Download MBSImP ™© Web-Based Interface for Patient Management and

MBSImP ™© Web-Based Interface for Patient Management and Reporting
User Guide
The designation of “Registered MBSImP Clinician” is earned upon successful completion of
the Reliability Zone. With this comes immediate access to the MBSImP interface for patient
management and report generation.
Designed by speech pathologists for speech pathologists, this extension of the MBSImP is
meant to be clinically useful and practical. It allows the Registered Clinician to efficiently
enter patient medical histories, MBSImP study scores, patient management data, and other
related information in a HIPAA compliant manner. Once entered, the clinician can quickly
produce clinical documentation of each MBSImP study, track the status of patients over time,
evaluate the success of patient management and treatment strategies, and optimize patient
care through practices consistent with evidence-based medicine. What may not be apparent,
however, is that this extension of the MBSImP is in effect a data registry dedicated to
swallowing disorders. Each clinician who enters information will be contributing to a pool of
knowledge that is dynamically expanding and has the potential to answer a myriad of
questions that will advance the understanding and treatment of swallowing impairment.
With this knowledge will hopefully come improvement in the health status and quality of life for
many, many people.
Patient History Entry
The entry fields are for the most part self-explanatory. There are some things that should be
pointed out, which is the purpose of this guide.
Before entering an MBSImP study, a patient must be added and the medical history entered.
At first glance, the number of entry fields that follow can appear daunting, and initially, input
may seem less efficient than desired. Once familiar with the system, however, the average
time to enter patient history and study/treatment information and produce the documentation
is ten minutes, which is significantly less than other means of reporting.
PtMgmtRepGuide 050911
1
The patient's name will never be entered. Instead, each patient is assigned a random
identifier that is a combination of letters and numbers, and it will be up to each clinician to
decide the best means of associating the actual identity of a patient with the identifier
assigned by the system. Also, only the year of birth is entered into the database. The only
exception to this is if the year of birth is 90 years or more from the current year, any attempt to
enter the year will cause the system to record instead “ 90 or older.” This was implemented,
of course, to assure HIPAA compliance across a large group of users.
The entry of dates is done through one method in the patient history screen, and another in
the MBSImP study screen. In the patient history screen, the year must be selected first,
which then populates the selection fields for the month and day. This allows the system to
accept only the year or the month & year, rather than requiring a complete date, which is
useful in accommodating a reported history that lacks specificity.
For the MBSImP study screen, in which the clinician controls the specificity, a calendar
format is used, and only a complete date is accepted.
Diseases and conditions are classified according to systems of the body, for example,
Circulatory System Disorders, Digestive System Disorders, Nervous System Disorders,
Respiratory System Disorders, and so on. Once selected, each disorder must be further
PtMgmtRepGuide 050911
2
classified according to Current-Primary Dx, Comorbidities, Morbidities, or Past Medical Hx.
(Of Note: the terms “comorbidity” and “morbidity” are variably defined, depending on the
source and the intended use. For purposes here, “comorbidity” refers to a condition other
than the primary diagnosis that significantly affects the patient's medical status, complicates
the care, and existed prior to admission. “Morbidity” represents the same, medically, but only
became present during the current hospitalization, developing, perhaps, as a result of
surgery, a procedure, or an infection.)
In this abbreviated example of the layout of the disorders and category columns, notice
that most have an associated ICD-9 diagnosis code, but some do not. Those without are
related to either a specific category of Cancer or to Cerebrovascular accident (CVA) and
when selected trigger secondary screens for the input of more specific information and detail.
The categories of cancer are Head and Neck, Thyroid, Esophageal, Lung/Mediastinal, and
Brain; the sub-screen for CVA discriminates hemorrhagic from non-hemorrhagic.
PtMgmtRepGuide 050911
3
The Cancer sub-screen includes the input fields for all of the previously named categories,
and is divided into sections that correspond with each. Simply scroll and select the
appropriate section. The Cancer can then be further defined according to classification/stage,
pathology, and other characteristics.
