Home Forums Discussions Feedback and Recommendations Best way to proofread and EDIT outgoing letters?

We have recently noted what appears to be one glaring deficiency in this otherwise intuitive program: The Insufficient ability to proofread and subsequently correct outgoing letters to referring physicians in AC .

Currently, once a new encounter is completed, and a letter composed , only a few options seem available for proofreading, correcting and sending it: either forward the unsigned chart to another staff member (allowing proofreading) but the chart data is now at extreme risk of being erased by an inadvertent closure, or . . actually signing the chart, locking in the chart contents, but now leaving no option for correction of dictation errors as the chart is signed/locked and although it appears copies of the letter are saved in ?imported items/outgoing letters, they are saved only in HTML form which interfaces poorly with word docs.
How are other people generating letters that later need correction before sending?

Yes, you hit one of the significant issues. Bert has a link to a procedure he worked out to use Word with AC, and something like that is going to be the best bet. Hopefully he will post the link here. The letter writer is a sore spot for many, but the powers that be don't have it high on the "to do" list of fixes.

http://www.box.net/shared/static/av78nn1dlp.zip

Downloaded 58 times. I haven't heard if anyone has used it. Most don't as it is a little complicated to set up. We use it exclusively. Much better than the default. Just a couple more steps and takes a little longer but worth it for us.

I concur with everything that David says, just that it is likely not even on the list. This has been the single most complaint issue for at least seven years. Don't expect it to change anytime soon.

Bert, I'm one of the 58, but the alligator level seems to stay so high with everything else that I just have not sat down and puzzled it out. I seem to remember that my version of Word was a little different from the one you use, and I was a bit stuck with that.

Thanks for the feedback David. The biggest issue with those workarounds is the fact that they don't save automatically to the chart. Kind of cumbersome.

I write my letter after the note is signed and the referral has been set up. I send an order for a referral to my MA and the reason for the referal is written on the order next to the consultant docs name. Once the ma has made the referral, they message me to write the letter which I do at that later date. Upside down and backwards but I get a chance to find out if the consultant will even take the patient, etc prior to writing the letter. Sometimes due to insurance issues, it actually ends up being a completely different consulting physician. Sometimes it is a time issue.

Although I'm newer to AC, it seems asking for a consultation should be easy - generate a simple letter to the consultant describing the reason the the consultation, and send to the consultant a copy of the chart notes and lab values ( which are easily generated from 'Past Encounters' tab)

My problem is as the consultant, writing evaluations back to the referring doctor - Once I've completed a patient visit and transcribed in all the components of the current visit (which will initially contain either typoes or word errors from Dragon NS) I'm stuck with one of two bad AC options: I either forward the chart for proofreading unsigned (though now I don't have access to it and more importantly, any inadvertent closure of that unsigned chart entirelyv erases the encounter!) or . . I can generate a letter and sign/lock the chart. - but now the chart encounter can't be corrected, and AC saves that generated letter in HTML form which is an ackward form that doesn't interface with Word processing documents.

I can see one of two easy solutions: either prevent AC from erasing encounter data when an unsigned chart is closed (and ideally, allow multiple users in a practice simply open the chart without having to "forward" it to each other --and let the provider] sign/lock the chart only after it has been proofread
or
Allow the letter generated from the encounter to be saved as a DOC word document that can be both proofread and corrected using standard word-processing, even after the original chart encounter has been signed and locked

The AC team has promised to look carefully at this flaw - but does anyone else who writesconsultation letters have a good solution to this problem? (I'm still looking into Bert's HTML ->DOC converter)
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Bruce Morgenstern, MD (Neurology)
Denver, Colorado

You can forward the unsigned chart to your own mailbox and you do have access to it...only you have access to it and only you could inadvertently close it without signing it. It can sit in your mailbox until you edit and sign it. Just be careful that you open it by clicking "pull chart" in the right corner, not from the drop down menu. The drop down menu gives you the last signed note. Pulling chart from the box on the lower right will give you your current unsigned document in process.

Forwarding the chart to myself, unfortunately, doesn't accomplish the intnded goal - which is to give my staff access to a correctable form of the chart or letter so it can be proofread & corrected, and placed in a form suitable for printing on letterhead.

That one needs to so carefully tiptoe around a work-in-progress open chart for fear of erasing it seems a major design flaw.

I also don't understand the philosophy of needing to "forward" the chart back and forth between members of the staff - allowing instant access to chart entries by various members of the staff enhances office efficiency and is a major ADVANTAGE of an emr, not something to be rigorously guarded against.

