Home Forums Discussions General Discussion Pediatrician Evaluating AC--Questions/Problems

Hi, I?m thinking seriously about using Amazing Charts but I?ve got some questions/problems re: configuration as I try to evaluate for my practice. I?m a solo pediatrician.
Couple of things:
1) I don?t seem to understand how (or if) I can configure immunizations. I?d like to:
a. Add second recommended Meningococcal (MCV-Menactra) at age 16 but system seems to not let me do that?
b. Refine Influenza to be able to clearly specify type to my assistant, ie. Influenza < 3 yrs (of age-killed vaccine) plus Influenza >=3 yrs (of age-killed vaccine)?these two share a VIS. Then add also FluMist (live, attenuated vaccine) with its own VIS. I see where assistant can select the type of influenza vaccine but I?d be more comfortable if my order were more clear?. Is that possible?
2) I would like to default vitals to metric---this is a current AAP/JAHCO recommendation to help avoid medication errors. I see the toggles but can?t figure out how to default to metric?is this possible? Also the height/length toggle is ?inches? and ?METERS?? not ?centimeters?? Is that adjustable ?cause I just got people used to centimeters---I?m never gonna get them to go to meters---infants just don?t do meters well---?
3) Does anyone know if World Health Organization Data (instead of CDC) data can be used for length, weight, and head circumference for infants/toddlers to age 2 yrs as is current CDC/AAP recommendation? ?WHO to Two??
4) Where/how can I store developmental testing done at well visits--specifically I use PEDS-DM at every visit and M-CHAT at 18 mo and 2 yrs?
5) Where is best place to put results of sensory screening--Vision/Hearing including Picture Audiometry?
6) What about Last Menstrual Periods? I can't seem to find a place for that.

Thanks so much for your input and advice! Kathy

I too am solo peds.
5--I keep vision and hearing testing results in "Tracked Data" on the summary page. it's a little awkward: L20/25,R20/40,B20/25 is what I type for a vision test, and 'better than 25dB throughout' for hearing screen. I also keep UA dip results, baby bilirubin tests, hemoglobin results there. I also keep in-office strep test results there.
6--I put LMP there if I want to keep track of it.
2--The rest of the world measures height in cm. I don't know why AC toggles from inches to m. And it is vexing for me and many others that weight toggles from pounds to kg, but without enough significant figures to follow baby weight in grams and they have had repeated requests for pounds and ounces, since this is the way we follow newborn weight.
3--I don't know about the integration of WHO data into the growth charts. This is recommended by the AAP, and at some point it will not be considered good medical practice to use the CDC data currently in AC.
4--I integrate Dev Testing into the notes.
5--immunizations are an ongoing frustration for me. Apparently, I am unable to edit the descriptions they have noted, nor the schedules they have loaded. So, after upgrading to version 6, for example, my PCV13's are coming up as "7-valent" The MCV issue I have worked around, by inventing my own immunization (the program does allow you to do this) called 'meningitis,' and then putting in the correct age range and interval as most recently published.

Thanks so much!! I'm gonna have to think on this one a bit. I need LESS frustration not more in my life and meters and immunization issues might do me in. I hate to have to create too many work arounds--it destroys efficiency. Kathy

Kathleen,

I think you will have to go with a much more expensive EMR to get all of those.

First, I agree with the metrics. But, that's not AC, it's U.S. As long as the United States thinks that inches and pounds is better than cms and kgs, this will be an issue.

Our hospital measure babies:

Weight in lbs and oz
Lenght in inches
HC in centimeters

So, how dumb is that?

Meters is obviously stupid and if you search the board you will see where I have asked for each to have its own column. Given no default, when you have a FTT baby, you will end up having 7 lbs, then 3.2kgs, 3.4, kgs, 7.3 lbs. It's crazy.

As far as the immunizations, you should try VIPER at www.medwaresoftware.com

It should take care of most problems. If not you can talk with my MA or another pediatrician on here.

Well, I'm actually dumping a much more expensive EMR/PM system and the amount something costs isn't always an indicator of it's worth... In many, many ways AC looks to be a much better product.

Right now, I'm just trying to find a way to get my charts documented without pulling out the paper again and get home to my family.

So, what exactly is VIPER? The link doesn't really explain what it does--just offers the download (unless I've overlooke something--which is completely possible)!!!

