Associates in Internal Medicine

Clinic Orientation

2008

I. The AIM Clinic How-To Guide

1. Some History and Background

Ø The Vanderbilt Clinics (at its original downtown location) was one of the first teaching clinic model established in the North America, it was written about in the Flexner Report.

Ø The AIM Clinic was established within VC complex as a general internal medicine clinic in 1976. It serves the needs of the local community, as well as the referral population to the academic center. Total visits to the clinic in 2006-7is ~ 80,000.

Ø AIM is a mixed faculty/resident practice- Attendings practice alongside residents, sharing the same patient panel as residents. Residents will care of own patient panel under the supervision of these attendings. Average supervision ratio is less than 1 faculty: to 5 residents per clinic session. There are 30 faculty clinic preceptors coming from diverse academic generalist backgrounds.

Ø Currently AIM exists in 2 spaces–AIM Clinic in Vanderbilt bldg. and AIM-East across the street. All resident practices are in AIM “West”, while AIM East houses IM subspecialty clinic.

2. The Administrative Staff/Area – VC Room 205 (staff pictures on website)

Ø AIM Medical Director -Dr. Lantigua, Division of Gen Med Director-Dr. Steve Shea, Clinic Education Director -Nancy Chang, MD, Intern Block Director -Steve Mackey, MD, Primary Care Resident Director Alex Montero, MD. The Clinic Administrator -Mr.Lester Govia , Floor Supervisor -Ms. Divina Guilfu/Florence Daniels, Clinic Scheduler -Karilyn Martinez, Interpretor Station (4 full time Spanish interpreters

Ø “Room 205” Administrative Office-contains a teaching Conference room, Fax (x5-6279, the staff helps with any faxes), copy machine (pass word 02205), and Resident Mail Boxes. There is an outgoing “mailbox” where you can leave unstamped envelopes to be mailed by us.

Ø Telephone room –(x5-6354) 3 full time staffers field over 300 calls a day. Telephone RN Message Center- RNs takes and triage incoming patient phone message for doctors/NPs. Expect to see these messages coming thru your emails. RN will only page you for urgent pt messages.

3. The Modules, a.k.a. Firms

Ø Each module has a waiting area, 4-5 physician exam rooms +/- 1RN office.

§ Room 214 houses a Walk-in clinic for pts who sick and want to see an MD or get and urgent medication refill. (allows access for patients of residents not in clinic that day)

§ Room 240 houses The Primary Care Residents. This module has the RN immunization/EKG stations as well as a special scale that accommodates wheel chair patients.

Ø Staffing- In each module, 3 Front-desk PFAs are responsible for patient check-in, registration, discharging/follow up appt/consults/test scheduling, and chart maintenance. One medical assistant (checks wt, ht, calc. BMI, pain scale, smoking hx; chaperone GYN exams, performs stat lab/EKG, and restocks rooms). The RNs administer medications, vaccinations, FSG test, and special counseling. Be sure to introduce yourself and get to know your staff team members and their roles (pictures/name are posted on website under “Staff”).

Ø Resident/Firms-Each resident is assigned to a “Firm” or home module, as well as a supervising Firm attending. Residents will usually been assigned to a room in their home module, if space is tight with a lot of same Firm residents in clinic the same day, you may be floated to another module.

§ NYS law requires that all unlicensed residents need to write prescriptions with the license number of their supervising attending. To simplify the process for the clinic, we have assigned you to a designated FIRM attending whose license #/UPIN can be used by you for this purpose. This number can be found on the website firm page.

§ Firm attendings (or Firm Chiefs when Firm attending are not available) are helpful for discussing complex pts, questions that may arise between visits, help with administrative issues, and even continuity of care (more info on website).

Ø Supervision- Preceptors are located in Rm 231, 214, and 240. This means each hallway has at a minimum 2 preceptors. The PIC room is also where the central printer is located, this is where your notes and prescriptions will print out to.

4. Typical Patient Flow

§ Prior to arrival, patients will receive mail and telephone reminders alerting them to their appt. Average patient show rate is about 75%, with lower show rates for new patients. To meet the ACGME visit training requirements of an average of 3 pts. seen per intern clinic session, expect to be asked to see unscheduled pts sometimes when you have no-shows.