Does anybody understand the reason behind this? Why not simply allow direct and instant chart content access to all providers and support staff? (or alternatively, to all staff who are given a certain level of security access, if that is a concern)

Do the AC developers review these threads? (not meant sarcastically - I'm new to this forum)

Bruce Morgenstern, MD (Neurology)
Denver CO

Well, you could actually forward it to yourself and then forward it to whichever staff person you want and if they inadvertently lose it then you will still have your unedited note in your messages under deleted files. Or when you forward it to your editor just don't delete it in your mailbox. Once you close out of AC your deleted messages are not retrievable.

Personally, I don't want just anybody in my office to be able to access a note that I'm working on. Others in the office are able to access the chart and work in the same chart, they just can't access your unsigned note unless you send it to them. Signing it makes it a permanent record....no way to change it. Part of the certified emr thing.

Always has been my biggest gripe of AC. The letter writer...which I actually have adjusted to. Join the crowd.

I hate that I click "sign it" then notice that I overlooked a typo or a med error and then I have to create an entirely new encounter to fix it. Then, I have two encounters on the same day without being able to delete the incorrect one or at least mark through it and say it was edited.

Travis, you can just select the name, right click on it, and generate a letter (along with the last progress note and demographics if you wish) and not create a new encounter. But, you still have two letters saved. So, that may be a little plus, but I still hate that my letters go out looking like my daughter's first attempt at using a word processor.

My answers to Brucel's two dilemmas tomorrow. Seems rather simple to me. Well, at least in my opinion.

Hi Dave-

You are correct in that by hitting CTRL P you can generate a new letter based on the initial chart entry. But unfortunately, the initial encounter on which any new letter will be based is still locked,(along with all its typos and dragon-generated paraphasic errors.) - so, as much as I wish it did, it does not solve the problem -

As far as I can tell, the solution must lie either in allowing the chart to remain unsigned and correctable without fear of accidently erasing the encounter until *the provider* volutionally decides to sign off OR - allow the encounter generated letter to be saved and exist as a more versatile form such as a *.DOC (currentlly the only AC option is HTML) independent of the locked chart, and the letter could then be corrected and modified through MS Word, even if the chart encounter itself has been locked.

Bert, I'm anxious to see your ideas - I'm at a roadblock.

Amazing Charts Developers have really been quite responsive in communicating with me and have promise to raise this issue on their next meeting this tuesday.

Bruce Morgenstern, MD (Neurology)
Denver, CO

I have had Bruce's problem for quite some time. He's right that once you sign the chart, you're hosed. Just seems that it should be an option to be able to "unlock" a note to correct typos...at least by the ADMIN.

Although all of the work-arounds with Word are fine and dandy, I despise having another program open to perform a task and then have to copy/paste/save/whatever into another program. It needs to be integrated into AC...period. I shouldn't have to have another program to work a true EMR. There are a few people who don't purchase Microsoft Office routinely, believe it or not.

It's a big weakness. The freaking thing is CCHIT certified and HiTech certified and Bert certified....blah, blah, blah. We just want it to work intuitively, simply, and do the most basic tasks that we do every day. Yes, I'm a broken record.

Be careful,Travis. You're starting to sound like me :-)

OK, both .avis came out good, but I can't use the second, because there was no way to get around HIPAA issues with my inbox. Too many patient names and diagnoses there.

Soooo....on the access to the charts, all you have to do is make a patient named First name (.) that's a period and second name of Charts. Just give it the lowest status.

When you finish with a chart but don't want to sign it off forward it there. Anyone can then access it by logging out and logging back in as Charts and password. Unfortunately, you can't just open, type and save. You have to open, type and then forward back to the same inbox. This will give you the latest version on the bottom. You can write comments in the comment field when you send it, but the time of when it is sent should clue you in. As someone said earlier, I would definitely send it first to your own inbox and mark it as original in case someone deletes the chart from the Charts inbox. When you need to sign it off, since it doesn't have signoff privileges, you need to forward it to your own inbox where you can compare the two and then sign it. I didn't put that much thought into it, so maybe there are some glitches or complete reasons why it won't work. It isn't the best solution.

