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

I am sorry. Just can't resist. I just don't see that big of a problem. I am not sure why the "Close Chart" is there, but I wouldn't consider it a bug, I would consider it something to never click on. But, it does what it says. It closes the chart. If you click on the red x, you get an option box, if you click on Save Chart under File (which I would never go to), you get an option.

Recent editions of Word have autosave that save rather quickly, but you can still click on the red x and choose not to save. So you can lose your Word Document as well.Choosing the diskette or Save As give you choices to save, but they are equivalent to CTRL - S or Forward Chart.

CTRL - S while getting the chart to your inbox is not as helpful as forwarding the chart with the button, because when you use that method, you can include a message as to why you are saving the chart and not signing it off. You may write waiting until CBC back. The cool thing is that whether you delete the message that was there before such as the HPI or leave it, when you pull the chart again, it reverts back to the HPI and your message disappears. I think that is rather ingenius.

I guess I am just missing what the problem is. Once the chart is open, you can either sign it off or forward/CTRL - S to inbox. The only way to lose it would be to hit the red x and choose Yes, or use the Close Chart option (which is pretty easy to avoid once you know it is there). It even saves the note if AC crashes and it's hard to blame any program for that.

Bert, I just find that all is just fine IF I remember to tuck in my shirt and brush my teeth, but only AFTER I have fed the dog and emptied the trash. I ought to be able to do it in any order, and not have the stove catch on fire.

LOL. David, please tell me (forgetting the File dropdown -- which is almost useless in EVERY program) how you possibly delete a chart by mistake.

Bert, It is starting to feel like you reflexively defend the poorer aspects of this program. This forum is riddled with complaints about how easy it is to lose an encounter in AC. The attempt here is to try to brainstorm on how to impove the bad aspects of the program while preserving the intuitive feel which we all enjoy

Help me (and potentially, any reviewing developers) understand why you feel an option allowing saving an encounter's contents upon closing the chart is a bad idea - would you favor an administrative option of, "Please Erase Contents Of Chart Upon Inadvertent Closure."

You are clearly experienced and knowledgable here- help us to improve this product, and in doing so, expand its market and insure its future viability for all.

Bruce Morgenstern, MD
Denver, CO

Bert, I'm not sure I remember exactly. When we started with AC, all of us seemed to have a painfully prepared note just sort of magically disappear. Maybe it was in the deleted items box and we forgot to look. My guess is it went like this:

1) make chart note
2) save to yourself
3) pull chart
4) hit red "X" before editing the chart
5) POOF... it is gone

Nowadays I know to look in deleted items, but I swear at the beginning there were times I could not find it anywhere, and others in the practice still have charts lost forever. I have self trained to save to myself at every little break in the action, just like I "cntrl-S" with Word every paragraph or so, as a holdover from the days when if you didn't you were seriously hosed. I am close enough to starting that I remember how overwhelming everything was, and how panicky it was to not know where my work suddenly went. As I said, it may not have been lost, but there were plenty of times I just did not know where it was. I could have used more help from the software.

It's interesting that you see Bert as defending the program, because I don't.

There are apparently a couple of closure problems that need to be fixed. They probably has been there since V5. One reason most of the older users do not find it an issue is that we developed other ways of opening and forwarding notes that does not expose us to these problems.

The problems are real. They are a real pain to those whom it happens. It apparerently does not apply to Bert, he sees a way around it and thus does not get upset. They need to be fixed, they have been forwarded and will get fixed. That does not mean he does not care, he chooses to put his energies in problems without solutions, especially when the problems to not affect him.

Now I am defending Bert because I do not sense he does not understand the problem, he just does not see it as a problem because he is not affected by it.

I, too, see the issue and have reproduced it. I have reported one as a bug (the file close issue) and will report the other (open saved closed without warning, see above.) The latter is not a major issue, it is in the deleted folder, just pull it back. It's a pain though.

Forwarding bugs is the way to make the product better. You can keep b**ching about it, but it won't be corrected until the next update.

I agree with pretty much everything that is being said. . . But I don't see this as just complaining - by raising and defining real problems with the software, ones that effect current users (at least those of us new enough to not yet be wearied into complacency or having developed compensatory meaasures) my hope is not just to define problems, suggest solutions, and try to develope consensus, it is my valient hope, and acutually my belief, that the developers follow some of these threads and use the information to help improve the program. I have been in contact with some of the development department, and received their promised to review these forums - and particulary this thread. So while it may on one level sound just like complaining, I'm really hoping this will serve a bigger purpose.

Lets see . . . . . .

Bruce Morgenstern, MD (Neurology)
Denver, CO

I have talked with one of the lead programmers and really wants to look at the letter writer and try to improve it - I brought up many of the issues and he said when is able to get through pressing isssues of certification and PM he will look at it. He understands (and Jon does also) that the letter writer for instance is very important.

Bruce,

I do not "reflexively" defend the poorer aspects of the program. Not to be defensive, but if you notice, I am 50 posts from 5,000 and I would venture that 80% of those are either making suggestions as to how to make the program better (I have more letter writing posts than everyone else combined):) or helping people. I should, if I disagree with others are saying, just sit back and say nothing, but it isn't in my nature.