§ Once a patient arrives and is registered, his/her chart usually ends up in 2 possible places. Before being processed by the MA, the chart will be located in your box at main desk. After the patient is weighed, the chart will appear in the rack next to your exam room door. (The MAs have been told to try hard to get all the weight and vitals done on pts, but during peak pt arrival hrs in clinic 9am and 1pm, you may not want to wait for them to process everyone before getting started.

§ The Epic Program’s Arrived Function will help you manage time and track patient arrival without stepping out of your room.

§ Once you get the patient’s chart, call out the name of your patient. With so many common names, we have a policy of asking pts for a DOB to confirm that the right person answered. Over half of our patients are Spanish speaking only. Be sure to use the translators if you are not fluent. (call x5-6262). If there is a long wait time for the on-site interpreter, use the Phone translator on your desktop speaker phone, access code is attached to the cord on the phone.

§ Always remember to undress and appropriately gown patients for exams. Exam done through clothing should be minimized. Unless truly pressed for time, all pts should be undressed and examined head to toe for their initial comprehensive visit. (gowns in exam table)

§ Although it is important to get to know your patients well, do not feel the need to be comprehensive in your every encounter. Understand that ambulatory pt care occurs over time. Unlike inpatient care, not everything needs to be decided nor completed in one visit. Realized that patients can always return on a shorter interval for more focused follow up visits.

§ Note writing: charting should be maintained in electronic format. Despite using the computer, be sure to always maintain eye contact and avoid typing notes when you interview patients. See below for more on note writing in clinic.

5. Computer Programs There are several computer programs to be familiar with in clinic.

§ CADENCE/EPIC- this is the clinic scheduling program which is accessed with your WEBCIS ID and password. The program will allow you to view schedule, track your arrivals, and schedule your own appointments.

§ WEBCIS- is the main EMR program used in clinic. It allows you to access data, maintain an outpatient list, fax Rxs. and enter free text clinic notes. When writing notes, used the “save draft” function, and submit the note only after you discussed the case with your preceptor.

§ We are preparing a transition to Ambulatory Eclipsys in the end of 2008. More details will be provided on this in the future. This EMR has the potential to bring us closer to a paperless operation. For now, the most helpful feature on the Eclipsys (Ambulatory Manager) is an “inbox” where outpatient results of labs/Xrays you ordered will be retrieved.

6. Clinic Note Writing –. The Main intention of writing encounter notes is to concisely RECORD AND COMMUNICATE the findings and your thoughts from the encounter. Always aim for quality- clarity, organization, thoughtfulness, NOT quantity. Use this task as a way to help you put the case together after seeing the pt. It is good to adapt a standard template in writing notes (see AIM template). Always avoid carrying over large chunks of unrefreshed/unreviewed or redundant copy and pastings on your notes. Try to limit each clinic note to 1-2 page printed (at smallest webcis font). “Run-on” notes that goes way long, impairs the ability of others (or even yourself) to grasp the true clinical picture. We recommend that you keep your health maintenance check list on the bottom of your note so it is not distracting, and is a good reminder at the end of your visit.

Standard AIM template – categories listed must be on every note (pointers in parenthesis)

o Name, MRN number, Emergency/proxy contact

o Problem List (problem list need to be reviewed and “weeded” at each visit, avoid redundancy, avoid “run-on” problem lists)

-Active

-Pmhx/Psurghx- inactive problems that are not currently relevant

o Chief complaint/HPI/Interim History

o ROS (questions unrelated to HPI)

o Med Allergy (document reaction to meds)

o Updated Med list (reconcile patient bottles at every visit, do not cut and paste list blindly, watch for polypharmacy)

o FmHx Sochx (can be copied and carried onto f/u visit notes as it may help you with ongoing care)

o Physical Exam

o Data (do not cut and paste webcis results, interpret results concisely. Old results may be included under proper heading of problem list. No need to carry miscellaneous results to perpetuity )

o Assessment –(one line summarize the big picture, stability of patient’s course, new findings of interest)

o Problem/Plan- (define issues by problems not organ system. A problem is a diagnosis, abnormal finding, or symptom under eval. Also be sure to document patient education)

o Health Maintenance (record vaccine hx, dates of last mammo, pap, colon etc..)