On the other, this is what I do for letters. It works perfectly, and you end up with a Word document in your imported items. I will upload the AVI for instructions.

http://www.box.net/shared/static/saiu3bmm69.zip

Hi Bert -

I'm going to look into your work-around; but for all that extra effort, wouldn't it be so much easier if AC simply allowed the generated letter based on the original encounter to be saved as a word *.DOC that was correctable even after the encounter had benn locked? - that is the way we ususally work. In addition, a consistent thread in these chats involves preventing the inadvertent erasure of encounter contents. - wouldn't it be so much simpler if AC simply saved, not erased, an encounter when an unsigned chart was closed? ( paper charts don't self destruct when closed before signing, why should AC's?). Finally, shouldn't the doctor, not the progam, decide when an encounter is complete and when to sign off an encouter (to me, it seems we are forced to sign off prematurely to guard against losing our chart entry)

I've forwarded these thoughts to the developers who've promised to look at them on their Tuesday meeting. Certainly the improvement in letter writing flexibility would enhance the marketability of AC to those specialties who need to write professional letters to their referring providers.

Does anyone have any suggestions on how we can stress the importance of these features to the developers ?

Bruce Morgenstern, MD (Neurology)
Denver CO

I agree with all the negative posts about the inflexibility and inability of the program to make changes to a signed note. It's not "natural". You can make corrections to a paper chart at any time! We should be able to do the same to a signed computer note. I've seen other programs out there where you can. This has to be my number one complaint with AC. I hope they fix this at some point!

Wayne
Medical Office Owner (running version 5.0.29)

FYI - Like others on here, I too am also too scared to update to any newer version yet since we have 10 computers to update and we ALWAYS have major problems after an update.

In NYS we can take a malpractice course and get reductions in our premiums. A very basic rule is that a note should never be altered. Make an addendum and correct it if you want, but altering a signed note is akin to a red flag. I understand proofreading and editing before signing but altering a note at any time is asking for trouble.

I agree - Never alter a note, particularly if a medial legal question exists - BUT . . . there still should exist a window of time during which you can proofread your enty and edit it before locking it - that doesn't constitute altering it, it just allows you to finish it.

One easy solution would be a dated "Sign It" -ie when you finalize the chart and sign it, it is dated with the date it was locked. - that would offer all the medical-legal protection you would need (but that choice of when to lock it should not be determined by fear of erasing the chart accidentlly, or determined by the need to look at another chart (ie close the chart you are presently working on without erasing it)

Another solution would again be to lock the chart, (even as inconveniently as AC does) but allow an edit-able (ie changeable, not eatable) letter (again, saved as a *DOC) to be generated from that chart - the locked chart offers you medical legal protection, the edit-able letter lets you profesionally communicate the findings to another provider.

The two solutions are not mutually exclusive, and would liberalize the utility of this program.

Bruce Morgenstern, MD, Neurology
Denver, CO

Wayne, it may not be perfect but Jon did add the ability to add the addendum directly to a chart.

Well, part of the difference is that I never have to add the PN to Word document. I had to work on that one for you.

I feel bad for you, but if you are able to get the developers to change the letter writer, you will have done much more than any of the rest of us. Now, I do think there is hope with how the PN flow goes.

Two comments. First to Bert. I assume you mean a PROVIDER not a patient with the period trick. Second, regarding letters for consults. I have many consultants who simply send me an augmented progress note with or without a standard cover letter rather than a dedicated letter. With the disappearance of Medicare consult codes, all I send out is a complete office note ending with full recommendations and verbage like "thank you for this consult". I have my staff fax the above to the hospital and elsewhere required and save the paper and postage. I have requested the same of my colleagues and most are helpful in returning the favor. 'Marlon

MK -

Even sending out augmented encounter documents, how do you handle the inevitable typo's or dragon-originated paraphasic errors that arise in the non-templated parts of your note (Subjective history and any discussion under assessment) - the content can't be altered if the chart is signed and signing it immediately seems to be the best protection against accidental erasure.

Do you sign your note in AC (scanned in signature) , or print them, sign them and then fax them? We're gearing up with a fax program to send direcly from Amazing Charts to providers - saves many steps, though again we're confounded by the locked chart coupled with the inability to edit saved letters generated in AC from the encounter.

Bruce Morgenstern. MD (Neurology)
Denver, CO

I still think if you don't have to have the PN along with the letter, which many of my consults come as, simply dragging a Word document that is templated with your information is extremely quick, effective and better than anything Jon can come up with.

There is a spell check for the notes (but it is horrible). My only suggestion is this:

There is no one, no one, more anal-retentive, obsessive-compulsive than I when it comes to letters or notes. But, I think you have to make one of two choices at least for now:

1. Either spend more and get an EMR that has more functionality or
2. Just bite the bullet, do OCD, anal-retentive sensitivity training and accept the fact that the progress notes you send to your referring doctors will not be perfect.
3. On the other hand, some specialists send only the note with a long discussion or plan or use the attached addendum and send it the same way you plan...which is via fax.

