Home Forums Discussions Problems Where to put stuff

In one form or another, I know this has been covered, but I have not yet gotten the picture. So, please forgive my redundancy.

There are things that happen that we want to be able to see quickly at the time of each visit. Like, when was the last mammogram or colonoscopy or TDAP. I want to see those quickly, without tunneling down through three layers of tabs or menus. So, we have been putting them in past history.

The problem is this: Billy Bob comes in for a wellness exam. We see in the PMH that his last colonoscopy was 9 years ago, and he has a family history of colon CA. So, we schedule this and it is done two weeks later. However, unless we take the time to open a new chart note with every test result that we import, and enter the date of this new procedure in the PMH, when he comes in next we see only the old date, tell him he needs to get it scheduled, and look like a moron instead of a hero.

We can use tracked data, but this also requires drilling down and a new chart entry when it is done. A chart addendum is not part of the typical chart flow. Health maintenance is similar and uglier.

Is there some elegant way to accomplish this I am missing, assuming that I am not Kaiser or the VA with an army of clerks to manually enter this stuff?

I still think the Imported Items Excel sheet is the best way to handle these things.

I use a single line in the popup note.

David - After six months of using AC, I'm beginning to beleive that the word "elegant" is one not frequently associated with this program. I've had the identical problem. Below is part of a list of suggestions I made to AC a number of months ago - I'm pessimistic that things will ever change:


Please ad an "Interventions" section to the patient chart to allow providers to easily access patient information that frequently needs to be reviewed.

An INTERVENTIONS section could easily be added to Amazing Charts in one of three ways:


Idea #1. Add an actual ?Interventions? field, to the Present Encounter view: This would be an empty field (theoretically on chart?s LEFT side, as it would be a cumulative list), that would simply be a space for providers to add synopses of accumulated important data


Idea #2 . Expand the use of 'Tracked Values": ?Tracked Values in AC is already designed to contain specific lab data a provider will frequently want to access ? By expanding its accessibility it could fulfill the need of an interventions field. For it to function optimally this way ,It needs to be more accessible. These are the parts of the chart where it should be addressable:

a. Most Recent Encounters Page:

b. Past Encounters Page:

c. Message Page

IDEA # 3. Liberalize the use of IMPORTED ITEMS to act as Interventions field. To allow ?Imported Items? to serve the use of a data repository, I would suggest the following:

a. Allow user-defined Item Types (Ie. the CAPITALIZED Item categories)

b. Allow the provider the easy option to *rename* a lab transmitted through messaging .

c. Finally, Imported Items would need to be modified to allow filing of comments from sources that didn?t contain an actual attached lab study. So, for example, if a message read,? Ms. Smith is stopping her nortriptyline because it makes her dizzy? that information could be filed under ?Imported Items? as well, perhaps filed in a user-defined "Medication Experiences"

I agree this is a critically-needed component of this program, but I'm pessimistic it will ever be addressed.

Bruce Morgenstern, (Neurology)
Denver, CO

I'm with Bert, an imported Excel sheet would allow you to track what's been done and needs to be done. It can also be customized to your liking.

Thanks to you all, and I'll look for more suggestions. The issue with the Excel spreadsheet is that you still have to drill down to it, wait, open spreadsheet, wait, etc. I want the Classic Comics edition, right in my face when I pull the chart. The yellow popup note box has little room, and I have to scroll around to see more than one or two items. Something like the popup yellow note that would expand with a single click would work fine. I hope Bruce is too pessimistic.

David,
I have a template for the PMH which includes Surgeries, Medical Hx, Immunizations, Colonoscopy, Mammogram, Bone Density Scan, etc. Under each of these headings I have a running list of what, when, and results. As I am not a proceduralist, I merely update these fields at the patient's annual exam.

Leslie,
That's kind of what we've done. However, then as new stuff comes in, you have to add an encounter just to add it to the PMH unless you have some place to store the data and can wait until the annual... this used to be called "the chart", and we could put those items loosely in the chart to review when we saw the patient next. If you add an encounter to AC, the previous visit list starts to get overpopulated with lots of stuff that are not really visits, and dilute out the ability to quickly review by clicking "assessment and plan only" filter.
The Excel spreadsheet fixes this problem well, but is still a couple of layers down. I was hoping for an "in your face" solution, like the PMH.

