Dr. Robert Oubre

If you're thinking of using Ambient AI scribes, then today's newsletter is for you.

Who are they good for?
Who are they not so good for?
Will I continue using it?

There's still time to subscribe.
Join 5,316+ other subscribers here: robertoubremd.com/newsletter

A lot of people have been asking me about Ambient AI scribes. So, I started using them.

In my newsletter tomorrow, I'm sharing my conclusions.
Will I continue using them?
Are they better for some rather than others?

Join 5,310+ other subscribers and join here:

robertoubremd.com/newsletter

"My job is to walk around and just talk to people" a fellow hospitalist said.

We do more than that, but MUCH of our job is communication:
• Expectation & goal setting
• Team coordination
• Explaining treatment plan
• Delivering bad news

It's the medicine beyond medicine.

With open charts, some feel uncomfortable documenting terms like "morbid" or "severe" obesity.

You can use classes instead:
🔹 Class 1: BMI of 30 to

How to document when patients are reading More than notes, the newsletter about using documentation to provide better care, prevent lawsuits, optimize billing, and save time!

Patients should be out of bed during the day if possible.

Preferably next to the window.

We underestimate the power of the sun and our environment (not being in bed all day) on our sleep-wake cycle.

If you wanted to tweet the same thing everyday for a month to drive home an education point from your specialty, what would it be?

Patient works at a nursing facility.
She gets her insurance through her employer (the nursing facility).
That nursing facility is not in network with her insurance.

Sometimes you just have to laugh at the U.S. Health Insurance System.

Go to order something.

🚨BPA.
Read alert. Click selection.
Type out reasoning.
Click okay.

Forget what I was going to order in the first place.

Ignore alert in future.
Make random selection.
Type in jibberish to make it go away.

=

Alarm fatigue.

Doctors who update their notes consistently have less things that fall through the cracks.

Notes act like one big checklist.

EPIC, is a one-click ability to graph labs too much to ask?

I've come across several bad doctors who ultimately have gotten fired.

The one consistent trait I've witnessed?

Inability to take feedback productively.

(With poor medical knowledge... likely as a result of this trait during training)

I love getting new testimonials! Another happy customer :)

Check it out for yourself with free previews:
https://www.robertoubremd.com/the-practical-guide-to-attending-documentation

The best physicians I know are of sound character, humble, and treat others as they would like to be treated.

They inspire me.

A discharge summary is NOT just a metric to complete.

It's a communication tool to transition from inpatient to outpatient.

Do it right and do it day of discharge.👇

I talked about how to do this efficiently and optimized for your target audience (P*Ps, etc) in a previous newsletter issue:

What is the ideal discharge summary? Forward this one to every provider you know

Think of something positive about someone else?

Don't keep it to yourself!

We need this in healthcare. Give compliments liberally!

Do you still use a pre-populated physical exam template?

If so, it may have unintended consequences.

Prevent them by asking yourself 5 questions:

The problem?

🔶 Auto-populated exams are often used to meet billing criteria (but are no longer needed)
🔶 They are frequently inaccurate
🔶 These inaccuracies may open you up to litigation or result in denial of payment.

So, 5 questions:

Question #1:

"Am I doing this for billing?"

If so, stop👇

But if you're still going to use a template anyway:

Question #2: Do I actually do this on everyone?

Ex: "PERRL"

Are you REALLY checking everyone's pupillary responses?

(I doubt it)

Question 3 also applies to PERRL...

Question #3: Are there consequences if I document this and they DO NOT have it?

Ex: "No focal deficit "

If someone has a presumed change in neuro status, your note may be used to determine baseline.

The consequences of incorrectly documenting this can be substantial.

Also...

"Well nourished."

If you document malnutrition in your A/P

but you've auto-populated "well nourished"

Insurances WILL deny the claim of malnutrition (refuse to pay).

(Same goes for "no respiratory distress" and "acute respiratory failure")

Question #4: Can I do it just by looking at the patient?

This one is about covering yourself legally.

You don't want to document something you didn't do.

What do you do on EVERY person just by observing?

"Not in acute distress" ?

"Abdomen not distended" ?

"No rash" ?

But you can pre-populate whatever you want if you answer "yes" to question #5...

Question #5: Do I have my pre-populated exam 100% memorized?

