Home Forums Discussions Feedback and Recommendations Running list of pt's Diagnostic/Therapeutic Trials

Does anyone have recommendations for an optimal way to keep an easily accessible running list of laboratory and therapeutic experiences in AC which could quickly be viewd with each encounter?

For example, in following a migraine patient, I may want to have the following accumulated information easily visible in the chart during each encounter :

"MRI Brain - normal 5/19/10"
"Inderal -> trial 12/10 made her bradycardic"
"Amitriptyline - patient refused due to possible weight gain."

While AC allows storage of the actual results under "imported items" it seems that one needs to leave the current encounter, or search through "past encounters" to find them..

I'm envisioning an easily visible simple running list to which such items could be electively added and maintained, a sort of running "Intervention/Diagnostic" field to electivley store such itmes (thus avoiding my asking the embarrassing question, " Ms Smith, why don't we get an MRI on you and try you on Inderal and amitriptyline?")

Any recommendations on how this task is best handled?

Bruce Morgenstern, MD (Neurology)
Denver, CO

Any recommendations on how this task is best handled?

Good question

I would simply pick a part of the chart you want it on and add it. For instance I like to have Past Medical History and Past Surgical History - so on all of my charts my Past Medical History looks like this:

Allergic rhinitis
HTN

Surgical History - Appendectomy, Tonsillectomy.

You could add at the end of this - interventions/evaluations....

I appreciate the recommendation, I also thought of placing such information under "Past History", but the real dilemma arises when new items take place *after* the initial encounter, particularly, in between visits.

So to use my inital example, If Ms. Smith calls two weeks after her initial appointment and reports that inderal makes her heart feel slow, where do I put that information? I can't add it to the "Past Medical History" field of the initial encouter because its been signed and locked. If I do add it there, I now am forced to save again the entire inital encounter as a new encounter (with the added clinical intervention), so now there are two differently dated initial encounters, differing only by the addition of the interval event. This becomes more problematic you use the "Past Encounters" tab feature because now there may be multiple past entries for the same initial encounter - when the initial encounter took place only once.

Ideally, there should be a section of the chart that remains alterable even when the rest of the chart has been signed/locked. - perhaps "Past Medial History" or perhaps adding a new "Intervention/Diagnostic" section to the chartt to which small entries in between visits could be sedquentially added without having to generate an entire new Clinical Encounter.

Other thoughts or ideas?

Bruce Morgenstern, MD (Neurology)
Denver, CO

I put info that arises between visits in an addendum. It saves to the same list that all past encounters are on. I may add new developments to past history during my next encounter but not until I actually see the patient again. You could add as many addendums as you want and you can attach them to a note. You access the addendum screen (I believe) by the drop down menu under "file". You can title your addendum to help you find the one you may be looking for in the future. Play with the program. There are many features other than the encounter. Go through all the drop downs and see what your options are. Make a dummy patient and try everything.
Personally, I love ac and its simplicity. If I run into a problem, I and my two office staff brainstorm a solution. The only thing we even print now is an order to take to the lab. I am extremely thankful for an affordable/usable/functional emr. I think that fixing or changing things in admin options is fine but if I wanted "everything" perfect I probably would have spent alot more money and then been really really disappointed and not happy and just out alot of money. There is no perfect system and I've known more happy AC users than any other.

Thank you for the "addendum" suggestion. I will experiment with it first thing this morning.

I understand, and apologize for the appearance that I may be trying to fix everything - really, I'm not. I've recently switched to AC from long time use of another intuitive styled EMR that did seem to haver easier provisions for some of these tasks (though AC has advantages of its own) , so my vantage point is a little different. I'll certainly try the addendum fix first - I'm just groping for solutions to the situations I encounter as I go - and certainly satisfactory solutions found within AC are the optimal choice (though still grappleing with default encounter erasurs with closing, and the ackward, almost unusable options for storing and editing correspondence - (ie the proofreading thread)

Bruce Morgenstern, MD (Neurology)
Denver CO

I played with the addendum function today - using the 'append' option it seems a very nice way of sequentially adding information to the "Past Encounters" portion of the chart.