I've actually created my own immunization inventory in Excel that counts down when immunization is given, pushs the immunization information to a "chart documentation" form and also to an "immunization record" that is in a parent/school friendly format. The MA only has to enter the patient name and DOB one time, and enter the site of the immunization and her initials. It also handles combination immunizations with single entry but pushs information to update individual components.

I've also created "WHO to 2" growth charts in Excel that will overlay the patient data on the charts--which can be printed and re-sized for viewing, automatically drop in date of measurements and automatically dropping in the correct percentiles in the data entry area.

So, I have some work arounds that are functional. That said--meters is a huge pediatric issue--and I see you agree. And, I'm not sure I have a work around for that one...

But, I just started playing around with AC a few days ago while I transition out of this other product (NIGHTMARE!!!).

This board is really awesome. And I look forward to hearing how VIPER works. Kathy

As far as the meter thing, the workaround is just to use inches.

As to VIPER. It's incredible. Does all the stuff you are talking about automtically.

You can download this video and check it out. You can also download it and install it. Won't change or hurt anything. My MA can also talk to you about it at any time. She is extremely proficient. Enters four vaccines in under ten seconds.

http://www.box.net/shared/static/ciql08xeri1yhc0yo0fq.zip

By the way, what is WHO to 2, and why is it so important?

I assume she is saying use World Health Organization growth charts for infants up to age 2. I had talked to Jon about this in the past as it is important to some pediatricians and he was going to look into this. I think it is amazing that we have to change growth charts - I basically look for trends.

Thanks. Yes, I knew she meant zero to two years of age. I just don't know why it is important. And, when I say that, I don't mean it in a bad way, I am just asking.

I would think have growth charts for Down syndrome or certain ethnic groups would make more sense.

To be honest, my biggest pet peeve about growth charts was when they changed from 5% to 95% to 3% to 97%. I used to be able to glance at them and tell a parent what they were. Now, I have to enlarge it and count the major percentiles: 75%, 90%, 95%, 97%, etc.

I am not sure why they changed from CDC to WHO ???

From the CDC re: Why the change?

"Why use WHO growth standards for infants and children ages 0 to 2 years of age in the U.S?
?The WHO standards establish growth of the breastfed infant as the norm for growth.

Breastfeeding is the recommended standard for infant feeding. The WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at 12 months.

?The WHO standards provide a better description of physiological growth in infancy.

Clinicians often use the CDC growth charts as standards on how young children should grow. However the CDC growth charts are references; they identify how typical children in the US did grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow when provided optimal conditions.

?The WHO standards are based on a high-quality study designed explicitly for creating growth charts.

The WHO standards were constructed using longitudinal length and weight data measured at frequent intervals. For the CDC growth charts, weight data were not available between birth and 3 months of age and the sample sizes were small for sex and age groups during the first 6 months of age.

Why use CDC growth charts for children 2 years and older in the U.S.?
?The CDC growth charts can be used continuously from ages 2-19. In contrast the WHO growth charts only provide information on children up to 5 years of age.
?For children 2-5 years, the methods used to create the CDC growth charts and the WHO growth charts are similar."

I've been doing this for about 1 yr now and it does seem to reflect more "normal" pattern--With the WHO charts I don't see that drop off in weight at 9 mo nearly as often---and by using cm instead of inches to measure kids my length charts make so much more sense. Using the small unit of measurement just gives more accurate results. And I, too, HATE the 3rd and 97th percentiles on those charts and dropped them off the charts I made. I much prefer 5-95... short, sweet, easy to read.

Will be looking at VIPER shortly.

Kathy

Kathy,

Thanks for the explanation. Very concise and very helpful.

Kathy,
It is amazing how clearly you read my mind on certain difficulties for pediatricians using AC. I am also a solo pediatrician and have now been using AC for just over 3 months, having many of the same issues.
I have wondered if we could get enough comments here maybe we could get a few changes in the programing to make this more functional for both pediatrics and family practice.
My biggest issue is that you can not lock the system in grams/kg for weight - this is clearly a big safety issue for medications.
Also you can not see the patients weight when doing e-prescribing, nor is there any type of calculator available so you have to plan ahead, check the weight, pre-calculate the dose etc prior to opening that window.
Not being able to track the babies weight in grams is a disaster here at an altitude of 8000ft where weight gain at 2 weeks is frequently an issue, we just put it in the notes section.
I was also looking for WHO charts, and when in doubt we individually scan them into the patients chart, -definitely less than ideal.
The immunization charting needs work in many areas, ?no ability to document that the VZ vaccine was given SQ etc etc.
Perhaps we could get a pediatric forum?
Overall I would tell you that I am really pleased with the program, and I have absolutely no regrets with choosing it. I have used a number of different EMR systems in the past and feel very optimistic that over time as this system is updated these issues can be resolved through physician input to make this a spectacular pediatric EMR.