Example of a clinic note is attached on the end of this packet, and on the clinic website under “charting”

7. Presenting to the PIC and the discharge process

§ After you see the patient, jot down some preliminary notes (or write a note in draft form), and come discuss the case with the PIC. He/she will help you identify the major issues, and come up with a plan. Clinic case presentations need to be much more concise than inpatient presentations. Aim for 3-5 minutes to cover the H&P and get to your assessment and plan.

§ If you are not sure how to proceed on a case, or are overwhelmed by the patient volume, be sure to step out early and speak to your PICs early. They will be able to help with time management, prioritizing a case, or help you to redistribute patients to other less busy colleagues.

§ Once the case presentation is finished, submit and finalize the note in Webcis. If it helps you think more clearly, you may ask the patient to step out of the room while you are composing the note. Your PIC will need to cosign a hard copy of your notes before the pt is d/c’d.

§ Make sure your patients have enough refills until the next visit, print Rxs from WEBCIS outpt med function. Unlicensed interns will need to make sure his/her attending’s License number is written on all Rxs. Medical supply Prescriptions like wheelchairs, fingerstick test strips will require a diagnosis code (i.e. diabetes 250), and an attending’s UPIN or NPI number.

§ Lastly, complete the discharge instruction sheet/test ordering requisitions and billing sheet. Make sure to include your first and last name and ICD 9 code for radiology/lab tests (this is important so patients do not get billed for inappropriate testing). Learning these administrative tasks may take a few weeks, be sure to ask your PIC for help!

§ When changing your patients’ meds, a medication reconciliation a.k.a. Updated Med list for patients should be provided to your patients (available in Eng and Spanish in Webcis Rx)

§ Finally, put chart, billing sheet, prescriptions, order forms in the “send home box” at the front desk. Your patients will have a seat in the waiting area, while the front desk begins to process discharge paperwork and follow up testings/appts.

§ To minimize additional clinic time stress, consider saving time consuming tasks (family phone calls/forms for patients/prior authorizations) for the end of clinic, or another day. Patients can return to pick up forms on another day. You can also mail it back to them.

§ When finished with clinic, be sure to look at your cubby or door rack to make sure no one or no messages are left behind. Be sure to say goodbye to your staff and let them know that you are leaving.

7. Miscellaneous AIM facts-

§ Resident Binders– Each resident is given an on-site binder, as a place for you to keep paperwork, favorite patient references/handouts,... Binders for all residents are available on the shelf of the PIC room of your home Firm.

§ Social Workers- there are four AIM social workers, there is a full time social worker assistant here just to help with transportation forms. Patient can be scheduled to see a social worker, or use the same day “walk-in” service. Reasons and scope for SW visits are detailed on the medicineclinic.org website under “social worker”

§ Telephone Room (3 receptionist fields over 300 calls a day, highest call volumes from 10-3pm). They sit next to a phone-triage RN who takes and relays messages for MD. Use your business cards and encourage your patient to call this number, x 5-6354 and DO NOT give out your beeper number. This phone number is covered 24x7, your beepers are not. You will occasionally receive email messages from our triage nurses. Please respond to them to confirm that you have received their messages. Non-urgent messages will be placed in your clinic mailboxes. Urgent messages for unavailable residents will be answered by the PIC or the walkin clinic. Discourage your patients and agency nurses from paging you through the hospital operators (5-667x), as it is both not safe (when your beeper is not on), and disruptive. Our Clinic RN message center is the safest method to ensure all messages get to you.

§ The Anticoagulations Clinic is staffed by 5 Nurse Practioners in AIM. This service assist AIM MDs with monitoring and managing patients’ coumadin dosing.

§ “Pap clinic” is a place to send all of your screening pap exams, it is staffed by NPs.

§ There is an on-site Diabetic retinal screening program, same day appts are possible.

§ Resident Clinic Mailboxes- pt message/lab radiology results/equipment orders/visiting home nursing forms will come here. Be sure to sign to acknowledge your approval of the orders, and return signature requests in a timely fashion. When not on vacation, please always check and clear out your mailbox every time you come to clinic, or at a minimum every 2-3 weeks. These mail ARE important, if you do not return these order in a timely fashion, your patients may lose their home services.

§ The WEBCIS Outpatient List –Add all of your newly seen patients to this list. This function will help you to keep on top of your patient panel. This list can help with cross coverage, weekly lab checks, and with various QA/QI activities that you will participate in.

§ We have an AIM Diabetes Teaching and Management Clinic, refer your patients who needs education and/or have uncontrolled diabetes.