If you ask referring doctors which they would choose:

1. A perfect document send two weeks later

or

2. A document with some typos sent that day that gets to him or her before the patient is home

A LOT will take the latter.

You don't know how many patients who call us same day or next wondering what the specialist was talking about and all we can tell them is we don't have the note yet.

I send the chart to my MA prior to signing. She will proofread charts before sending back for me to sign. She is very good about getting them back to me before the end of the day. We have a half sheet scrap paper for each patient as a doublecheck. If a chart 'goes missing' as long as I have not logged out, I can find it again in my outbox. I just wish it would stay like a full day just in case. I have adjusted and rarely have to recover work. marlon

This, I think, is the root of the problem. I, and my staff, have been more bothered by this than any other problem in AC! If anyone goes to save the chart and accidently mouses the option right above 'save,' which is close the chart, it will actually close and lose the chart. It will trash it and often not even ask if you want to save it. I don't know why it asks at some times and not others. Further, if you navigate to other tabs like the 'imported items', get caught up in what you are doing and accidently hit the 'red X', it trashes the chart and you have just lost half an hour of typing, including the vitals and everything else. AC really needs a better warning system and get rid of that 'red X' and replace it with a 'blue save' button. The default should be saving it back to the message inbox where I got it! Are you listening AC?

Boondoc,

I agree that it should auto-save back to your inbox. But, I hope you don't take offense as I do not have the same issues as you.

First, I NEVER, EVER use the File dropdown tab for the very reason you mentioned. There are too many other ways to deal with a chart, and that one takes too many mouse clicks.

So, if the chart is open and anything has been entered anywhere, I can't find a single way to delete the chart without a warning. For me, once the chart is opened and entries have been made, if the File tab is not used, here are your four options:

1. CTRL + S -> Saves the chart to your inbox
2. Forward the chart -> Does the same as CTRL - S but allows forwarding to other inboxes and/or leaving a message in the window.
3. Signing it off -> Self explanatory
4. Clicking on the little red "x" which gives you the error message. In fact, if you don't use the File tab, it is the only way to delete the chart. That's why I like it small and red

I was unable to reproduce where the chart was completely deleted if you changed to a different section of the chart.

I'm not saying it doesn't, I just couldn't get it to do that.

Help me out.

I will post more completely on this later; this thread involves a series of inter-related topics that I feel strongly about.

I think some of these things are problems with the program, and some are issues with work-flow. Boondoc, if this is your biggest complaint with the program, I think it is easy to fix with a small change in the way you use it.

1. I would suggest that you do NOT EVER go to the file menu to hit "Save"; instead always hit "Ctrl-S". Stay away from the file menu and you will never hit "Close" by mistake. Train your staff to do the same.

2. "I don't know why it asks at some times and not others."
One of the "two-edged swords" of AC is that you can do the same thing in several different ways. I use that term because this makes it easier to accomplish certain tasks, BUT sometimes you get different effects. To see what I mean, you might choose to experiment with a fake patient chart to follow this:
a. if you close a chart by hitting "Close" in the file menu, it closes with no warning and no saving. That is one reason I stay away from it.
b. If you close a chart by hitting the "X" in the right upper corner of the chart, it will close IF you have made NO changes to the chart, but will ASK if you want to close if you have made a change (even typed so much as a period in one of the fields). So this is the preferred way to close a chart (in my opinion).

Of course you can also "close" a chart by signing it or putting it in a mailbox (Ctrl-s). Signing will save your changes: permanently. Saving to a mailbox will save your changes, but you can always alter the note further by re-opening it.

I hope that is somewhat helpful.


Please tell me about this "red X". I don't see that; I am using Version 5.0.28. Is this something new?

Ok, Bert...you beat me to it.

As I see it, the major work flow problems in AC revovle around three or four inter-related issues:

1. The default erasing of chart contents if the chart is accidently closed before being signed/locked -AC should consider changing the default of closing an unsigned chart to simply saving the encounter contents, not erasing them, without having to forward the chart to anyone

2. The necessity of signing/locking the encounter to prevent accidental erasing prevents physicians from completing their workflow in a normal fashion (yes, there is an ackward work-around by self-forwarding an unsigned encounter, but why should the program contain ackward fixes when the workflow can be so much more easy?) AC should consider allowing the provider to sign/lock the chart when he has finished his clinical work and not as an insurance policy against accidental erasure). Possibly consider placing a small visible stamp on the encounter indicating when it has been signed and locked.