This is the most important.

Why?

If you KNOW to change it when there's a difference, pre-populate whatever you want.

But most people THINK they do...

But Don't...

I see "alert" pre-populated and "lethargic" or "intubated / sedated" free texted OFTEN.

They forgot what was in their template.

So, have it 100% memorized.

So, 5 questions to ask about your physical exam template:

1️⃣ Am I doing this for billing?
2️⃣ Do I actually do this on everyone?
3️⃣ What are the consequences if I document this, and they DON'T have it?
4️⃣ Can I do it just by looking at the patient?
5️⃣ Do I have it 100% memorized?

We all work in the US Healthcare system...yet few actually understand how it works.

Last week's newsletter on RVU's was so popular, I'm continuing the series of how the US healthcare system works.

This week?

Accountable Care Organizations.

What the heck are they?

This morning, 5,276+ subscribers have a better understanding of how outpatient medicine works for many large health systems.

Read it and subscribe here: https://droubredigest.beehiiv.com/

If you belong to an ACO and not quite sure what that is, then my newsletter tomorrow is for you!

I'll explain why you get bugged about documenting HCC's and what this term "capitation" means.

Don't miss out and subscribe here: https://www.robertoubremd.com/newsletter

My previous newsletter on RVU's was so popular, that I'm continuing the theme of writing on how the US healthcare system works.

My next topic might be medicare advantage.

Any suggestions?

Also...

We're continuing our discounted price (through August 5) for the "CDI and Coding Village" exclusive online community.

Join 45 others here:

https://www.skool.com/cd-integrity-village-6101/about

To advance in career & life, develop a relentless genuine appreciation of others

Let me tell you I'm a dad without telling you I'm a dad:

I called a bedside commode a potty.

Didn't think twice about it...

Until the patient, PT & OT all started laughing

Today's launch day of YOUR community for CDI's and coders.

But why this community? Why now?

It was September 2021...

and after being offered a CDI Physician Advisor position, I searched Twitter to learn from other CDI professionals the way I used “medtwitter” to learn and stay up to date.

But I found no one.
I felt like I was on an island.
This stuff is a big deal. Where was everyone?

LinkedIn was better, but after 3 years of posting content the same recurrent themes kept showing up in my comments, DM’s, and emails:

“I finally feel heard”
“I’m the only one doing this stuff at my hospital and I feel alone.”
“I wish I had found you years ago.”

We need a home.

👉 A place where every new coder goes to learn.
👉 A place where every nurse looking to make a career change to CDI can find encouragement.
👉 A place where every new CDI Physician Advisor, anxious in their new role (like me), can find comfort.

A place...

where mentors thrive.

So today, I’m launching your online community “The CDI and Coding Village.”

We’re offering a special discounted launch price (which you lock in for LIFE) for this enrollment which opens today and closes August 5 at midnight.

Join below:

See you there, my fellow village people!

https://www.skool.com/cd-integrity-village-6101/about

Medicine can be a roller coaster of emotions.

1st Patient: Literally crying bc I'm going off service and asks me to be her P*P.

Next patient: Calls me a liar and curses me out.

🤷‍♂️

We do not read EHR notes top to bottom.
We scan them looking for information pertinent to us.

Make it easy for other people to scan your note.

This is best done with lists.
Even with MDM, this can be done.

MDM reasoning = sentences
Action plan / recommendations = List

Reminded by recent experience: Doctors, don't send messages through nurses to other doctors.

Ever played the "telephone game" as a kid? Messages evolve.

Pick up a phone.

With EPIC secure chat, there is no reason to not communicate directly.

Two failures of anticoagulation I've seen recently:

Xarelto = not being taken with meals.
Eliquis = taking both bills at once rather than twice a day.

Education on proper dosing can't be stressed enough!

Also...

While we're talking about anticoagulants:

It's time to stop using "NOAC" as a simple space can communicate a VERY different meaning:

"NO AC" = No anticoagulation

Over the past 8 years, I’ve admitted >5,000 patients.

I use the same strategy every time to:

• Stay organized
• Be Efficient
• Be complete

Admissions can be overwhelming.

Stop stressing, steal my 4 tips below ⤵️

Do you struggle with:

• Remembering a patient's PMH and problems?
• Worrying you're forgetting orders?
• Admissions taking > 1 hr?

