Home Forums Discussions General Discussion can Amazing Charts do this?

Hi all,

Still in the process of evaluating EHRs. We are going to be using Dragon Medical v10.1 and a tablet. One thing that my partners are set on, is that we want to have a template in the ROS and Exam areas where we can tap with a stylus and check off boxes. At the risk of committing heresy, I will add that we looked at UniCharts, which from a design standpoint is exactly what we would like - but the software works very inconsistently with Dragon, and that could be a user nightmare...


I know that with Dragon you can make variables and navigate the fields, but can you make a template where one will be able to tap on a box/area to designate say, a "positive" or "negative" and have this appear in the body of the chart?

What we would like, for instance, is this kind of thing:

Constitutional: [box, or similar field] WNWD in NAD [box]fever [box] weight loss

HEENT: [box]PERRLA, EOMI [box] conjuctivae clear

etc. etc. - you get the idea.

I know that a template can be made and imported using PaperPort (or the like), but I have always assumed that because it is not integral to the actual AC chart, it would NOT be searchable - is that correct? (Obviously, it needs to be searchable for PQRI and meaningful use purposes.)

We have used a paper "smart chart" template for years, and feel that this kind of setup is a necessity to make this as seamless as possible for us. My limited experience with AC has been that it is heavily weighed towards typed/dictated input - or macros where one has to "fill in the blanks" with dictation or typing.

If AC can do this, it would be a huge, huge plus - any thoughts on the feasability of such a setup?

Thanks!
Melanie

I don't know of a way to do this within AC... but, I'm wondering if there is a way to do it from within the specific tablet preferences or capabilities? Is there a utility, for example, that would let you turn on a "tap equals X" function, whereby you could do the usual AC macro, and rather than a checkbox just have a space where you could put an "X"? Or, can you use the handwriting/stylus function to do a checkmark? The answer to this would come from either the makers or cognoscenti of your particular tablet.

With Dragon and my tablet (ASUS EP121 slate) if I use my stylus, I can readily change between handwriting and typing utility. If I were to make up a macro with a space to use a "check" mark, how would that appear on a printed note? Would the check mark show up? I would think that it wouldn't - but hope that I'm wrong!

Melanie

There is nothing very magic about the AC fields. I have almost no pad experience, but why not just make up some simple text document and try? My vague recollection was the pad I played with would turn handwriting into typed text. You might have to settle for an X and not a check.

You can download AC and use it for 90 days for free. You could download and try it??

I also have an ASUS Slate (EP-121), Dragon Medical 11, and AC. I am able to use the variable delimiters feature of Dragon (ie: when you say ?<next/previous> variable? or ?<next/previous> field? -- it will highlight the next or previous pair of []s along with any text included in the brackets). However, it does not allow a checklist, as requested by melanie, only the text in the brackets. You could use the stylus (or touch) to display the soft keyboard & change the highlighted text, but the idea is to dictate the change, of course.

I have an idea - don't know if it will work or not...

I have a Wacom stylus, and am going to see if I can program the stylus click button to write a word - like "positive" in the variable delimiter window of a macro...it may not work, but I'm going to try.

As an alternative - how clunky would it be to scan a template in by using Paperport - which can be formatted so that I can check off positives, and then attach it to a pts. chart? In real use, is it difficult to do this quickly? I would still use the AC chart to dictate the HPI, and also the Assessment and Plan - but use a scanned template for the ROS and Exam. As I think about it, there is really norhing in the ROS or Exam section that will need to be searchable for meaningless use...

As far as scanning a template, the sections in the AC encounter note will only allow text entry. There is no way to put a .jpeg or .tiff from a scanner directly into the template list. I think that you could process the scan with word recognition software to generate text however.

Well, I am pretty happy with myself - it only took me all day, but I was able to figure out how to program my Wacom stylus to put a "+" sign into a template - all within the chart!! Probably easy for some of you, but it's hard for a non-tecchie like myself.

I was able to generate a template (I made it for a ROS) in which I could do the following:

- I use a SpeechMike, so I programmed a button to go to each "next field". I then simply hover the pen tip over each variable area, click the button on the pen, and presto - I have marked the text as a pertinent positive!! No dictating or typing at all - a click of the mike button, then a click on the pen is all that I need to do - only on the positive findings, of course.

If I were doing a ROS on a pt. with a viral URI, the HEENT section ends up looking like this (this is a draft version, so don't pay much attention to the text!)


HEENT: + No visual changes + No ear pain [] No nasal discharge + No sore throat

Abnormals: Clear rhinorrhea


I wish that I could figure out a way to have the positive signs come up in red, but it's not possible.

There are Wacom pens with a 2 button switch - which means that I could be able to put in a "+" or "-" sign in each variable box! It would look nicer that having the blank "[]" areas. On the other hand, I think the "+" stand out better the way it is presently.

I also added the "Abnormals" section below each area, and programmed it so the text starts a couple spaces after the word, just like the example above. All I need to do is to tap the Wacom pen after the word, and I can dictate the abnormal findings if I choose to. I thought this might be nice to have, to elaborate when needed.