Frequently asked questions

1. How do I keep track of labs ordered on my out-patients?

· Lab Results- Our clinic nurse Belinda get daily lab reports for all 150 doctors in AIM, she review these results for markedly abnormal values and will alert you (or PIC if you are away) of these immediately. Mildly abnormal numbers will be placed in your mailbox With so many doctors in the clinic, for ultimate safety, we also recommend that you track your own outpts labs by adding your clinic patients to the Webcis “outpatient list” and running a weekly check on the 7 day lab summary (this should take you < 5 minutes each week).

· Radiology reports are printed and mailed to us weekly from the Radiology dept. To be certain that the rare but very important test result do not get lost by mail, we recommend each of you to keep a short list of important studies ordered on your PDA to follow up on personally.

· Abnormal mammography notifications/reordering, we will help you respond to these requests for f/u abnl imaging (a copy of the recall reason will be placed in your mailboxes).

2. How do I get my discharged patients to follow up in clinic?

· Use the Cadence/Epic program to schedule patients for f/u. The unit clerks on the floors have recently been given the ability to schedule appts for you on cadence. Another option is to call the AIM scheduling line, but there may be a wait depending on when you call (10-3pm is busiest). Since the Epic program is only available on some of the inpatient computers. Another option is to book the discharges when you come to clinic. If you do not have a timely appt available ask your residents to help with seeing the pt in the interim.

3. What if all of my clinic slots are fully booked, and I want to get a patient on the schedule?

· As you start your new practices, you should realize that the show-rate for newly referred patients is somewhere around 60%. Often times when 5 patients are booked, only 3-4 will show up. Think about using your overbooking function, all resident have the capability to overbook themselves on CADENCE. Also if you do not have any open slots, you can have the patients scheduled with your FIRM NP, residents, or attendings. Write a note in the computer to let the interim provider know what needs to be done, or followed up on.

4. How should my patients call me, and how are the phone messages handled?

· Patient phone calls comes to the clinic’s main number 305-6354. Phone calls for MDs are currently handled by our “phone triage nurse” team. This nurse may text page or email you the messages based on the urgency. If you are not available (vacation/nite rotations), the PIC will assist in responding to these urgent messages. Be sure to sign out your beeper “out of hospital” when you are not working, it is also helpful to turn on the email vacation notification on your work email if you are not in town. This would help the nurses to know whether the message was delivered.

· A few home visiting nurses/patients/pharmacies have an old habit of paging doctors thru the hospital operators to an outside line (these outside pages will show up on your pager looking like -5667x). You should instruct your patients and nurses to avoid this habit, as our clinic telephone line is a much safer option, with coverage by MD/RN 24x7.

5. What about phone calls from patients overnight or on weekends?

· During the after-clinic hrs, 2 outpatient block residents, along with one attending physician are assigned to cover the AIM phone call service. Notes of your patients’ phone call will kept on WEBCIS or placed in your mailbox.

6. What is the billing/encounter sheet and how do I fill it out?

· An encounter form is a billing document to go along with every patient visit. In general one picks one primary diagnosis/ICD 9 code, along with up to two other secondary diagnosis codes. The level of visit is purely based on the complexity of visit. Without going into too much details, one should keep in mind that “Level 1” visit is an extremely straight forward focused visit, and “Level 5” visit is generally one with well documented extensive history, exam, and complex decision making. Ask your PIC to help gauge the appropriate levels.

· Only patients who are completely new to AIM clinic should be marked as a “initial visit”. A patient who was followed by a recently departed resident provider, should be billed as a “follow up” patient, as they are not “new” to the clinic.

· If you ordered a mammogram, a FOBT, a vaccine, be sure to mark the ICD code for those tests on the encounter form. Not marking these codes correctly may result in your patients getting a bill for the test, as their insurance may deem the test “inappropriate” and not cover it.

· Finally, be sure to sign the encounter form at the end of the visit.

7. Why do patients bring us so many different forms to fill?!?

· It is a fact of life that physicians are called on to attest to their patients’ medical history for a growing number of reasons and agencies. These forms include those for school/work/outside clinic physical forms, home care (M11Q), disability, welfare, housing, transportation etc... Remember our patients are mostly indigent and disadvantaged, and these forms may allow them to access important services. Be sure to ask your preceptors for help whenever you encounter an unfamiliar form or request. Unless you are having a slow day in clinic, do not attempt to complete the forms during your session. It may get you stressed out and frustrated during a busy clinic session. Tell your patients that you do not complete paperwork during clinic sessions, but will have it ready for them in several days. You can either have them return to pick it up or mail it out for them.