If you already have a system that works for you, stick with it.

If you’re learning, this is what has worked for me for 8 years⤵️

Tip #1 / Write it down

You MUST stay organized.

You need one place to jot notes through the admission while:

• dissecting the chart
• talking to ER doc
• interviewing the patient
• walking to and from patient room
• placing orders
• writing your note

My simple trick?

Pen and paper.

If you try to remember it all?

You WILL forget things.

Keeping notes on computer/phone?

I found several problems with this:

1️⃣ Computer wasn't available in the patient's room or walking to/from.

2️⃣ Logging into a computer in the patient's room was inefficient.

3️⃣ I couldn't format my notes easily in my phone.

4️⃣ Frequent "screen switching" on computer

No matter where I go / EHR I use, my process is the same.

Pen and paper are always with you.

This keeps you organized with all of your info in one place.

Why is this important?

Tip #2 / Keep a list of orders

Ideas for orders come at all times but you may not be in a position to place them at that moment.

So you need a reminder when you ARE placing orders.

That's why tip #1 is so important.

Whether to work-up a differential or "maintenance"...

Ex: When I see "diabetes", I immediately draw a 🔲 and write "SSI" as a note to my future self to order insulin (if needed).

This helps you avoid jumping to and from order placing which
• prevents context switching
• improves efficiency

Tip #3 / Explore the chart for high level info first.

You have limited time, you don't need to explore every small detail.

1️⃣ Read ER note / talk to the ER doctor.

Why did they come?

This will give context and focus for chart history.

Later, you can dig into the details.

2️⃣ Find last H&P / discharge summary and/or P*P note.

This will
• help you capture medical history and
• expose recent issues which may have lead to current presentation

3️⃣ Glance for an echo.

You do not want to discover they have heart failure the hard way.

4️⃣ With PMH as context, scan the medication list for medications you NEED to confirm for admission

AND look for medications which seem absent.

EX: Anticoagulation for Afib, DAPT for CAD, insulin dosing

Tip #4 / Keep a list of PMH and active problems.

Just like orders, keep a running list as you discover them.

(This has important CDI implications...but I won't get into that)

Check this while putting in orders and writing your note.

It becomes a massive check list.

This may sound complex and time consuming, but it saves you time and becomes muscle memory.

Below is an example of a quick template I might make as I'm initially reviewing the chart

In summary, to stay organized, be efficient and complete:

1️⃣ Write things down with pen and paper
2️⃣ Keep a list of orders
3️⃣ Explore the chart for high level info first
4️⃣ Keep a list of PMH and active problems

Asking a patient how to correctly say their last name is a subtle way to show you care about them and the details.

In Louisiana, we got some weird ones! (I would know...)

This happened the DAY after I read about a med mal case that hinged on a provider's addressing of a BPA:

A pop up appeared...

RIGHT where my mouse was and where I was about to click.
I accidentally clicked the button.

P**F.
It went away.

What was it?
Was it important?
What if there was a med mal case and it came back that I addressed that BPA?

I probably wouldn’t even remember this instance.

Heck, even I would probably assume I DID ignore the BPA. I'm writing this now, days later, and I don't remember the patient's name.

How could I years later?
This scares me.

Humans are imperfect.
So is technology.
That's all.

SOAP is dead.

No, I don't mean APSO instead.

I mean pure SOAP for the sake of being a purist.

Let me explain:

Med students and residents come out of training with post-traumatic levels of feeling the need to remain pure to SOAP.

Anyone will who gets stopped in the middle of a presentation with an entire team of people watching:

"Why are you listing labs in the subjective section? Tell me the history..."
etc. etc.

Yes, there's a difference between presentations and notes, but those mentalities often become engrained.

What am I getting at?

Yes, standardized structures exist for a reason.

I'm a BIG proponent of not making me (a reader) going on a wild goose chase to find your plan. But...

I do not shy away from adding, for example, commentary in my physical exam:

"Erythema in bilateral lower extremities. Patient states this is unchanged from baseline"

Or

An ER course (including labs) in my HPI. It's a vital part of telling the story of why I am now involved in that patient.

So, for any new graduates out there: let me free you from the burden of SOAP purity.