During our first series of talks, we will discuss creating a high-quality GI consultation note as well as guidance on onboarding and professional development to optimizing the role of the advanced practice provider. We will continue with discussions on a successful APP and MD collaborative relationship and avoiding burnout, which we all know is very important and timely. To kick us off, it is my pleasure to introduce Dr. Joe Vacari. Joe Vacari joined Rockford Gastroenterology Associates Limited in 1997, previously serving as managing partner. He has held a faculty appointment at the University of Illinois College of Medicine at Rockford since that time, holding the academic rank of clinical assistant professor of medicine. Dr. Vacari has served as chair of the ASGE practice operations committee and currently chairs the ASGE Advanced Practice Provider Task Force and serves as a counselor of the ASGE governing board and director on the board of the GI Quality Improvement Consortium. A further note, he is section editor for Advanced Practice Providers for ASGE's newest journal, IGIE. Take it away, Joe. So I want to thank John and Jill for inviting me to this course. This course is just part of a larger platform of educational offerings we have, and you will hear a great deal about these offerings over the next two days. Our goal is just to create high-quality content for all of you so we can make you the best possible providers delivering high-quality care. With that, I will jump into my presentation. I have no disclosures, and we will start off with a couple of questions. The first question, high-quality documentation in the patient record is important for all of the reasons below except A, good patient care, B, protection against patient complaints, C, mitigating medical legal liability, D, communication with referring providers, and E, opportunity to educate referring providers. A good assessment and plan and a documented note allow which of the following? Highlight most likely diagnosis, suggest reasonable differential diagnosis, outline immediate next steps for evaluation and management, and includes recommendations for follow-up. E all of the above. I made these very simple and straightforward so we can then jump into the real important parts of the talk. All right, with that said, our objectives today are to review the key components of a high quality note, outline key information to include in a GI note, and both from the inpatient and outpatient perspective, and to offer tips and strategies to increase efficiency and reduce note burnout, and just talk a little bit about what may be coming down the road as it relates to artificial intelligence in our clinical notes. A big picture view of the importance of a quality consultation. It allows us to begin to tell a story, and that's really what we're doing. We're telling the patient's story so that we can solve a problem or solve their problem. So it's an accurate and timely record of a patient's care. It allows us to give good communication between us, the GI provider, and the referring provider, but also other parts of the team, the PCP, and in some instances, ancillary services that may look at our notes. It justifies the medical necessity of services rendered. It demonstrates the standard of care was met, and that helps us mitigate against some risk, and it supports the build level of service. And today's talk will really be focusing on the clinical aspect of a high quality note, and Jill will talk later on about reimbursement. You're all familiar with the components of a consultation. I'm going to really focus most of my time on what I think are the two most important pieces, and that is the chief complaint in the history of present illness, and then on the assessment and plan. I'll have a few comments on the other sections. Very simply, the chief complaint is the reason for a consultation that patients own words. I don't think we want to make this too complicated. Here's a nice, simple example of, I'm passing blood mixed with stool for three days. It's a good example. I've had the onset of burning in my chest area for six months, so keep it simple, and let the patient begin to tell the story, and I think that's one tip I would give you as you start to put your note together. Let the patient tell the story. Don't jump in with your questions 10 or 15 seconds into the interview. Let the patient tell their story before you start jumping in with questions. Not only will it allow you to be a good listener, you'll start to build credibility with the patient as a good listener and as an advocate, and that's what they're looking for as part of their healthcare experience, is a patient advocate. The history of present illness, I like to break down into four parts. I like to think about an introduction and purpose. I learned this acronym a long time ago, and I still find it very helpful, called OLD CARDS, and we'll go over that. It's an opportunity to bring in all the information or have a little bit of a mini review of symptoms, and then wrap up the history of present illness with an interval history, and again, I'm gonna say this multiple times. Remember, we're starting to begin to tell a story and a very important story. So as the history of present illness, the intro part, obviously, we need the basics, age, sex, major medical problems, but this is where we have kind of our introductory chapter in the book. So here's a nice, simple example. There's a 72-year-old male with past medical history significant for atrial fibrillation and on chronic anticoagulation and stage three kidney disease who prevents four, and we'll start building that in the next phase of the talk. It helps, as we start to look at this, we already identify a couple of potential hurdles for us. One, we have someone who's chronically ill with cardiac