8. What is the AIM intake/discharge instruction sheet?

This sheet list the intake vital signs and weight for the patient. It also helps us communicate clearly to the staff when we want the patient to return, and what test we want to the patient to have. After you finish your note, write down on the d/c instructions what you need the staff to do for you (i.e. “Labs before return, mammography, renal clinic”). For JCAHO compliance be sure to complete the tobacco and pt education assessment sections.

9. What is the ACNC screening sheet?

· This is a sheet devised to assist physicians with obtaining comprehensive histories from pts, while meeting minimum JCAHO standards. The sheets are filled out by new patients to our practice, and others who have new clinic chart volumes made. Please review the content of the sheet with the patient, and sign the bottom to acknowledge your review. (In general pts are suppose to have completed the sheet before seeing you, however if the sheet is not completed, please go through the questions with them as it is also helpful for your history taking.)

10. How do I avoid having to obtain prior authorizations on prescriptions?

Obtaining prior authorizations for medications or pre-certification for testing and or other services is an unfortunate part of our physician’s daily tasks. Although the process is painful and time consuming, given the at times excessive practice pattern of modern day medicine, one can understand the emergence of this degree of external practice “management.” Luckily, most insurance companies do provide a comparable and efficacious list of alternative medications; therefore, before launching on this tedious endeavor, review the companies’ formulary or preferred medication list first.

A few manage care companies require MDs to obtain prior authorizations for expensive tests like MRIs, cardiac nuclear tests. Before you launch on the painful process of getting the PA, run the case by a PIC. They may be helpful with talking you thru the PA procedure, or even suggesting alternate test that may not need prior authorization.

IV. Clinic Cancellations Policy:

To ensure our patients’ continuity and quality of care, your best efforts should be made to avoid unnecessary or last minute clinic cancellations. Cancellations of any outpatient clinics or conferences must be approved in advance by the Chief Residents and/or Dr. Nancy Chang

If you do need to cancel a session, please alert us as soon as possible;

For:

1. Predictable cancellations- (example: away electives, ACLS/BCLS training, Boards part III, routine physician appointments, jury duty, conferences, “special” family events) Please communicate this request to us at least 2 months in advance. Email instruction below.
2. Unpredictable cancellations- (example: last minute fellowship interviews, last minute jury duty notices, personal/family illnesses) these must be communicated as soon as you are aware of the dates.
3. Cancellations during the OPD blocks need to be approved in advance by Dr. Nancy Chang. Coverage will be required for cancelled walk-in clinics (coverage may be required for last minute (<1-2wk) cancellations of preop/AIM diabetes).
4. Clinic will not be cancelled or altered to accommodate personally arranged shift swaps and pay back.
5. Fellowship/job Interviews (Jan-Apr)-Please Email us as soon as you know the dates. Depending on the number of sessions/pts cancelled, we may ask you to provide alternate clinic dates to ensure patient care do not get compromised. During OPD blocks, coverage will be required for cancelled any walk-in clinics. To help you plan your interview dates, feel free to email Dr. Chang for an advance copy of the OPD block schedules.

• All AIM Clinic cancellation emails should be addressed to all 3 of the following: Karilyn Martinez (kam9005@nyp.org), chief residents (intmedchiefs@columbia.edu), and Nancy Chang (nmc5@columbia.edu). ACNC residents must contact chiefs and Dr. Finkelstein.

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Thanks for wading through this complex document, put it away for now and refer to it again in 2 -4 more months, I think you may find it even more helpful with some real world clinic experience.

Please always access the clinic website for more extensive listings of clinic info. Also always feel free to email me with any other clinic related questions. My email and other information about the clinic can be easily found on the home page of the www.medicineclinic.org website.

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Summary of 2007 USPSTF Guide to Preventive Service Associates of Internal Medicine. Columbia University Medical Center USPSTF SCREENING 07	(USPSTF grade) age	Additional info
Breast CA	(B) rec mammo +/- clinical breast exam >40 every 1-2 yrs	(I) insufficient for clinical or self breast exam alone