Hi Mtnpeds. First, if you make an auto-signature with your first name, it would be great. I have been rather negative on here, but this shouldn't be construed as negative but more just giving you my eight years of experience. Amazing Charts tends to add versions and add its own things and fix bugs. I think you will find it hard to get things changed like this. I have tried for years to change the way grams and kgs and inches and cms have been done but to no avail. Also, the majority of users on here are FP, and they really have significantly less pediatric patients in general almost to the point where it is not an issue.

This is another thing I have opted for for a long time. It would be great to have the weight transfer each time to the prescription writer. Or, at least if the program did what a lot of people wanted, which is for the windows to be able to remember where they opened. If you could at least see the patient's chart instead of having it behind the script writer where you have to drag it down each time. I am not sure which version (I think v6), but there is a very good calculator on the ePrescribe window. I also think you will find per above that once you open the prescription writer window and need to calculate 90 mg/kg divided bid for amoxicillin, you can put in amoxicillin and when you get to the sig, just draw the window down, and you will see the weight.

http://www.box.net/shared/static/ciql08xeri1yhc0yo0fq.zip

I think I may have misunderstood your question or I am missing something. There is definitely a "how given" field in the immunization module. I may be missing where you are referring to. The site above is taken from the post above, which is a rather detailed demonstration of VIPER, which is freeware. We use it exclusively, and it is much faster. I definitely don't plan on adding a pediatric forum. There are just too many PCP, specialists and sub-specialists to have forums for each.

Hope this helps.

If you want to make changes, this is not the place to do it. You can send the suggestions via the recommendtions section on the computer. AC Central does not always read it here.

You can move the prescription writer down and see the vitals boxes. Yes,I agree that having them on the Rx writer box would be better, but this can help.

So, some questions re: VIPER. I guess it interfaces with AC? and the patient's demographics are pulled over from AC to VIPER but you give all the shots via VIPER as a second program and those don't push into AC? Or do they? Where is the documentation of the date of the VIS in VIPER and that it was given to the parent? And, where do the initials (or whatever) of the person who actually gave the shot go? Thanks, Kathy

1. It interfaces with AC and the vaccine record.
2. You give all the shots via VIPER.
3. What is in AC is in VIPER and what it is VIPER is in AC except for the erroneous vaccines in AC. VIPER would not be worth it if it didn't put the vaccines in AC.
4. Working on both of the last questions.

I would add to this discussion that I love most of the changes made to v6 of AC with regard to entering immunizations. It's really easy to enter immunizations, and multiple immunizations at a single visit. V5 had a silly omission that was a big deal--when we printed out a kid's immunization history, our letterhead was not included, so the printout looked like a spreadsheet made at home. It's WAY better than a couple of the other systems I have used. A mild gripe on this specific issue is that they have done a nice job of incorporating most of the current guidelines. BUT the guidelines change very frequently. I was just notified that we will be giving HPV to boys. In the last 6 months or so, a second meningitis vaccine has been added. Locally, there's a mumps outbreak, so there might be a local recommendation for a 3rd MMR. It would be great to be able to edit some of the rules.

I have found the WHO charts especially helpful for some babies, but my experience suggests that growth charts are an important big-picture perspective. Is there clinical significance to consistent growth at the 40th percentile vs. 60th percentile? I will always be vigilant with a child losing multiple percentiles over months. If they are failing to thrive on the CDC charts, will they look fine on the WHO charts? So it would be great to choose this charting on AC for younger kids, but it's not a crucial issue for me.

In general, I love AC. There are NO alternatives that are easier to learn or maintain. The Centricity practice I used to work with employed 2 full-time IT people, and still they needed 'service' visits from Centricity tech people very frequently. Just because we all want it to be better, and have features that would make it more useful, the cost/value ratio is very high.

I would still say that VIPER is five times easier and five times faster than AC's method. And, the printout format is better.

4) I am a peds MA and office manager. I store the MChats and develop screening by scanning them in under the "imported documents" tab, then choose a catagory ( I use "other"), then save it.

1)A) if you go to the Admin, log in, go to Health Maintenance- you can change the recommendations.

1)B) if you go to the Admin, log in, go to Orders- you can add and change here. Orders don't really affect the chart: they are just for your MA. What you MA actually does and adds to the chart is seperate, so you can place whatever order you want on this list.