David,

You can still use the Excel spreadsheet without an encounter. Leslie's excel sheet works well (thanks Leslie) and it is opened through AC under the Imported Items section. You can update it without having to add an encounter.

OK, so we addressed this at our weekly provider meeting this morning, thereby once again displacing our customary journal club and medical review time with computer stuff :-( We have decided to go with the Excel spreadsheet. Thank you.

Now the detail to struggle with is this: Who makes sure the spreadsheet is in each chart, and who makes sure it is current and up to date? What we really want to avoid doing is create yet one more low level task for the provider to deal with. The spreadsheet, once created, has to be brought into the imported items for each patient if they don't have one started. This seems like it can be a task for the lowest skilled employee, maybe working off a patient list and having that as the sole task for a week or two. Then we will need to populate the spreadsheet with data that has been put various places. That needs some level of medical knowledge, so maybe that will be a medical assistant, maybe trying to keep a week or so ahead initially. And, it needs to be reviewed for accuracy, hopefully just before the physician sees the patient if possible.

Again, I am struck at how much of the Electronic record deals with management stuff and not medicine. We have to figure out who is going to do what, who is working to the top of their skill curve, who is stretching too far, and what to do with tasks that can and should be delegated. Then, of course, there is employee turnover, and the entire playing field changes.

The basic rule we have made is that everyone should be working at the top of their skill set, and avoid having situations like doctors addressing envelopes. I get the sense that if I were solo, and had one assistant doing everything this would be relatively easy to figure out. And, if we were a 20 doctor clinic, it would be formalized and an employee would be hired for a clearly defined set of tasks. But, we are in the middle, and it is very frustrating. So, I'd like to hear from others (Bert? Marty? ) whom you have doing these specific tasks. I'd especially like to hear how any small groups like ours approach this.

David,

For the present time, we have AC running on the two newest computers so all data entry for now is done by me and the other PA.

The goal is once we have all the computers in place, the front desk person would place a copy of the Excel spreadsheet into the patient file with all the demographics information filled out.

Then the nursing personnel (MA's) would then input the data into AC before being seen by the provider. The providers will review it.

That's my take on it. I'm sure others have different ways they do it.

This is one solution, another is that the person who is importing the results in the chart could do a note (main AC page) that will pop up as interim material (if you have it turned on) since the last visit.

The note could either give normal or see results in imports if it is too complex for the staff member entering the note.

I don't do this, I just look for the result. I don't send out as much stuff and I review all the faxes coming in, since I am solo, so I know the results usually before I open the chart.

I don't know why we can't have a "send to a field" button when importing of viewing imported items. If I can send a message to my staff when I'm reviewing imported labs, why can't i send "colonoscopy done 7-15-2011" to the PMH?

David,
Some food for thought that goes a little beyond your initial question.

Actually, using addendums might be a good way to accomplish what you want here, but you are right about typical chart flow. But maybe "typical" is wrong. AC opens every chart by taking you -by default and without any choice- to the "Most Recent Encounter" tab. What if it instead it opened to "Past Encounters"? Or what if you immediately switched to that tab, or opened the chart with F8? I think that would make more sense.

Why do I suggest this? First, for your purpose, you would see the past encounter with its date on one line. Above it would be a line that says: "Addendum colonoscopy done" with its date. Above that is "Addendum CT done" etc, etc. You could immediately see what has been done in the interim. If your on-call partner talked to the patient over the weekend, the phone message would be there, too. Record keeping is pretty simple; staff is instructed to create a one line addendum for procedures or other events you want noted this way. You then know to go to the imported items to look for the actual report.

The other reason I question why AC chose to open the chart by default this way (and we all go with it) is that it is often confusing for new users. They open the chart, and see "Most recent encounter": but it really isn't the most recent encounter. It has today's date...it has meds added that were prescribed in the interim...it isn't signed. It's NOT the most recent encounter. In my experience, new users and staff are confused by this.

As you point out, when you sit down to see a patient, you want to see your last note AND a review of what has happened since the last visit. Why not see start with "Past Encounters" where you can see if there is anything new at the top, and then see the actual "Most Recent Encounter" below that? Oh, and this way you can see the whole note; on the "most recent" tab, you have to tab through each chart section and scroll through each box to see the text that doesn't fit.