PtMgmtRepGuide 050911
4
Details of surgery, radiation therapy, and chemotherapy can be entered, as applicable.
Similarly, the CVA sub-screen contains categorized input fields to more specifically describe
the stroke according to hemisphere, site(s) of lesion, and associated treatment(s), if any.
A disorder that has recurrent episodes can be represented by marking the appropriate
category, which provides a separate sub-screen for each episode. For example, the specifics
of a current diagnosis of Head and Neck Cancer can be described separately from an earlier
diagnosis by selecting “Head and Neck Cancer” and indicating “Current Primary Dx” as well
as “Past Med Hx.”
No doubt there are conditions and disorders that have not been included in the diagnoses
provided. To accommodate this, at the end of this listed diagnoses, there are five areas to
enter and categorize “Other” conditions. These will be monitored and the most frequently
cited will be added on a quarterly basis.
PtMgmtRepGuide 050911
5
After input of this base medical history, sections follow for present and past Surgical History,
present and past Medical (non-surgical) Treatments, Medications (prescribed and over-thecounter), Vitamins/Supplements, Alternative Therapies, Allergies, and Social History.
(Of Note: any surgery or treatment information that was entered via either the Cancer or CVA
sub-screen should NOT be re-entered in a similar area that follows. The information is
already captured.)
The final step, SAVE the data!
MBSImP Study Entry
Once saved, the study input screen can be accessed from this medical history screen (at the
bottom or the top).”
PtMgmtRepGuide 050911
6
or by returning to the home screen, selecting “Patient Data & Reports,” and then the specific
patient just created.
Again, the MBSImP study entry fields are for the most part self-explanatory. There are just a
few things to point out.
In pilot testing, several clinicians questioned what was meant by “Time-out Time,” which is
near the beginning of the study screen. The Joint Commission mandated that procedures
performed by more than one person, invasive or not, should pause just prior to initiating the
procedure and ensure that the correct patient is about to undergo the correct procedure and
that the correct materials for performing that procedure are ready and available, then record
the time.....and this is what is meant by “Time-out Time.”
Along the same lines, areas for “Pain Assessment,” “Special Needs,” and “Barriers to
Learning” have been included. Once selected, an area for free text input appears, if needed.
Very few areas ask for either a “yes” or “no.” The general rule is that selection of a statement
is in effect a “yes” and not selecting a statement is a “no” or indicates a non-applicable status.
PtMgmtRepGuide 050911
7
Often, the ability to enter greater detail is nested within the first statement. For example,
when “Tracheostomy Tube Present” is selected, the additional selections populate.
PtMgmtRepGuide 050911
8
Entry of MBSImP Overall Impression scores for each component is relatively straight forward.
The description of each score, however, is not included, only the numeric choice, so always
have a copy of the Component-Scores Definitions list, if needed. There are a few things that
when selected cue the system to include additional information in the clinical report.
Each component has an alternate, non-numeric selection, which for all but one component is
“Could not test.” When selected, it signifies that for some reason other than physiologic
impairment, a component could not be adequately assessed. Some examples of this might
be poor fluoroscopic image capture or the patient who is always moving. It will most likely
occur on components 1, 13, 14, and 17, but could potentially affect others. Notice that for
component 3, Bolus Preparation, the term is changed from “Could not Test” to “Solid not
Given.” This is the only component whose overall impression score depends on one
consistency being administered.....the cookie. There are two reasons that the solid would not
be given.
The first is that physiologic Impairment in other oral domain components was observed during
the study when given liquid and semi-solid boluses, and the impression developed that giving
a solid would not be successful and could potentially harm the patient. When this is the case,
score 3 and “Solid not Given” should be selected. The report will then state that no solid was
given, and that the decision to eliminate this bolus is linked to oral impairment.
