] Topical terbinafine 1% cream BID for flares. Tapered to used of OTC shampoos for maintenance[_] Econazole 1% cream BID for flares. Tapered to used of OTC shampoos for maintenance[_] Ketoconazole 2% cream BID for flares. Tapered to used of OTC shampoos for maintenance[_] Fluconazole 400mg x 1. Sweat out medication and avoid showering for 12 hours. Repeat in 1 week. Can repeat at monthly intervals if severe. Cr and LFT's at baseline[_] Fluconazole 300mg x 2. Sweat out medication and avoid showering for 12 hours. Repeat in 2 weeks. Cr and LFT's at baseline[_] Other: ------------------------------------------------------------------------------------------
Example• Chief complaint: Lesion on R temple
History of present illness:Location of concern: R templeDuration: 6 monthsPersistent/Intermittent/Other: PersistentAssociated signs/symptoms include: Pain, occasional bleedingTreatments tried include: NoneAnything that makes it worse: SunAnything that makes it better: None
Personal history of skin cancer: None
Other concerns aside from chief complaint: Rash in groin x years, itchy, worse with sweating, tried OTC hydrocortisone which is somewhat helpful, persistent. Scaly brown spots on the trunk and extremities which are persistent, not symptomatic. No treatment tried
Past skin history: AK's, solar lentigo, SK's, actinic damage
Family skin history: None
Social History: Patient is a farmer. Retired. No T/A/D
ROS: Pertinent negatives: No wt loss, fever, chills, adenopathy. All 12 systems were reviewed and included on intake sheet with no other pertinent findings aside from information included in HPI
Physical Exam:Patient is pleasant, alert and oriented, and in no acute distress
[x] Full body skin exam including scalp, face, neck, bilateral upper and lower extremities, chest, abdomen, back, lips, oropharynx, groin and/or buttocks, eyelids[_] Upper body skin exam including scalp, face, neck, upper extremities, chest, abdomen, back, lips, oropharynx, eyelids. Patient declined full skin check[_] Lower body skin exam including lower extremities, groin, buttocks, nails. Patient declined full skin check[_] Focused skin exam of _. Patient declined full skin check ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Example• O: 0.4cm erythematous telangiectatic and translucent papule located on R temple
A/P: Neoplasm of unspecified behavior of bone, soft tissue, and skin (D49.2)- Shave Biopsy recommended today
Shave Biopsy NoteR/O: Basal Cell CarcinomaProcedure: Skin biopsy. Risks including infection, pigment change, scar, bleeding, recurrence and neuropathy discussed. Benefits including; diagnosis, cosmesis, and alternatives including; no treatment also discussed. Written consent signed. Details: alcohol, 0.5% lido/epi + 1/10 sodiumbicarbonate, shave biopsy of lesion using curved blade, alum chlor 35% for hemostasis, antibiotic ointment, sterile bandage applied. Pt. without complaints or complications following procedure. Wound care instructions sheet reviewed and given. Specimen to path
Appropriate f/u for discussion of biopsy results was discussed-------------------------------------------------------------------------------------
• O: erythematous plaques with satellite papules/pustules involving the following area(s)[_] inframammary[x] crural[_] infraabdominal folds[_] Other: A/P: Intertrigo (L30.4) - Keep area clean, dry, and cool as much as possible. Sweating may be reduced with a gentle antiperspirant- Short term steroid cream/ointment is needed to calm inflammation. Recommend OTC Hydrocortisone cream BID for 2-3 weeks then tapering with improvement. Discussed risk of steroids in folds including but not limited to atrophy- Discussed that treatment depends on the underlying cause and that empiric combination treatment is often used for this condition as it is often multifactorial- Bacteria may be treated with topical antibiotics such as fusidic acid cream, mupirocin ointment, or oral antibiotics such as erythromycin- Yeasts and fungi may be treated with topical antifungals such as clotrimazole and terbinafine cream or oral agents such as itraconazole or terbinafine[x] Econazole 1% cream to affected areas BID[_] Zeasorb AF powder QAM[_] Ketoconazle 2% cream to affected areas BID[_] Other: -------------------------------------------------------------------------------------
Example• O: See other objective findings
A/P: Pruritus (L29.8)- Discussed various causes of pruritus including eczema, xerosis, drugs, renal, liver, malignancy (such as Hodgkins), psychogenic, ACEi's or other medications, etc- Discussed dry skin care in detail and provided personalized handout on dry skin care recommendations- Recommend Sarna lotion as often as needed for breakthrough itch in addition to any needed topical steroids, antihistamines, other medications that may be prescribed given other cutaneous findings- Discussed potential for UVB treatments- Discussed that steroids are not typically helpful if no lesions are seen- In patients with liver/renal disease or other systemic problem leading to itch, medications such as cholestyramine, mirtazapine, doxepin, naltrexone may be beneficial- In this patients case, pruritus is likely 2/2 to _- Discussed risks of antihistamines not limited to hypersens, CNS depressant, renal/hepatic impair, bronchospasm, anaphylax, seizure, AMS, sycope, drowsiness, HA/N/V/D, dry mucous membranes, etc- After thorough discussion of suspected etiology, importance of dry skin care, risks/benefits of various tx, pt elected for:
[_] Dry skin care, OTC Sarna lotion[_] Hydroxyzine 25-50mg QHS PRN for itch at night[_] Cetirizine (Zyrtec) 5-10 mg QD-BID[_] Fexofenadine (Allegra) 180mg QD-BID[_] Loratadine (Claritin) 10mg QD-BID[_] Cholestyramine 4-8mg BID before meals[_] Doxepin 25-50mg QD[_] Mirtazapine 7.5-15mg QD[_] Naltrexone 25-50mg QD[_] Topical amitriptyline 2%/ketamine 1% cream BID PRN for pruritus[_] nbUVB[_] Other
If not improving, consider the following studies: (ESR, CBC with diff and platelet count, BUN/Cr, LFT’s, LDH, TSH, HgA1c, Iron/ferritin, stool for ova, parasites, and occult blood, PTH with Ca/Phos, CXR, skin biopsy, DIF, TTG IgA, Viral hepatitis screen, HIV, antimitochondrial/anti smooth muscle antibodies, serum IgE level, allergen-specific IgE antibody tests, prick tests, patch tests, serum tyrptase, histamine, and chromogranin-A levels, urine for sediment (24 hr urine collection for 5-hydroxyindoleacetic acid and methylimidazoleacetic acid which are serotonin and histamine metabolites respectively), CT scans, SPEP/UPEP)
-------------------------------------------------------------------------------------
Chief complaint: Lesion on R temple
History of present illness:Location of concern: R templeDuration: 6 monthsPersistent/Intermittent/Other: PersistentAssociated signs/symptoms include: Pain, occasional bleedingTreatments tried include: NoneAnything that makes it worse: SunAnything that makes it better: None
Personal history of skin cancer: None
Other concerns aside from chief complaint: Rash in groin x years, itchy, worse with sweating, tried OTC hydrocortisone which is somewhat helpful, persistent.
Past skin history: AK's, solar lentigo, SK's, actinic damage Family skin history: NoneSocial History: Patient is a farmer. Retired. No T/A/DROS: Pertinent negatives: No wt loss, fever, chills, adenopathy. All 12 systems were reviewed and included on intake sheet with no other pertinent findings aside from information included in HPIPhysical Exam:Patient is pleasant, alert and oriented, and in no acute distress[x] Full body skin exam including scalp, face, neck, bilateral upper and lower extremities, chest, abdomen, back, lips, oropharynx, groin and/or buttocks, eyelids------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
O: 0.4cm erythematous telangiectatic and translucent papule located on R templeA/P: Neoplasm of unspecified behavior of bone, soft tissue, and skin (D49.2)- Shave Biopsy recommended today
Shave Biopsy NoteR/O: Basal Cell CarcinomaProcedure: Skin biopsy. Risks including infection, pigment change, scar, bleeding, recurrence and neuropathy discussed. Benefits including; diagnosis, cosmesis, and alternatives including; no treatment also discussed. Written consent signed. Details: alcohol, 0.5% lido/epi + 1/10 sodium bicarbonate, shave biopsy of lesion using curved blade, alum chlor 35% for hemostasis, antibiotic ointment, sterile bandage applied. Pt. without complaints or complications following procedure. Wound care instructions sheet reviewed and given. Specimen to path-------------------------------------------------------------------------------------
O: erythematous plaques with satellite papules/pustules involving the following area(s)[_] inframammary[x] crural[_] infraabdominal folds[_] Other: A/P: Intertrigo (L30.4) - Keep area clean, dry, and cool as much as possible. Sweating may be reduced with a gentle antiperspirant- Short term steroid cream/ointment is needed to calm inflammation. Recommend OTC Hydrocortisone cream BID for 2-3 weeks then tapering with improvement. Discussed risk of steroids in folds including but not limited to atrophy- Discussed that treatment depends on the underlying cause and that empiric combination treatment is often used for this condition as it is often multifactorial- Bacteria may be treated with topical antibiotics such as fusidic acid cream, mupirocin ointment, or oral antibiotics such as erythromycin- Yeasts and fungi may be treated with topical antifungals such as clotrimazole and terbinafine cream or oral agents such as itraconazole or terbinafine[x] Econazole 1% cream to affected areas BID[_] Zeasorb AF powder QAM[_] Ketoconazle 2% cream to affected areas BID-------------------------------------------------------------------------------------
After the Visit is Complete
After all diagnoses have been entered, the MA and I switch positions at the standing ergotron
When the MA and I switch positions, the following are already complete