5) results of hearing and vision: make orders that say these. when you order it, and your MA gets it on her message screen, she can open the order (double click), then right click on the empty results area; this gives templates to use. use one already there or make your own. I place all the results as normal (example: R:20/20, L:20/20, B:20/20) and that is my template. I change a number if I need to, then "move to chart"- this places it on your order results area. Then mark "completed", "update" order, choose Dr. for the message, save/send. The Dr will get the message of results; then the Dr. can "save to chart". All messages and results are under the tab of "past encounters". Here is my hearing template:
RIGHT
20>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.
25>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.
40>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.
LEFT
20>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.
25>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.
40>> PT= yes , 1000= yes, 2000= yes, 4000= yes, 500= yes.

Until I read this, I didn't know about viper! I downloaded it but I just got a demo version and there is nothing that says how to get the regular version. No company info to email or call- ----

Are you sure you downloaded v5 and not v4. I took v4 off the site. v5 as all of the programs on the site are all freeware. Let me know if this is incorrect.

Can you please clarify where Viper comes from? I could not find it on the AC website. It appears quite appealing. Anything to save time!

Bert worked with an uber programmer to develop it. It has been around for a while and iHas alwaysBetty better than AC. Jon has seen and liked it, but to my knowledge has not tried to annex it. He (Jon) stated he supports 3rd party development with AC

Bert,

Don't be so selfish! :-) Pediatricians are not the only ones struggling with tracking vaccinations, you know!

I was not clear from watching the V.I.P.E.R. video... is this a stand-alone application that accesses the AC database?

If we don't care about reports, but want the quickest possible way to just see for what vaccinations a patient is due, is V.I.P.E.R. still going to be our best bet? True, it is much less of an issue in adult medicine, but AC is still cumbersome. I just want a really quick way to say "yeah, you're due for pneumovax" so I can rapidly send my MA the order. I'd like the fewest possible mouse clicks to have this happen. (As an aside, I have started to count mouse clicks to accomplish a task, and some tasks are getting nuts. To import a lab, and send it with a note to the UpDox patient portal then sign it off took 22 mouse clicks.) What do you suggest?

Well, I don't use UpDox, so I cannot comment there.

VIPER is found at www.medwaresoftware.com.

v5 should not require any username or password and should not be a demo. It actually interfaces with AC. What goes in AC is in VIPER and vice versa with the exception of combo vaccines where Pentacel goes in as one DTap-IPV-Hib rather than splitting them.

If any problems or questions, please email me using my email on my profile.

While V.I.P.E.R. is good for documenting vaccines, it does not tell you what is due.

That is done by Health Maintaince in AC, you can click on the the tab next to the PLAN tab (the DECISION SUPPORT tab) and it will tell you what needs to be completed for the patient in HM.

And, you can still do that in AC even though using VIPER.

Is health mainainance better in version 6? It was not very useable in 5.029

It is better. I have been using V6 for almost 6 months, hard to say how much better since I am a little fuzzy on HM on V5. We primarily use it for immunizations. I do know in that specific arena 6 was a lot better.

Thanks, Wendell. It looks like the ultimate EHR is within our grasp, finally.

Health maintenance continues to evolve and the ability to track things are getting better. I find it most useful when I am with patient and bring up HM and look at last immunizations, colonoscopy, etc.

I think it is much better in 6.1.1 than it was - still need to figure out how best to use as colonoscopy still just shows last date and your comment - not able to set some for 3 yrs, 5,10 years. Unfortunately I find even poor adherence to standards about frequency of repeats even among specialists.

I can think of no other area in adult medicine, at least, where the financial self-referral bias is stronger. I find it very disturbing.

Steven,
You can edit the colonoscopy interval for an individual patient. In a patient note, click on decision support to show the large HM box. RIGHT click on the colonoscopy rule, and you can change the interval for that patient. I am not sure that the date works correctly though, if I set 5 years, it then shows next date 1-5 years hence. Hopefully this will get worked out.

I really like the HM section. I have created some new rules to remind me of things I want to check or follow. After I do ROS, I go to HM section to query patient about these items.

Just changing a line or two of code would fix the meters problem I would think. Maybe some developers are watching... I have been changing lbs to kg for so long (divide 2.2) I hardly think about it.

thanks! I did upload v4 because v5 said beta- and I didn't know what that meant.
how do you put in PREVIOUS vaccines that they had elsewhere?