3. Post encounter letters: the letter writer is an unsophsiticated tool. AC should allow letters to be saved as *.DOCS document under "Improted Items" (in so they can be proofread and edited as professional correspondence, even *after* the chart has been signed/locked. (Allowing letter to be composed and edited, even containing edited contents from the encounter in no way produces medical-legal jeapordy - As long as the provider can prove the original encounter is sign'/locked, than he/she is protected against accusations of chart-tampering.

4. (slighly lower priority)A llowing multiple providers or office personel (who in advance have been given a certain level of security clearance) acces to the chart , even simulatneously, without having to forward it back and forth - this is an advantage of an EMR - why not make your EMR *better* than a paper chart, instead of trying to simply emulate paper's disadvantages? (Soapware, another EMR based on SQL server allows multiple office personel even simultaneous access to the chart (the chart fields become slighly tinted indicating someone else is in the chart at that moment)

While Amazing Charts is an intuitive tool, it seems ,to me, optimized simply for self-contained intraoffice use. I would like to see them focus now on expanding its capabilities to handel tasks outside the narrow realm of simple charting/documenting and in doing so, it will expand its utility outside the realm of primary care and into the realm of medial specialists.

Does anyone have additional thoughts on improving the work-flow, or how to deal with these issues? I've emailed the AC developers with these ideas and they have promised to get back to me.

Bruce Morgenstern, MD (Neurology)
Denver, CO

I think AC works very well with my work flow. It took some getting used to when I first started using it but I really like how it works now. I rarely if ever lose a chart and my work is done at the end of the day. I have no unsigned charts in my mailbox. I write my letters and they go with the last encounter note via our multifunction fax maschine. AC already allows multiple office personel to have access to the chart. They do not have access to the note you may be writing until you send it to them but that is not a problem for me. I can be seeing a patient and documenting an encounter and others can import into that chart or print a med list or make orders or add addendums or change demographic info. They can't change my note unless I send it to them unsigned. It is difficult getting used to the differences in the program when a new verizon comes out with significant changes. We upgraded during beta testing last year as we didn't want to wait and upgrade during our busiest time during the summer months.

Bruce, I like a lot of your suggestions. After a while, it is hard to tell when the program is working with our work flow, and when we have just adapted our work flow to its peculiarities. I almost never lose a chart note any more, but then I have just trained myself to always forward it to myself, just a conditioned reflex. Like hitting "cntrl-S" regularly in many programs, even if not necessary. Seems I should not have to have done that, but it is easier to train myself than to get the program changed. And, like you, I have no idea why AC can't let a decent word processor do its letter writing for it if it is too difficult to do it correctly themselves.

@st lawrence ......perfectly put!

@jon

Lol. The red X is the X in the corner.

David,

I agree with you and, as I have often said, the user needs to be able to adapt to the EMR. There are numerous different ways one may alter the work flow of their office and still have AC be a useful tool. But, in the end, one must use the EMR as the basis for the way the office runs.

None of the changes I'm proposing would necessairly affect existing users, only improve the product for new ones:

1. Default *saving* unsigned encounter contents instead of erasing them when the chart is closed. - (perhaps this could even be an administrative option, for those who still prefer the automatic erasure option)

2. Elective signing/locking the chart by the provider (perhaps by clicking on an icon) producing a small dated time-stamp on the page. This could be an option (under administrative opions). And indeed, becomes less critical if closing the encounter doesnt risk erasing the contenets without signature,

3. Allowing other providers/office staff, with the appropriste AC security clearance to open a chart without it having to be forwarded. Again, if the office providers don't want a specific empoloyee to have access to the chart, they wouldn't be given that level of clearance.

4. Saving correspondence in Word-compatible form. This only helps those of us in medical specialties who use write letters and wish to edit them in a convenient form - it doesn'treally materially affect others.

My goal here is to suggest changes that optimize the program and expand its use to newer and potential new users, while not making it more difficult for existing users.

Bruce Morgenstern, MD (Neurology)
Denver, CO

I just duplicated the close (without warning) error. I have sent an urgent error message to AC from the bug report in the program. While this is a good place to gripe, you have to get it to there attention and the bug reports are the way to do that. , and they do not always monitor the boards.

As to the red x and going to another tab, it ALWAYS tells me that I am closing a changed box.

I usually do it manually, with the Forward chart option above the signoff button. At least that way I get a second chance if I am clumsy (not uncommon ;-) ). The closing/losing if hitting the X also makes me crazy. It really needs to be more idiot proofed.