Practical ideas on how to streamline assessments and report writing

Fostering Efficiency and Flexibility in

Your Psychology Practice

... or ... How to caffeinate your workflow without getting the shakes

Michael Decaire, M.A., C.Psych.Assoc.

Credentials/Background

Member of the College of Psychologists of Ontario

Practice in Clinical Psychology (Child; Adolescent; Adult)

Specializing in psycho-diagnostics: learning/attention disorders; full spectrum AXIS-I/II disorders

Private Practice (Hamilton/Toronto) & Hospital (Lindsay/Virtual)

Former clinical consultant with PsychCorp Canada

Michael Decaire, M.A., C.Psych.Assoc.

Disclosures

Business: FLEX Psychometrics

Special Interest Group Work: Ontario Association of Psychological Associates (President); Coalition of Regulated Health Professional Associations (Board Member); College of Psychologists of Ontario (Task Force Work)

Honoraria: Purdue Pharma

Workflow Analysis

A different world. Several years in the test development and publishing world provided a unique environment of workflow efficiencies and quality control mechanisms.

Big Surprise. The psychometric experts spent a lot of time measuring themselves.

Overwhelming? 1000+ clients; 100+ client contacts a day; 80%+ of the month out of the office/town.

Self-evaluation, focused strategies, and support mechanisms kept it together.

Returning to the real world...

I returned full-time to the clinical world in search of a more balanced and less pressured work life.

Reality. Leaving the business world also meant leaving structures that I had in place to manage information and to get things done - well.

Overwhelmed! My first year back saw no vacation, many evenings of scoring and report writing, and literally dozens of 7 day work weeks.

Workflow Analysis

The reality of the situation was that I had lost all my structure and was working from A to Z in one not so fluid step.

I needed to realize that I was still in the business world. All that had changed was what business I was in.

Turns out I was well prepared to reverse this trend by combing big-business principles and psychology strategies.

Self-Evaluation

What am I being asked to do?

What steps are there to reach this goal?

Am I combining more than one step at a time?

How much time is each step taking me?

Am I the best person to be doing this step?

Where am I feeling overwhelmed?

Before the solution - the results..

Year Two

33% increase in clients

500% decrease in evening/weekend work

Took a vacation

Year Four

90% increase in clients

Evenings and weekends down to a handful

6 weeks off for vacations and conferences

Year Five (so far)

Maintaining same client load

Two weekends worked so far

Down to four days a week

Away 4 weeks so far ...

Examining The Process: A to Z

Let’s walk through my current workflow.

Remember that this has been the culmination of a four year process of self-assessment, development, and a bit of trial-and-error

Trying to adjust all of this at once would have undoubtedly failed.

Everyone’s workflows (and brains) are different so some of this may not fit with you, your client base, or your environment.

Is there one thing here that could make a change for you tomorrow?

Assessment Workflow

Intake and booking the client

Planning the assessment

The assessment

Scoring

Interpretation

Report Writing

Feedback

Booking & Client Management

If you start off disorganized you are not likely to become increasingly streamlined or focused as you move through the assessment process.

The reality is that many of us don’t integrate the administrative and clinical aspects of our work in a way that promotes fluid and flexible movement towards are end goals.

We spend a lot of time with logistical busy work, when we should be spending time being clinicians (and office managers).

We asked ourselves if there was a better way?

The New Way... CRM

Amongst my partners we literally evaluated dozens of cloud (online) and locally based CRM’s before I settled on CapsuleCRM (www.capsulecrm.com) for my client management.

It is an entirely mobile solution that allows me to manage a client’s entire file from any computer, tablet, or smartphone.

It integrates with other free or for-fee solutions that allow me to expand my business.

Cloud SolutionCurrent Cost:

$36/month (3 users)

http://www.capsulecrm.com/

The New Way... CRM

I initially explored this option because I was having difficulty keeping up with a lot of the small logistical aspects of my practice:

Documenting all points of contact

Keeping track of to-do’s that were not in my normal workflow

Keeping track of my team when either of us are off-site

In the end, a good CRM solution solved all of these problems and added structure to all aspects of my practice.

Keeping Track: Contact/Intake

A phone call, email, or web-inquiry comes in regarding a potential client

This is added as an “opportunity” in order to not fill our client files with people we’ve never seen

We can assign a step-wise “track” (workflow) at this point (e.g., therapy; psychoed; gifted)

Assign to a specific staff

Keeping Track: Workflow

Client either books during the initial call, calls back later, or does not book.

If they go ahead with the booking, they are converted at the press of a button to an active client.

Those who do not book are left as opportunities (just non-active ones)

These are not deleted because we can use the opportunity vs. converted data to plot our intake conversion rates

Keeping Track: Booking

Now that they are a client we go ahead with collection of additional information.