The note is finished
All diagnosis codes have been entered
Patient education has been printed
Medications have been proposed
I review and sign my note, bill, sign off on proposed medications, and complete my medication reconciliation
This takes ~1 minute per patient
While doing this, the MA is either setting up for biopsy, reviewing patient education, or discussing follow up
All biopsies are done after completing documentation
This allows the MA and I to focus 100% of our attention on tasks related to the procedure (taking photos, confirming sites, 2 identifiers, informed consent, wound care)
Using MA’s as Scribes
• Average patient visit when MA’s not being used as a scribe• 15 minutes per patient
• ~9 minutes in the room with the patient • ~6 minutes of paperwork (documentation, billing, med rec, patient education, etc)
• Average patient visit when MA is being used as a scribe• 10 minutes per patient
• ~9 minutes in the room with the patient• ~1 minute of paperwork (documentation, billing, med rec, patient education, etc)
• Seeing patients every 15 minutes vs every 10 minutes from 8:00am to 4:20 pm (with 1 hour and 15 minute lunch)• Volume of 30 patients per day vs 44 patients per day
Using MA’s as Scribes
• What is the cost of an extra MA?• MA pay range of $12.50/hr to $21.00/hr ($26,000/yr - $43,680/yr)
• MA benefits at 32% of annual pay ($34,320/yr – $57,658/yr)
• Dermatologist working 48 weeks/year, 4 days a week• 1 added patient/day generates an additional ~$48,000 in revenue/year
Identifying a Problem/Clinic Setup
• Problems outside of the room• Knowing where our MA’s are• Knowing which patient is next to be seen• Where our pathology specimens are processed• Proximity of office to exam rooms
• Problems inside of the room• Appropriate lighting• Space limitations, particularly for procedures/setup• Having a computer that is fixed to one location• Turning our backs to patients• Charting while sitting down behind a computer• Not being able to face patients and their guests at the same time• HIPAA
Office/Exam Room Setup
• Allows for quick and efficient charting
• Don’t have to return to office for charting/coding, etc
• Can move right to next room after finishing with a patient
• Walking from exam room to office after each patient encounter takes ~10-14 minutes per day
• Sliding doors to maximize room space
• Boogie boards
• MA Name
• Patient order
• Separate path station • Path Log• KOH Log• Isotretinoin Log
• Specimen labeling is all completed in patient room in front of the patient. Then logged in a pathology log at this station immediately after the visit.
• When the courier picks up the specimens from this station, they double check that all specimens are accounted for in the log and then sign off on every specimen that they take
• Standing ergotrons so we are always facing our patients and their guests
• Laminated coding cheat sheet on the standing ergotron• Contains all of my shave biopsy,
shave removal, excision, IL, E&M codes, etc
• Allows quick billing in the patient room while completing note
• E&M coding cheat sheet on the wall next to the ergotron
• Body maps to map AK, SK, VV txsites, etc
• After I have completed examining the patient, treating AK’s, etc, my MA and I switch places and she will either counsel patients on dry skin care, acne, take biopsy site photos, setup for biopsy, etc. While she is doing this, I am completing my note and billing.
• If we are performing a biopsy, the site has already been marked on the patient, measured, and documented in the note by my MA.
• I sign my note and bill before I biopsy. This way I can focus 100% of my attention on the procedure and performing a time-out prior to procedure
• Once I finish with the biopsy, I am able to leave and go straight to the next patient room.
• Wall clip to hold pillow so when I lay patients back I can pull the pillow on and off of the wall quickly
• Pre setup trays
• 2 separate kits on 1 tray. One for shave or punch biopsy and another for comedoneextraction, paring, etc
• Numerous kits which my MA’s prepare prior to clinic, so once we go through a tray, there is another one which is already prepared in our cupboards
Measuring Change
• Using a scribe model effectively• Evaluation of staffing
• More MA’s• Change the way MA’s were being utilized
• Clinic setup would need to be safe and efficient• Computer placement• Lighting• Tray setup• Processing specimens
• Average patients per day increased from ~27 to ~39
• Addition of a 3rd MA was justified by increased revenue
• Cut my time at the computer from 3 hours/day to 1 hour/day
• High MA satisfaction
• High patient satisfaction
• Very high physician satisfaction
Disseminating a Process that Works to Other Clinics
• Scribe process being implemented at other locations
• Model being tested in other specialties including rheumatology, family medicine, internal medicine, ENT
• Providing ongoing support during implementation of EMR