The second is that over the course of the study, the impairment seen in other non-oral domain
components indicated that it is in the patient's best interest to avoid giving the solid, but that
this decision is not necessarily related to physiologic impairment in the ability to prepare and
manipulate a solid bolus. In this situation, only “Solid not Given” should be selected. The
report will then explain the absence of a solid bolus and the inability to score the component
in a manner consistent with the circumstances.
As a reminder, component 13, “Pharyngeal Contraction,” can only be scored in the anteriorposterior (AP) viewing plane. If for some reason this cannot be achieved, then no score is
given and “Could not Test” is selected. Component 17, “Esophageal Clearance in the Upright
Position” can be scored in the lateral view if the esophagus is adequately visualized, but AP is
PtMgmtRepGuide 050911
9
always the preferred plane. If neither position provides adequate imaging, or another nonphysiologic reason exists, no score will be given and “Could not Test” must be selected.
Following the section for score entry, the Penetration – Aspiration (PA) scale can be used, if
desired. Upon choosing one of the eight descriptions, the consistencies become available for
selection, as needed.
Typically, for a given consistency, only the descriptor that represents the greatest level of
airway invasion and consequent reaction is selected. It is not necessary that each of the
eight levels be addressed. It will do no harm to do so, however.
PtMgmtRepGuide 050911
10
For the report to provide insight into the functional significance of the physiologic impairment,
the section following the PA Scale asks for the evaluation of up to five components that
significantly affected swallowing ability.
Upon selecting a component, the available choices emerge. Select all that apply.
PtMgmtRepGuide 050911
11
If any physical abnormalities were noted, such as osteophytes on the cervical spine or
perhaps suspicious fullness in structures, checking “structural abnormality” will provide a list
of things most commonly seen, ending with an field for free text entry of anything not listed.
As is customary, each selection reveals a list of additional descriptor statements that can be
selected, as needed.
Nearing the end of the study input screen, any compensatory strategy that was used during
the study can be evaluated for effectiveness and indicate whether or not it will be included in
therapy and/or a management plan. This applies to strategies that were first used in the
particular study as well as those that have been targeted in therapy and patient care.
PtMgmtRepGuide 050911
12
Similarly, any exercise that has been used in the preceding therapy period can be evaluated
for seeming effectiveness. If therapy is to be initiated or a new exercise is to be introduced,
this can be indicated and included in the report, then available for subsequent evaluation in a
follow-up study after a period of therapy.
Or perhaps
The study input screen ends with areas to indicate that education was provided to the patient
and/or family/caregivers, to recommend referrals, if needed, to other medical specialties or
services, and to indicate if therapy is to be initiated, continued, or discontinued. These are
followed by free-text fields to enter an overall assessment, prognosis for improvement, the
patient's personal goals, and the clinician's short- and long-term goals for the patients care.
Keep in mind, with all free-text fields, the clinical report will reflect the appearance and
manner of what is typed into the fields.
Save the entered data, return to the home screen, select “Patient Data & Reports,” and then
“View Report” for the selected patient.
From the
PtMgmtRepGuide 050911
13
screen that follows, the patient's studies are listed and can be chosen.
Once selected, the report is generated in the browser for viewing, and with the “Print” icon at
the top of the report, it can be sent to a printer, virtually printed as a PDF document, or
downloaded for editing or archiving, providing the ability to enter a file name and specify the
subdirectory into which it will be saved. The format will use the common .doc extension.
That's all there is to it!
In closing, take some time to become familiar with the data fields and the method(s) of input.
Try not to rush through the entry of the first few patients and studies. This initial patience
should lead to more rapid acquisition of skill in efficient entry and in turn, a corresponding
decrease in the time needed for each study.
A fully featured forum system is built into this interface. Please use it for peer support and
discussion, and please provide feedback and suggestions via the Forum Administrator. If
needed, clinical and technical questions can also be addressed to the Forum Administrator.
PtMgmtRepGuide 050911
14