The actual client becomes an “organization” (main client) which is then tagged with supplementary “people” (e.g., parents).

This keeps the system cleaner regarding who is the actual client.

Keeping Track: Workflow

Once they become a client the “workflow”-track tag initiates a series of to-do and appointment items that will be completed as part of the assessment.

Each individual team member is alerted to their new tasks

Anyone can view the progress of the case and what the next step is

We can make sure that we’ve always dotted the i’s and crossed the t’s.

Keeping track: Points of Contact

From either a computer, tablet, or smartphone I can click on the email address to open my email client and send an email that will automatically be attached to the client file.

I can forward replies back to the CRM with a push of a button and they also get attached.

On my phone I can click on the phone number to initiate a phone call.

Keeping track: Notes and files

All of the teams session notes are organized in one place, by date, and identifying who made the entry.

Paper based notes, consent forms, releases, and other small paperwork are taken as a photo. This can be attached as a JPG or as a PDF (e.g., JotNot app).

Reports attached as PDF’s and/or editable formats.

Rest of file scanned (Fujitsu), backed up, and into shredder.

Productivity boost: Dictate notes from your computer or smartphone.

Keeping Track: Calendar

You can view any or all team members calendars in either a traditional format or as a task list.

This can be exported securely to a diverse range of calendar applications (e.g., iCal; Outlook; Google Calendar)

The task list workflow allows you to see the clients progress regardless of the team member involved and to quickly assess what step is next.

To-do’s can be sent as a daily email.

All of this is integrated in a single “client file” page

When away ...

The majority of this is also available on my smartphone:

Contact information

Notes and email history

Tasks and calendar entries

Assign new tasks with full delegation features

Available on and offline

Keeping Track: BillingCRM’s generally don’t have billing and invoicing integrated in directly

Local (non-cloud) CRM’s generally pair well with other local invoicing solutions (e.g., QuickBooks)

Cloud CRM’s often allow you to integrate your workflow with cloud invoicing solutions (e.g., Freshbooks)

Keeping Track: Expanding

CloudCRM’s generally include a number of additional integration opportunities that may expand or streamline your practice:

Estimates and time-tracking

Invoicing and accounting

Mailing lists / Newsletters

Website contact forms

Surveys for collecting client information

Email automation

CRM: Summary

Organizing your client information and workflow from the very start will allow you to stop spending mental and physical resources keeping track of logistics and instead focus on what you do best.

Onsite hardware/software combinations (e.g., Microsoft Dynamics CRM; Daylite CRM):

Powerful tools that can usually be adapted to your specific work environment

Hefty set up costs and will usually require initial consultant support

May lock you in to specific technology

Cloud based CRM software (e.g., CapsuleCRM; Salesforce)

Powerful if they can fit your workflow

Mobile access and cross-technology compatible

Less risk of theft

Assessment

While assessment (and treatment) is the first time we can flex our psychology muscle in an assessment, there is still a marked difference in how smoothly this process can go.

Many small and easy to implement steps can focus your work and provide information that easily integrates into your report writing workflow.

How can we see the forest though the trees?

Assessment

I looked at how we could streamline, focus, and improve each major step:

Assessment Planning

Client-Parent interviews

Structured Observations

Diagnostic Verifications

Digital Administration

Keeping Organized

Similar to most of you, I keep a list of potential tests that I can use as a checklist of “to-do” and “completed” items for myself and my psychometric team.

I generally label this by the session number, whether something is a wish-list, and whether something is to be done through a prescriptive approach (e.g., if this - then that)

With a few exceptions, each area is broken down in a manner similar to how the report will be divided.

Parent Interview

Parent interviews are developed to match the manner in which I report on these in my background:

Birth, Developmental, and Medical History

Behavioural, Social, and Emotional Development

Academic History

Assessment and Treatment History

Observation Sheets

My goal was to be able to write reports off-site with literally no paper on hand.

A missing element was when I came across outlier data that I could not easily explain during my interpretation and report writing without referring back to notes within the original record form.

Borrowing a great idea (now abandoned) from the WIAT-II record form, I created a series of “observation” checklist sheets to be used by my psychometrists and myself during each assessment.

Currently we are using this on paper and scanning to PDF - but we will all be moving to an iPad/iPen (an alternative stylus from Cregle) shortly.