I am not so much saying these aren't flaws as I am disagreeing to an extent as to point out ways where those who are losing charts may be making their mistakes.

These closures actually go back to at least v4. What I find both strange and interesting is this is the first thread EVER that has talked about this subject. I am not making light of David, et. al., I just wonder why all of a sudden this is an issue.

To David, who I consider a friend, I would say two things: One, don't hit the red button (I don't mean that sarcastically - I simply don't understand why one would have a chart up and then rather than sign it or forward it again, they would delete it.) I mean clicking on the red button means, I am going to close this chart. While this gives you a warning in some situations, we all know now that in the instance of clicking on the red x after the chart is pulled from the inbox, you will lose the chart. And, yes, you can undelete it, but you need to do it sooner than later.

Personally, I think the best fix would be to make deleting the deleted charts something that needs to be done manually and then only by an admin.

If you go back and read my posts, something I wouldn't necessarily recommend doing, you will find many criticisms of the program. But, while there seems to be some movement in the direction of developers listening to the users, I have been around long enough that while AC is a great program and the cost can't be beat, that trying to fix things on the board isn't as effective as finding the best workflow the program can offer, finding workarounds and working within the confines of the program.

It isn't as if I have two options: 1) work to make the program better and 2) defend the program, and I choose the latter. I have just resigned myself to realize that I am not able to change the program for the most part.

My reflex action in "hitting the red button" was to close the record; not delete it. Think of the human user's guidelines followed in other programs. What happens in Word or Excel or really any other program that creates a document if you hit the red button. It comes up with a big DO YOU WANT TO SAVE? warning, and the default is not delete. You have to work hard to NOT save the document.
I know Apple published a set of human user's guidelines ( http://developer.apple.com/library/mac/ipad/#documentation/UserExperience/Conceptual/AppleHIGuidelines/XHIGIntro/XHIGIntro.html%23//apple_ref/doc/uid/20000957) as a reference for programmers, and I suspect there are a common set of standards out there. I think parts of AC do not follow those guidelines.

You make a good point and, yes they do. And, AC could probably do the same. Of course, Word, Excel, etc. make a living out of making and saving documents. Maybe a poor argument.

I understand what you're saying. I guess I am not sure why you would want to choose close when you now know the option to use CTRL - S is there. Or don't choose the Yes button when you pull a chart from the inbox. Sorry, I don't mean to give you a hard time. I guess I am trying too hard to understand all this.

Well put it down to being green and flustered and reverting to what I knew. Recheck the above post... I modified it... And check the link for "forgiveness". A properly written program should save me from myself if I am inexperienced or clumsy. We want to coddle new users, not frighten them.

David, you are anything but green and flustered. I understand your frustration. I think I will bow out of this one, because I don't think I am helping.

You should have been with me last April!! ;-)

I think I would have waited to May. Don't think I could have stood to watch in April, lol.

A chart should not be able to be unintentionally lost or deleted. Ever.

AnneMarie,

Just to be clear, are you referring to the chart being open, data being entered into it, and the chart closes and that note is lost; or are you stated the actual chart with all of its data, progress notes, etc. being lost so that the person's chart itself is completely gone?

Thanks.

Bert

For purposes of this discussion I was referring to the ability to "close" a chart and thereby lose data/notes. I recognize that loss of data can, and will, happen, but the way AC allows it to happen so easily is unacceptable, in my opinion. I believe it should be a rare occurrence which is near impossible for another to replicate.

Thanks for clarifying.

Brucel,

I am glad to see another neurologist posting and if you search I have exactly the same problem. I tried the suggested workarounds but they do not work in my office. I dictate my note with Dragon and just like my transcription this needs to be proofread by my staff. We have simply lost too many charts in the handoff, and while I like the program in many ways it seems my only options are to proofread myself, which slows me down tremendously and does not catch all errors, or forget about proofreading and sending out files with errors, both of which are unacceptable.

It seems that specialists have a much greater problem with this as the completed note is their "product", something that must be near perfect. Neurologists in particular regularly produce long, descriptive notes that must be proofread if one does not want to come of sounding like an idiot, literally. I have cringed when I read a few letters I had sent to referring docs without being proofread.

I have been monkeying around with Quest's Care360 which allows for a location to store "Notes in Progress" and allows you to specify who in the office has access to that location. I have yet to lose a file. No forwarding or other confusion that I cannot for the life of me explain to my staff. I don't know who is more scared to move a chart in AC, me or my staff. This issue has been the only one limiting my adoption of this otherwise wonderful EMR. I am back to the old system of transcription - no EMR benefits, but so much quicker and failsafe.

Please tell me what gives.

I am certain you and your staff will develop the knack of working the way AC works. I can't remember the last note that anyone in my office inadvertently closed and lost content.

From what you both say, I guess the flaw is the handoff from doctor to inexperienced staff. I know that this has been said before, but it is possible to "Save" a message to the "Saved messages", and then forward it to staff. Or forward it to both yourself and staff. Put something like "draft" in the title line. This way you have your own copy.

