The Vision
As we learn more about how to improve our health and as we are able to change the future of our health more, excellence in healthcare increasingly is dependent upon two things: a team approach and the automation of those standardized tasks, which while they are critical to excellent care, can be completed without requiring the time and attention of team members. This gives the team more time to interact with one another personally. This standardization and automation of care brings us one step closer to the ultimate promise of electronic patient management which is the ultimate goal of electronic patient records. The Automated Team is the logical extension of clinical decision support.
The Team
The majority of healthcare is delivered and received in the ambulatory setting in a clinician’s office. While the healthcare team is much boarder, in the ambulatory setting, the principle members of the team are the patient, the nursing staff and the healthcare provider. Ultimately, while the standardization and automation of this team’s functions will spread across all areas of care, Southeast Texas Medical Associates’ efforts begin with diabetes. Each member of the team -- patient, nurse, provider -- contribute to the excellence of ambulatory care for diabetes.
The Plan
When a patient who has diabetes makes an appointment, based on evidenced-based medicine and national standards of care, the electronic record will immediately search the patient’s entire medical record to determine what tests, procedures, consultations or interventions are required and which have not been performed. Each of these interventions will be directed at the prevention of the complications of diabetes and/or at the improvement of the care of the patient with diabetes. Because diabetes is a progressive disease, excellence of care at one point in time may not reflect excellence of care at another time, thus the reason why the “automated team” needs an updated, current and complete plan of care and treatment plan at each visit.
The Automation
When the patient presents for their appointment, three documents will have been prepared:
- For the nurse, a document will have been prepared which lets the nurse know what elements of his/her contribution to the team’s effort are not up to date and need to be addressed, such as The LESS Initiative, the 10-gram monofilament sensory examination, immunizations, medication reconciliation, etc.
- For the patient, a document will have been prepared which tells the patient what tests, procedures or referrals have been scheduled. An explanation will be provided to the patient as to why he/she is being asked to have these tests, procedures, or appointments. As stated above, all interventions will be directed toward the improvement of the patient’s care and the avoidance of the complications of diabetes. With this document, the patient will know what his/her responsibility is to support the efforts of the team.
- For the provider, a document will have been prepared which explains the information which has been given to the nurse and the patient. The provider will be alerted to whether or not the patient has been treated to goal for diabetes and if they are not treated , the provider will be encouraged to change medication, life-styles, education, etc., in order to achieve control.
The Team’s Activation - True Patient-Centered Care
Each team member will have access to the documents given to other members of the team. Each team member will know what is expected of the team and each team member will know the goals are for the entire team. Because the team will be spending less time on the tasks of ordering and scheduling tests, procedures and referrals, there will be more time for the building of relationships and for the engagement and activation of each member of the team.
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