Observation Sheets

Diagnostic Interviews

Much of my graduate research and my early clinical career was in forensics

That environment demanded that diagnostic decisions be made on the basis of quantifiable criteria and not just statistical elevations on surveys and general perception that a person has a disorder or not

While I left forensics behind, this approach always stuck with me and seems to have inadvertently led to a great deal of referrals from physicians and psychiatrists in my area (which at first surprised me outside of LD cases)


I spent a lot of time speaking to these referrals (and I continue to do this) to determine what exactly they wanted from psychology, given that they are just as capable of making most of these diagnoses

Looking for a fine tuned assessment that will sort out diagnoses in logistically complex cases (e.g., comorbidity vs. differential diagnosis)

Want a step-wise evidence based approach to diagnosis that they can stand behind for the purpose of disability applications and program referral


Providing a criteria driven approach to diagnosis used to mean that I had to lug around the DSM

I did use the SCID, which I continue to use in many cases, but several disorders were almost entirely ignored (e.g., GAD).

DSM-IV on iPad/iPhone was a logistical nightmare

My DIY Solution: PDF’s of diagnostic criteria stored on my iPad (can be filled out right on the device with a stylus or Cregle iPen)

Digital Expansion

The DSM project made me think about how I can digitize other aspects of my assessment process:

How can I have more of my toolkit on-hand when I need them

How can I do this without breaking the assessment flow

Where do I risk compromising standardized administration procedures

What can I do that does not violate copyright/fair-use laws in my region

Digital Expansion

A long history of damaged audio CD’s and now useless cassettes meant my first step was to make electronic copies of my audio-stimuli for tests like CTOPP, TEA-Ch/TEA, & SCAN-A/C-SCAN

These can be managed through an MP3 player or computer or across all platforms through cloud services like Dropbox

Now no matter where I am (or what I forgot) I have easy access to my audio stimuli

Digital Expansion

Digitizing visual stimuli like figure drawing and projective activities has been tempting, but do bring up potential standardization concerns (e.g., Can the sizing be done correctly? Does the medium impact attention?).

The test publishers have increasingly promised computer and tablet based products so the future may be increasingly expansive in this regard

While there may be little else that can be done from a stimuli perspective (I’m open to ideas!), these devices can also be used to record oral responses or to take photos of non-permanent stimuli (e.g., the dry-erase activities on the Test of Everyday Attention; Behavioural Assessment of Dysexecutive Syndrome).

Scoring and Interpretation

Scoring

Everyone’s favourite activity!

Some of us may have convinced ourselves that the time lost during scoring is an opportunity to be immersed in the data.

Would we encourage educational clients to study by simply note-taking?

Reality is we should get through scoring as quickly as possible and focus on interpretation distinctly.

Hand Scoring

A test like the CTOPP can take longer to score by hand than a WISC-IV when using the scoring assistant.

A test like the Beery VMI can take longer to score than it takes to administer.

Unfortunately, the inordinate cost of building scoring software means that software solutions are unlikely to emerge for many of the tools we use on a day to day basis.

Hand Scoring

While I have not found a way to resolve this issue, one of my partners came up with an idea to streamline the hand-scoring process.

We photocopied the scoring and norms pages for all manual based tests.

These were filed into a scoring binder that also included any templates (e.g., symbol search) and other scoring tools (e.g., ruler and protractor).

This meant less trips, flipping through books, and missing manuals.

Then I timed it - old way: 40 minutes; new way: 30 minutes

Hand Scoring

That wasn’t good enough for me, so I decided to go digital

Revisited Dropbox

Placed all my norm pages in one folder, synced across my work and home computers, my iPad/Android tablets, and my smartphone

This means I can look up scoring data anywhere and at anytime.

No more return trips to the office!

Computer Based Scoring

Scoring assistants can be a huge time saver when they are available.

Surprisingly, these have been quite difficult to sell in the past

Technophobia

The “interpret as I score” argument

Complaints regarding cost


Much of this software is also locked into one ecosystem (e.g., windows PC)

You have to be on-site or use a laptop that can’t be easily shared amongst off-site staff.

Some companies have moved towards online scoring options, but these can bring browser limitations (no tablets) and may have a cost per use despite having all-you-can-score solutions available for on-site use


While I’m a long time user of scoring software and have seen substantial gains in my workflow and what scores are available to me as a result

I’m not willing to have multiple copies of the same program just so I can score off-site once and a while

I’m not willing to pay a per-use fee for something I already own unlimited access rights to.

Came up with my own do it yourself cloud scoring solution

DIY Cloud Scoring System

Ingredients:

A low end windows computer ($300)

Local backup hard drive ($50)

Secure online backup service (free)

A LogMeIn account (free)

LogMeIn Tablet/Smartphone apps (free)


This allows you to login whenever you want and wherever you are. I can login with my iPad/ Mac/ Pc or in a pinch my iPhone and control my scoring assistants back at the office


The system has worked amazingly well for us and we’ve now implemented “Cloud” scoring computers across each of my practices.