Is this faster than dictating the entire ROS? I don't know. But I can certainly envision being able to fly through a ROS and Exam field pretty quickly, with nothing more than a click on the mike button and a click on the pen button....

Now, I have to see if this will satisfy my partners!

Very cool!! I hope this does it. AC is a really fine program, and it would be unfortunate to move away from it for a tiny detail.

I will say that we had to adjust the way we did several things to accommodate the EHR, and it continues to annoy me that I have to do a number of things "their" way. I suspect others have had similar experiences. Mostly, after I whined long enough, I learned to suck it up and do what was needed, and now I mostly don't remember the "good old days." Mostly.

Out of curiosity, which other programs did you look at? Whichever one we end up with, one thing has become abundantly clear - it must be truly compatible with Dragon. All 3 of us are too old to have taken typing in High School (didn't think we'd need it!) and will have to dictate. We looked at UniCharts (good for the money, but not fully compatible with Dragon). Also looked at Practice Fusion (free, but ugh - you get what you pay for). We recently got a quote of about 40K for our office with a system called Criterions. The web demo was very nice, but to have a working trial of it, it would cost us 5K!!! Too much to try it out and find out we don't like it.

How awkward have you found the e-precribing to be with AC, and (if you don't mind my asking) what things did you have to change to accommodate it?

My partner was on the committee to evaluate which EHR's the State Electronic Health Exchange would choose for group rates and tech support, so many products were evaluated. This was before AC became certified, and for that reason it did not make the cut; but, she thought highly enough of it that when time came for us to go electronic, she chose that one.

Melanie,
I dictate every note in AC with Dragon. I'm a very fast typist, but typing is no match for Dragon. Frankly, I don't understand how so many docs can use AC by typing alone. Also, I have no use for those point and click EMRs you're talking about. When I get reports like that from other offices, they're generally worthless. Dragon allows me to "tell the story" of the visit and provide much deeper and more memorable documentation of the visit. That's important because I'm mostly telling the story to my "future" self.
For what it's worth,
Dave

Dave,
I am totally in agreement with you. I did not say anything in earlier posts, largely because there is a highly regarded contingent here that insists the note be done when the doctor leaves the room, and I do not want to belittle other styles. Reading your post however, released the beast inside me. I only use templates for those things that I feel have no significant value, like the ROS; if it is important, it is dictated into the Present illness. Checkboxes are one step below templates. I believe they epitomize what is wrong with the EHR.

Guys,

I hear you. When I did a trial on a few pts. using AC, I dictated everything. My Med. Director, who has said that he can dictate faster than anything, is the one wanting AC to be able to do what my template does. After he downloaded and tried UniCharts, he seemed to like the point and click + and - thing, and felt that it duplicated our current paper "SmartChart" nicely - and we are very fast at that.

The other considerations are that we also have a partner who is a non-typist, very computer illiterate (really!) and VERY RESISTANT to changing to an EHR system. I think he feels that my template will be easier for her to adapt to.

Another consideration is that we are all in the habit of "counting the bullets" in the ROS and Exam sections to be sure we are coding at the proper E&M level. Our major insurer, Blue Cross Anthem (California) has historically allowed us to check the "all other ROS negative" box at the top of the ROS section and count that. Soon, they will be disallowing this. They want to be able to audit our charts and make sure that we are addressing each and every bullet that we are counting towards substantiating the E&M level we are billing at. I was going to have a line that said "all bullets not marked with a + are considered negative" to address this. With careful crafting of how the bullets are written, this should fly.
If I put in a bullet saying "no ear pain" and check it, that is different that one that says simply "ear pain". My template would say the latter, and I would only check it if it was a positive finding. The former indicates that I actually addressed it with the pt., while the latter is more nebulous. Nebulous is good. If I saw a patient with eye symptoms, for instance, they might question me "Did you really ask the patient about ear pain?" and I don't want to go there. Semantics, granted - and only important if we were to be audited by BC. But, we WERE audited last year and it was a giant PIA. First, we got a letter saying that we were being audited b/c are charges were higher than 95% of other docs in our specialty (IM and FP). We were SHOCKED to read this. We knew that there was NO way that this was true. We had to get our billing company to send us figures which showed that we were WELL within the norms. We sent this is in protest, and - get this - they sent back an "oops" letter stating that their computer program had actually counted the E&M higher levels TWICE!!!! They were very sorry, etc. Of course, they held up all of our payments during this time...

The only times I would use my template is for the ROS, FH/SH, and Exam. All of this is basically chart filler/make-our-lawyers-insurance companies-happy stuff. If I seeing one of my partners' pts in F/U, all I really look at is their assessment and plan (and occasionally the exam, if they had pneumonia for instance, and I wanted to see where the rales were heard).

The nice thing about AC is that we can dictate when we want, and template when we want, and mix and match when we want.

The other thing is, that since I was able to pull off making a point and click template, my director is closer to pulling the trigger on getting AC. I still think it is a great system for the money, and he agrees - but he wanted it to be able to do this one feature...