But . . . for the purpose of adding laboratory data to a pool of easily accessible frequently referenced lab values for an established patient, the process seems a bit ackward (enter the new laboratory value or clinical comment as an addended encounter, then, at a later visit, re-review "Past Encounters" looking for addended lab values or clinical comments, scoop them up and place them in a"Diagnostic/Therapeutic section of the chart - perhaps under PMHX.

I DO think it would be much more elegant if there were a discrete "Diagnostic/Thrapeutic Interventions" field in the Present Encounter screen, and, like the "current medication list", that field remained continuously addressable so new labs or important interactions, labs or events rolled in, they could be added and kept in one easily viewable place. (Soapware had such a field and I always found it very helpful)

Thoughts?

Bruce Morgenstern, MD (Neurology)
Denver CO

If you go to the summary page, there is an area on the right hand side called tracked data....you can put whatever you want to track in there. HgAC, colonoscopies, inrs, etc. You go into the administrative options part of the program to set this up. It is a simple quick way to look something up if you use it. When I sign off on labs or tests I want to track, I just put it there if I want to. It is just a couple more clicks.

Learned about this aspect of the program at ACUC 2010. It is new in version 5 think. I like it.

You are right! The Tracked Data is just the type of function I wsd looking for. I played with it, and it does exactly what I want, but I had a few thoughts:

What about having it accessible in :

messaging - so when an important lab comes in, it can be cut and pasted into "tracked Data (I DO very much like the function that allows it to be automatically appended to the recored in 'past encounters' ) , but what about easily accessing tracked encounters from messaging page so important labs can easliy be entered into it as they arrive.


in Past Enncounters: there is that HUGE grey area occupying 30% of the left side of the encounters page - why not make the past encounter field bigger-eliminate some of that blank grey area - (with bigger print in the encounter field too, while we're at it) and have "Tracked Data" viewable in some of that grey space - allowing important labs to be viewed while also purusing the lineage of past encounters

Finally, have 'Tracked Values" viewable in PRESENT ENCOUNTERS - In the upper rightportion of the Present Encounters portion of the chart, there are a number of file tabs ("Pictures" "illustrations" "Confidentials" etc) - why not add another tab for "Tracked Values" so it can benquickly and easily reviewed while seeing a patient with the present encounters page open.

Thanks again - let me know your thougts on these Ideas?

Bruce Morgenstern, MD (Neurolgy)
Denver, CO

Brucel

I like your ideas but I think right now AC is very busy getting the PM system and meaningful use up to snuff. I very much appreciate how useable and affordable AC is right now and I would not trade these things for any added features right now. I believe that AC is more interested in our needs as users than probably any other emr but the wishlist is long and costly and I'm willing to wait for some things.

In the tracked data area, did you note that it is important to use caps in naming your categories in order to have those categories consistently searchable or something like that. It is funny....copying and pasting is very difficult to me but typing is much easier. Are you sure you can't copy and paste right now? I go from imported items to summary sheet and enter the data before I've even finished signing off on the imported item. It is very quick for me. I go from imported item to tracked data and back to import, sign off and send message to whomever regarding any followup necessary.

Have you talked with Nancy at AC. She is the product development person. She is very interested in hearing ideas. I can't remember her last name but she is the only one. Have you visited the AC facebook page. She is in some of the pictures from the ACUC with her full name I think

And Brucel....do not let perfect be the enemy of good!

" And Brucel....do not let perfect be the enemy of good!"

Totally agree. But if they are somewhat responsive, and they seem to be, where better to get the fuel for improvemnt ideas than the users themselves - particulary in a forum that allows users to comment and tweak each others proposed ideas to help perfect (eh, make more good ) and refine them.