I’ve scored from different offices, coffee shops, a pub, bed, my car, and even in the Caribbean.

The downsides are minor but include the inability to have multiple users on the software at the same time and the inability to print at your location without the pro version of LogMeIn.

Printing limitations were easily resolved by adding a “pdf printer” that saves the files to a dropbox folder that then auto-syncs with each of our personal devices.

Interpretation

Interpretation

I used to sit there with all the data around me and try to formulate the ins-and-outs of a clients clinical profile.

Information overload. This used to work when first preceptorship advocated for WISC and WRAT.

Those days are over. Now I have such a diverse test list that I was forced to use a smaller font for my title page.

In keeping with my previous format-for-the-report approach to parent interviews and assessment design, I created interpretation sheets that follow my assessment plan and tie directly into my reporting workflow

Report Writing

The Forbidden Word: Templates

Templating certainly has become a negative word and is usually thought to mean poorly written reports.

It did not help that a significant number of end-users started using software driven interpretive writers back in the mid to late 90’s.

We’ve all seen bad templated reports that convey data and definitions but don’t tell you a story

Templates fail if they are used in place of clinical judgement (report writers), a focused description of the current client beyond the scores, and are inflexible to different referral concerns.

The Forbidden Word: Templates

At the same time why would you spend time:

Redefining working memory for the hundredth time

Formatting sections, fonts, and headers

There is many cases where we do not need to reinvent the wheel and we can spent our report writing time on areas of clinical importance.

Step One: Templates

My Templates

Formatting

Logistical introductions (e.g., what percentiles are)

Find-and-Replace key words

Domain definitions and introductions

This lets me to focus on the clients clinical profile

Step One: Templates

Step Two: Text Expansion

Even things that change from one client to the next don’t need to be reinvented once you have worded it well.

How many different ways can you say a developmental history was normal?

Text expansion software (e.g., Text Expander for Mac; Breevy for Windows)

It can turn a phrase like “..‘s health unremark” and turn it into “Jon’s medical history remained unremarkable, with no significant history of hospitalization, surgery, medication use, concussion, fracture, or hearing/vision loss.”

Text Expansion: without - 3 minutes

with - 78 seconds (including a mess up)

QuickTime™ and aH.264 decompressor

are needed to see this picture.

Time can be saved everywhere

QuickTime™ and aH.264 decompressor

are needed to see this picture.


The trick with text completion is to introduce only a few short cuts at a time (or you won’t remember them).

I started with having “..” auto insert the clients name and “pp” to insert the word percentile.

“..” saved me from typing a clients name on average 142 times in my first ten reports.

Taken the average length of the name from those clients it saved me 1988 keystrokes.

For Ms. Smithinovski (not her real name but similar in length, syllables, and my inability to spell it) this saved me between 12 to 20 minutes!


This has became such second nature that I am actually unable to type percentile in full without applying conscious effort to do so.

I next moved to expanding composites and subtest names (e.g., VCI turns into Verbal Comprehension Index; “ SS,” turns into “ Symbol Search,”

Next full blurbs: “health unremark” to “medical history remained unremarkable, with no significant history of hospitalization, surgery, medication use, concussion, fracture, or hearing/vision loss.”

In total I’m seeing on Average at least an hour time savings as a result. Over a month of report writing this single and cheap (<$30) “tweak” has provided me a day off a month.

The Future of Reporting

Imagine a parent interview that auto generates the background history, but prompts you for input in areas that were atypical

Imagine a quick prompt screen that auto generated all of your test data into tables

Imagine an adaptive recommendation list builder that creates research driven recommendations based on your specific clients profile

What is the clients gender?

What is the clients grade range?

What is the nature of the clients disability?

What areas needs specific supports?

Is the client in a private school setting?

What do referrers think?

I’ve maintained a survey-group of parents, physicians, teachers, special educators, peers, and allied health professionals that I run each significant change by.

They’ve universally agreed that these reports are clearer, cleaner, and better meeting the needs of a diverse support network.

Not every change we’ve tried has led to improvements. You’re just not hearing about those ones!

Feedback

This has been the biggest struggle to streamline

Primarily because of diversity of diagnoses and varied client/parent needs, knowledge, and comprehension levels.

Tried having a checklist of measure domains to anchor but held things up even longer

Lately simply asking what level of detail/coverage they want helps

Next step is to produce Dx specific information sheets

Questions?

I’ve just used up two hours of your time ... I assure you there is information in here that will make you gain that time back 10 fold.

Presentation available online at: www.flexpsychometrics.ca

Email: [email protected]

Practical ideas on how to streamline assessments and report writing

Health & Medicine

Transcript of Practical ideas on how to streamline assessments and report writing