disease, and they're on a medication that may provide some challenges if we're going to perform endoscopy, and we have someone we have to be concerned about, perhaps fluid and electrolyte management. So it begins to start to help us think about questions and in our mind, ask some simple questions. Can I safely scope, for example? Can I scope now, or do we need to better tighten up the patient's management? So we start to tell a story with an introduction. Old cards. I know it looks simple and in some ways silly, but I like acronyms. So as we think about whatever that chief complaint, whatever road that chief complaint leads us down, start to think about onset, location, duration, character, aggravating factors, relieving factors, timing and severity. So a very simple example is GERD. Patient comes in and says, I've had the onset of burning in my chest about three months ago. It typically occurs around meals. It might last five or 10 minutes. It's not very bothersome, maybe mild on a scale of the bothersome factor. Some things that do make it worse include meals, and unfortunately, should we say chocolate? Because we should never have chocolate bother us. It should only make us happy. And I do notice when I take some antacids that I tend to feel better. So just a simple way of always keeping this old cards acronym in mind will help you really delve into their problems and continue building that story. In our particular case, we have an 82-year-old male with a past medical history significant for atrial fibrillation on anticoagulation. We've gathered more information. Now we find out maybe they're a little sicker than we thought. They have a low ejection fraction. They're on some O2 at home, and yes, they have their stage three kidney disease. They gave us their chief complaint. This may be a very nice way of continuing this story. He was in his usual state of health until three days ago, developed mild abdominal cramping. After about 30 minutes, had a bowel movement, and there was bright red blood mixed with the stool, had some cramping, had some more bowel movements a little bit as the time progressed, and then states at the end, has not taken any anti-diarrheal medications and denies any correlation to oral intake. So we continue to build that story. The third piece is it's now an opportunity to bring in kind of a mini-review of symptoms that are pertinent to the chief complaint, and that's the key. What is pertinent to the chief complaint? And another, I think, important point to take away from this is this, as we bring in the review of systems at this point, as we develop our story, it really starts to tell us how sick a patient is. In this case, this patient may be fairly ill given his chronic illnesses. And I think one of the important things all providers, physicians and advanced practice providers need to learn is how to identify a sick patient. That is one of the most important things you can do when you're telling the story to your physician collaborator. One of my nurse practitioners, and Aaron knows we all go by first name, so our nurse, we happen to have nurse practitioners, they usually call me Joe, they might say Aaron, but one of them, when she would come to me and say, Vickery, we have to go see this patient, I knew when she was using my last name, I could tell with her tone of voice and body language that we had a really sick patient. I knew that she knew we had a sick patient. So that's a really important point to learn as we go through our career and as we build our notes. Let's identify who's really sick. Some common things to include for GI, weight loss and other symptoms related to GI, I'm sorry, general things, weight loss, maybe fever, chills. In this case, cardiopulmonary symptoms are important because of his history. And this is where we wrap up bringing in all the other symptoms that could be related to GI disease. And finally, we wrap up the history of present illness with an interval history, bring in all the latest data, any recent CT scans, any recent labs, and any recent evaluation that may be pertinent to the story. I'll quickly move through the next because I wanna spend the most of the rest of the talk on the assessment plan. Past medical history is important so we can understand the chronic illnesses. I think it's also a time to make sure, in addition to the chart check, we make sure we have an accurate list of medications. So understanding the past medical history is a good cross-check with medications we think they should be on. So if this patient came in on aspirin and omeprazole, we would know something was off given his chronic illnesses. And I think an important piece to remember, when you look at the EMR, remember that not everything is always accurate and not everything is always complete. So make sure when you review the EMR, you're cross-checking with records that you have to make sure everything is accurate. And then for any past surgical history is important, looking for incisions and scars that may have some implications for performing endoscopic therapy and perhaps making a procedure a little bit more difficult. Family history is important for us. GI tract malignancies are certainly what we're going to really focus on. So just make sure you get an accurate review of their past medical history. Physical exam, as Jill will talk about later for reimbursement, we obviously have points that we need to hit in our physical exam to justify our level of billing and coding. However, for presentation to your physician collaborates, make it a focused physical exam. This way you can keep moving through your day efficiently and you again tell a good story to the team so that you can make the right decision when looking to perform procedures, especially endoscopic. Always include your labs. I like to look at labs in reverse chronological