'Im just starting to explore messaging in AC - I pewrsonally would like the messaging to accomplish the following goals:

1. Receive the message from staff, be able to write a reply back to staff, send that reply back, while appending and preserving the whole transaction (office message to me AND my reply) to "Past Encounters" for documentation

(Eg, Office message: Ms Smith is Dizzy on her 800mg Dilantin"

My reply: " She's only supposed to be taking 300mg, tell her to stop for a day and then start 300mg" - I of course want to forward the message to my staff to call Ms Smith, and to record the whole exchange in "Past Encounters"

2. NOt only store important labs presented to me in messages, (which AC does quite nicely), but then easily allow a synopsis of that important lab to be stored in "tracked Data"

Eg. Message from staff - Ms Smith's MRI is noraml (with the report attached)

My response: I File/store the actual MRI report in her chart (which AC nicley does), then from the messagee screen, be easily be able to file a brief comment into "tracked Data" section (Ms Smith's MRI of 1/22/11 is normal". And Finally, have that "Tracked Data" screen easily accessible when taking care of patiets: from "Present Encounters" screen (again, easy - just design a new tab leading to it in the upper right file tab section, next to "confidential" or "illustrations" tabs and have "Tracked Data" also easily accessible for review when looking at "Past ENcounters" - again, there is a huge BLANK grey area occupying ~30% of the left screen space - Make some of the Past Encounter Writing Field bigger by using it (and perhaps that will allow option for less micrographic fonts there)and place an icon or button there to access "Tracked Data"

SL - I really think AC is listening - help me make tweak my ideas so I can possibly present them.

Thanks,

Bruce Morgenseterr, MD (Neurology)
Denver , CO

I use the message system all day long. My MA messages me that a patient needs a refill. I eRx a script and message back that it is done. I message my MA my comments on lab results and patients need for followup appt and they do as I say. The only way a message is saved is if you click on save message to chart in the lower right corner. Message system is outside the patients chart unless you save it to chart. I will save my message to chart when I send certified letter for example. The letter is there too without saving it. Look right under the message and there is a reply or forward button.

The message system also lets you send yourself or anyone else a message for say, 6 months from now. For following a pulmonary nodule for example. Review CT and send yourself a message to repeat CT in 6 months and have that message in your mailbox for 6 months from now. Then I message my MA that that is my plan and to let the patient know or make the patient an appt or whatever. In the right corner of the mailbox, where you can delete messages, you can see all the messages that are in there for the future. I use the messaging system for stuff like follow up testing. I use the tracked data differently. That is more like a work area. I'm primary care so I use it to track diabetic patients and their compliance/ need for follow up. I put colonoscopies and mammograms in tracked data but I put abnormal colonoscopies and mammogram in the messaging system for follow up. I must "look" at the tracked data. The message system is "automatic" as far as reminders go.

I don't like the idea of you making changes to a system that is already working great for me. Your suggestions would probably make good "administrative" options. We all have different roles in this "doctoring" system. The way AC is now, we can all put it to our own uses rather than one size fits all. Just my opinion.

You can also "Save" a message in the "Saved Messages" box without adding it permanently to the chart. Then you can retrieve it and reply or forward when you wish.

The changes I'm proposing wouldn't necessairly effect current users it they did want to use them. Basically three ideas:

1. When one writes a reply to a message in the message box,BOTH the original message AND the reply could (but don't have to) be saved to Past Encounters via the existing save to chart option (as far as I can tell, only the original message, not the reply can easily be saved to the chart now)

2. Allow quicker access to "Tracked Data" via an icon in "Past Encounters", and via a new tab added to the existing upper right tabs in in "Current Encouter"

3. Does anyone else think the font size in "Past Encountes" could stand to be enlarged a bit, and that perhaps by Bolding the date and Title of each encounter in the "past Encunters" field (when displaying the actual contents of all past encounters,) that it would become easier to quickly distinguish between different dated entries if the Date and Tiltle were in Bold?

Bruce Morgenstern, MD
(4th floor nursing station, Denver , CO)