As far as Excel, Leslie's is quite good. Also, consider that the sheet you make may be with you a while, and there are many people out there that are Excel experts, possibly even setting it up where data such as HbA1C's can be averaged easily.

Jon,

I used to talk about this all the time, but just gave up. I wish that AC opened to a problem list so you could see everything about the patient at once. Meds, PMH (not all the notes), PROBLEMS, etc. Even the last impression and plan. I don't know how many times I have told parents their child has a murmur we need to check only to find out he or she has pulmonary stenosis. Or the child is a little reserved, and I wonder about Asperger's, and he already has it.

I also think it would be cool if you could see the impression and plan after the MA charts and possibly click on a tab to open a new impression and plan field.

BUT, we must remember that this is the least expensive (except for the free ones) EMR there is.

There seem to be two different trains of thought here... how we would do it if we had developed AC, and how to make do with what we have.

As to the first, I have no idea what Jon Bertman's practice was like before he started developing AC, but clearly it was different from mine, and his documentation priorities were way different. Bert, I do not feel the fact that AC is not overpriced is a reason to just shrug about it and say "well, it's cheap, so what do you expect?" I expect something that meets my needs. I do worry that the longer Jon is away from clinical practice, the less in tune he and his group are with what we need. Software designers have a distressing tendency to get wrapped up in the beauty of their code, and forget what it is supposed to do. I know from experience; the databases I have written become my "children", and I tend to be very hostile to my staff who suggest that my interfaces are less than stellar, or the program locks up at times.

As to the second issue, however; Marty, your approach is one we have thought of. I'd like to know more about your practice... how many providers, and what kind of support staff. Our front desk/receptionist/scheduler is pretty much maxed out, so we are going to use one of our front office folks. Our setup is a bit difficult to describe as we have full time, part time, trainee, end experienced folks in the mix with different levels of training and ability. I really do not want to start with a system that has providers doing unnecessary data entry; in my experience it is harder to get others to assume a task I have been doing than to have them doing it from the get-go. And, Bert/Leslie, a concern about the spreadsheet is whether we will have to re-enter everything if health maintenance eventually becomes easier and we want to migrate the data to that. Have you played with it in version 6? Do you think that is going to be the place to put a lot of this stuff?

Exactly. We grapple with all the time. It is natural for us to suggest changes to the way the program works; we use it all day, every day. Let's be realistic, though. Jon B's intentions in this area are certainly good, but I would ask the old-timers here, those with some institutional memory, to point out significant recent changes in the program that came in response to user requests. Bert is sitting on a list of more than 80 such suggestions. Not that all of them are worth implementing, but which will be incorporated soon? And by soon, I don't mean V8 in 3-4 years (after all of the nasty governmental MU stuff is worked out, and after PM is sorted out). Sorry to get off on a rant.

My suggestion was firmly from the "we can do it now" mindset, but perhaps got lost in my verbiage:

Have staff enter a one line addendum when they import procedures, surgeries, significant radiologic studies, etc. Get in the habit of opening the chart and looking at "Past Encounters".

Do those two things and very soon you will start to see that the patient got the colonoscopy you recommended, the ECHO for pulmonic stenosis, etc.
I like the spreadsheet idea; (Leslie can I get a copy?). It certainly would create a repository of a lot of useful information. I just wonder if this just would be a quicker, less work intesive way to accomplish part of what you are looking for.

On the way

Thanks, Leslie.

And here is another idea. Maybe it is the most efficient way to handle this issue:
Take a sheet of paper, one for each patient, and write their name at the top. As the results come in, have the MA record them on the paper. Keep the papers in a file cabinet and have the MA put each one on your desk when you see the patient.

Is there a "tongue in cheek" icon? I feel the need to use it here so no one tries to shoot this one down.

What's a file cabinet?

Leslie,
You remember the file cabinet, don't you? It's where ladies keep their purses and staff keeps their brown bag lunches and stuff...

I am new to Community Chat and my concern has probably been addressed. But..could you give me a recommendation of how to track referrals/authorizations which have a visit # and date expiration? We now have to have referral from Freedom Health for every office visit! Pat

David,

Our office is a mix of part-time and full-time staff. I am full-time here, I have another PA who works two days a week. We have an MD that comes in two days a week (soon to be three days a week).

We have two full-time front office staff, one part-time front office. Then we have two full-time MA's.