order. And the medical record is really helpful. Now the EMR, this is a nice example of how you can look very quickly and very nicely at labs in reverse chronological order. So just remember to access all those labs and get a good review of all the labs. Okay, let's focus now on the assessment because I think this is the second most important part of the story. Important part of the story and allows us to complete the story to make sure we get onto the problem solving portion of the evaluation. So this is where I like to briefly restate a history of present illness. So a nice little summary, mostly using the introduction portion of that assessment. Make sure you update in the active issues and complaints here. And then this is your chance to shine. This is all of our chances to shine. We now generate a differential diagnosis based on the story. Two points I wanna make. First, remember the history of present illness, probably 85% of the time, if we listen to the words of the father of internal medicine, William Olsener, who said 85% of the time we can make the diagnosis from the history of present illness alone. So coming into our differential diagnosis, we clearly have good knowledge about what we think is going wrong. But it's your chance to think. That is another important piece of what all providers should do. But since I want you, our APP colleagues, to always shine, to always show that you are delivering high quality care to the patient and to your collaborating physician, think through a differential diagnosis. Think of the possibilities. You don't have to have 10. Most of the time, two to five differential diagnosis really gets us on to what the diagnosis is. So I would say, think, think, think. It builds credibility with patients. And remember, they are viewing you not only as someone who's taking care of them, but as their advocate. So you want to show that you're going to deliver high quality care, and you get a chance to shine with your physician collaborator, who now you're building trust with as you work through patient care. Just a note that's unrelated to the initial consultation, for continuity visits, whether it's in the clinic or in the hospital, just make sure you indicate whether the problem that they've been evaluated for, is it controlled, not controlled, poorly controlled, because it will help you understand what the next steps will be. Another acronym I like to use is vitamin D. Again, it helps me think through a differential diagnosis. So if I think, if I have someone who presents with say right upper quadrant pain, I just quickly run in my mind, could this be vascular? Could this be infectious? Could it be toxic or traumatic? Could it be allergic, metabolic, iatrogenic? Could it be a malignancy or could it be drug related? More than anything, this acronym makes me think. We can't be right all the time. And when, if you put, if you think through clearly a differential diagnosis, you're going to be right 99 plus percent of the time. And it's okay to have in your differential diagnosis, things that are wrong. That's how we learn. And that's how we learn to become better thinkers. This may be some typical language you might see in differential diagnosis. Another point, I think it's important. This is a way that I like to do a consultation, but you may have a different style and a different format. As long as you tell the story accurately and solve the problem accurately, it doesn't matter whether you're a lumper and like a paragraph, or whether you're someone who likes to have a list and likes to list things out. As long as it's clearly elucidated and tells the story, that's all that matters. Okay, so as we start to wrap up our assessment and plan, a 72 year old white male, we know the past medical history and their problems. We've gone over the recent labs that shows an acute anemia that's symptomatic. Last had a colonoscopy in 2014, that was normal. Hemorrhoidal bleeding, infectious diarrhea, potential diagnosis. However, based on his presentation, age and chronic anticoagulation, consider malignancy, ischemic colitis, and less likely IBD. So there we are. About five different thoughts. Any of these could certainly be in play here, but think, think, think. Our plan is where we outline the steps that we would like to proceed with in our evaluation. I'm not gonna go over every detail, but you can just look through, you're all familiar with how to develop your plan. But again, what I like about both this assessment and plan, the story is told, we've thought out what the potential problem is, and now we have a nice efficient list of what's going to happen next. If the patient has multiple complaints, it's usually helpful to separate by problem for clarity. I think if you lump everything together in a couple paragraphs, when someone has multiple complaints, that can get very confusing, can be very difficult to read. Again, you want to show that you're delivering high quality care, that you're a smart person, and that you understand the patient's problem. So make it clear to everyone who's reading your note that this 56-year-old male in this case has hypertension and has GERD that's well-controlled on a PPI. Couple little remarks, constipation, again, a few remarks. So separating out definitely helps for clarity and tells a efficient story. All right, some strategies to increase efficiency in our note writing. I think we would all agree that although the EMR is very helpful in many ways, it certainly can be overwhelming in some ways because we have so much information at us and trying to synthesize all this information can be time-consuming. You know, the last thing we want, and we'll talk about this more when we talk about the work-life satisfaction topic, we don't want people taking their work home. We don't want your workday, which may be eight or 