I had a lot of questions from my staff when I decided to use AC as an EMR. After the break in period, I told them they had to to get familiar with its use & quirks. The alternative was to go back to filing and copying and pasting in typed dictation. No one wanted to go back.

I think you will succeed in streamlining the process in your office too. Likely long before AC fixes the bug.

I think everyone wants it perfect right out of the box. I see where it would be better if AC would change the workflow. Personally, I would never send a chart to anyone, which is probably why I don't have lost charts.

Why not do the following:

Write your note to the point of signoff. Save it to your inbox. Whoever proofreads your notes could log into your inbox (we have only one password that we use). What's the harm of that. Is she/he going to write their own progress notes?

They proofread it, make changes, save it back, then change the color to blue or red or whatever (if possible) and it's done.

" . . . I think everyone wants it perfect right out of the box. "

Bert - One of the strengths of this forum is to introduce and exchange new ideas and perhaps optimize them enough that the can be presented or reviewed by the AC developers as well thought out improvments.

It is clear you have developed many work-arounds probably the best possible within the limitations of the program. But also , why not think about how to improve the program and simplify the work flow.

Again, instead of your work-arounds, why not consider the following:

1. Simply allow closure of an encounter without having to lock it, with default *saving* of the encounter data when the encounter is closed, not a default erasure (I agree fully with Ann Marie, encounter data is unique and irreplacable - the program should do everything possible to preserve it).

In addition:

2. Allow access to the non-locked encounter by other staff memebers with the appropriate level of security so they can proofread and/or add to the chart - and allow this access not just by ackwardly fowwarding the chart back and forth but by allowing multiple user access - again use the *advantages* an EMR has to offer, instead of emulating the disadvantages of a paper chart.

3. Allow the provider to electively sigh-off/locking of the chart - not as a protective mechanism to be invoked against inadvertent erasure, but when the provider is ready and truly feels the encounter is comlpete. (perahps a small date stamp appearing in the corner of the chart wold allow a provider to know when the individual encounter has been locked.)

4. Save encounter-generated correspondence in a more versatile form such as a *. DOC form. The current correspondence saving as an HTML provides no versatility - the provider is left wtih a prematuarely locked chart (with typoes and dragon-generated paraphasic errors) and a unalteralbe encounter-generated correspondence which, by virtue of the HTML form is also unalterable and almost unusable

Bert - I appreciate your suggestions for work-arounds - but lets also try to use this forum to generate new ideas, and by virtue of input from other users, optimize those ideas enought to present them to the AC developers.

Bruce Morgenstern, MD (Neurology)
Denver CO

Bruce,

I appreciate your comments. I still think you misunderstand me. I am 100% for fixing small or big things that will make AC much improved. Trust me, we have tried to get Jon to fix the letter writer since v1. It is horrible to say the least. Saving in HTML is terrible. I have written more pleas to Jon in emails and on here than you can count.

As to the charts being lost, I agree with AnneMarie and you and countless others that making it where you can't lose the chart would be a huge improvement. If I can help count me in.

But, since I can't change it, I try to have the users show me where they lose the note (since I could not reproduce it), and there is only one place. Closing the chart after it has been saved to the inbox. Based on this and based on NOT being able to change the whole program at present, I try to help users by coming up with ways they could change how they view the work flow. It is not a workaround, it is simply ideas.

I think if you think about the Letter Writer, it would be rather easy to allow it to find its default program (Word), but it may be difficult to save it to Imported Items. Maybe when it prints from the letter writer to Word, it would save still in HTML, but you would have Word. But, there is no program I am familiar with that allows one format to print to Word. And, everyone would still be stuck with how do they save Word. Sure, you can name it and save it anywhere on your PC, but you can't save it to the Imported Items folder as 1) there may not be one, and 2) you wouldn't be able to pull it up from Imported Items.

So, it isn't as easy as you think. I still find my "workaround" to be doable until a better way comes out.

So, please understand I am not against changing the program to make it better. If Jon asked me today would you prefer a perfect letter writer and a perfect way to save notes, I wouldn't tell him, "No, I have a great workaround." You have to remember, a lot of us on here have tried many times to get these things fixed and have gotten nowhere, hence the other ways of doing things. This year's ACUC may change all that. And, more and more people seem to be contacting the developers personally.

Well articulated - my apologies Bert if my post sounded a bit aggressive - we are in full agreement.

Regarding storage of truly usable and edit-able letters, sounds like there may be a few opions:

1. Save the dictation in Word*Doc form, but designate a place other than "Imported Items" to store it in and place in AC an icon or tab to point from AC to where that folder of word documents now lies. Still keep imported items under "Imported Items", just design a new tab or icon called "Letters" (or Correspondence)

2. Store the letters in a form similar to Word's *.Doc-form, but is not actually a *.Doc and can stored in "Imported Items" but still allows the letter to be modified and edited (including adjusting spacing and margines as well as grammar). Unfortunately I'm not computer savvy to know what that form would be.

Let's hope for the best -

Bruce Morgenstern, MD (Neurology)
Denver, CO

I couldn't agree with #1 more. All I will say is if you start with the Word document in the Imported Items field in AC, then it will save there. Just a thought.