Tracking things that have and haven't been done isn't exactly ideal in AC as you already know. Health Maintenance is a good start but is far from perfect. For example, there is no way for me to currently query health maintenance to see how many people are due for a pap smear in the month of December. I can query and see what's due for health maintenance but I can't separate anything. Lab tracking doesn't work, so that's no help either.

Pat,

I use an excel spreadsheet for all my referral/authorization requests for all patients. It's in a shared folder on our server and anyone can access it. In the spreadsheet, I enter patient name, DOB, date of request, tracking #, service requested, authorization approval date and date patient was notified.

Thanks, Marty. Our mix is fairly close.

And, Jon, my preference is to keep the addendum list as uncluttered as possible, so I will probably not go that route.

BTW, it took me a while to get the flow of an encounter going after adopting the computer. I am not all that bright that I can trust myself to remember anything about the next patient. So, if I have a moment, I will pull the chart just before going into the room and quickly review past encounters filtering for assessment and plan only. If not, after greeting the patient, I say "give me a moment to turn my brain on and review where we are", and then do the same. I worried patients would be put off by this, but it seems to go OK. I guess they realize they are better off that I look like I'm being careful than that I pretend to know everything about them.

I think my statement was taken out of context. Do we have less of a right to complain with a cheaper EMR? Yes. A cheaper EMR means less developers, less support, etc. Ideas from users will get put into the program much more slowly. (Yes, I realize here it is mainly not at all). Purchase Microsoft Word, you will have very few complaints. Use the free Wordpad, and you will be asking for improvements all day. Same with Outlook. Use Windows Mail. I have asked Microsoft for many things. All I get is an email thanking me, but no changes are made.

You are correct as is everyone and I have said it for months on end, that AC would likely be better if Jon practiced more. But, certain things are more important to people. For Jon, clearly formatting is not. And, therefore, fixing those things aren't as important to him. It should be if he wants to keep his user base.

I don't think anyone wants to improve AC more than I. I spent many, many hours with the survey and sending a well-organized list of things that can be changed to ACUC. Personally, I think some would be integrated if it weren't for MU and CCHIT, etc. And, for those who want changes in AC that also want PM, I will go out on a limb here and say they have no right to complain about AC. Because PM is going to be buggy and take up much of the developer's time. And, just like with AC, there will be 100 things that people want different.

I am not saying because it is cheap, we should expect a cheap product. I am saying that there are less resources because of this.

There are many of us (whom I cannot name) that wish that AC would be the little engine that could that made it so good in the first place. And, fix the issues and add ideas, etc. But, now the company is growing bigger, MU is in full swing with all the health maintenance and soon PM will be the major focus. Where to put stuff would likely be much easier if it weren't for the MU and HM and PM, etc.

I think we are either a little spoiled or see things from a distorted perspective. Because the message board and AC seem so intertwined it is easy to make suggestions or complain (which we have every right to do). AC is flawed either because it doesn't fit someone's needs or because it is simply flawed. And, of course, there are many areas that could be done better. The famous 81 is the first time AC has actually had an organized list of suggestions and complaints. Let's see if they are incorporated. I doubt they will any time soon because we all want the official release of 6.x and then everyone will want PM.

Just my thoughts.

Bert, I think Travis put this well, about a year ago:

"You have t[w]o rooms. One room is perfecting AC on the EMR side. Make the letter writer more robust, make orders a little more seamless, enhance the abilities of the scheduler to match competing EMRs. These people should be testing other EMRs that people like and figure out ways to bring AC to that level in the weaker areas. Go to several docs offices like Bert's or mine and watch how we use the system, where it slows us down, where it can be better, where it shines.

The other room is the room to keep you from getting left behind. Its the PM developers. These people need to have a hang out with actual billers in various specialties offices to see what is most needed from a great PM system"

I wonder if there are two development rooms at AC?

Well, they just moved to new digs, so I hope so.

I am surprised nobody is using the Tracked Data/Flowsheets section, under the Summary Sheet tab. It seems like it would work just fine. New colonoscopy comes in. You can open chart, go to Summary Sheet tab, and add a row in the Tracked Data/Flowsheets section that says today's date, "colonoscopy" under Item, and "adenomatous polyp, repeat 2014" under Value. Is this really harder than going through the hassle of adding a spreadsheet to each chart?

Agreed Amazing Charts could do a much better job at tracking such data