10 hours, all of a sudden, because you take work home or you're coming in early, get increased by a half hour or an hour. That's not productive for you or anyone that is in the practice. So make sure you learn everything you can about your EMR. Take full advantage of smart phrases or the equivalent of smart phrases that can be built in. If the group can build their own templates that they can share, obviously everyone can then individualize it after that, but having a basic template to build on can really make yourself much more efficient. A voice recognition, we happen to use Dragon medical version. It's very, very helpful. And so learn everything you can about EMR. Remember, if you do copy and paste, be very careful to make sure you review anything you copy and paste from previous visits. Otherwise that can really make the note confusing and obviously be inefficient and ineffective. So learn everything you can about your EMR. And any other features that are available, setting favorite settings. Again, I mentioned voice recognition or anything else the IT team can help you to build within your EMR and for you personally becomes very helpful. And anything we can to reduce documentation volume, emphasize quality and accuracy is much better. So always make sure we're documenting better, documenting accurately to have that high quality note. Artificial intelligence, and I'll end with a slide on artificial intelligence. I think this is going to really be a game changer and really revolutionize how we gather information, how we create our notes and how we finalize our notes. At DDW last year, there was an absolutely amazing session on artificial intelligence in GI. And the part on generating notes was fantastic. There was a healthcare team from Google. And the interesting thing was there were no physicians on this team. And the amount of medical knowledge, specifically GI knowledge to have was incredible. And so they walked us through how this will, how they see this unfolding. And essentially long before you actually start interacting with the patient, the patient's already going to be interacting with AI through bots and communicating and basically downloading or recording their history onto this artificial intelligence system. Your staff will help clean it up a little bit. And then you, at the end, will have some input to the note, clean up the note. And over time, artificial intelligence is going to learn how you write a note for Melana, how you write a note for GERD. And it's incredible that they built this note in front of us, and it took less than one second for the note to be generated. I think it was, whatever the time was below one second, they were disappointed because it was a little slow and thought it might be the connection they had. So it's going to happen incredibly fast. The note, when it's done, including coding and billing, you will generate very quickly. And so what's going to happen over time as this data is entered ahead of time with the patients interacted with the bots through artificial intelligence and other aspects of how information will be entered, this is going to save you a lot of time and allow you more time with the patient. It's going to make us more efficient and I think make us more productive and perhaps, hopefully, more happy with our interaction with EMIs, which sometimes can be frustrating. So very interesting stuff to come. This stuff is developed at warp speed. I'm sure some of the larger institutions are already using this, but I think this is going to unfold in the next few years. And I think it's going to be a big asset for us in generating our notes. Just a reminder slide. I took this from one of Jill's talk, this is about reimbursement, but I want us to think about this in the realm of quality. We get a request from a referring physician, we see the patient, we develop a story, develop our plan for the patient. We then send that report out to all of the referring physicians and ancillary services, and then our procedures are performed. It's just one big circle of information passing the process of your evaluation around. And I think the most important part of the slide, there'll be many eyes on the notes we generate. You're all in this room have achieved high academic success. You're smart, and it's really our chance to shine and show our patients and our referring physicians that we are delivering high quality GI care. In summary, as I said, it's our chance to tell a patient's story and tell it accurately, efficiently, and effectively. It doesn't matter the style you use, just make sure it's effective and clear. I want you to think every time you see patients, I want you to think about those acronyms, the acronyms of old cards and vitamin D. Think, think, think, that should be our motto. That's what helped us generate good differential diagnosis, make the right diagnosis, and most importantly, take care of our patients. It's important to complete our notes timely so that that information is passed to the referring physicians and other members of the healthcare team. It helps establish good relationships with our referring providers, and certainly high quality notes have quite a bit of medical legal risk mitigation, and Jill will talk to us more about reimbursement. Risk management, this is really a huge piece for us in risk management. I don't wanna overemphasize that because quality always comes first, the patient always comes first, but it is good to have risk management built in high quality notes, and the evolution of AI over the next couple of years, I think is going to be incredibly interesting and incredibly fascinating, so we'll look out for that. Thank you very much for allowing me to spend some time with you this morning, and I'll be back a few more times today.

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