Home Forums Discussions Problems Long-Standing AC EMR Problems

I appreciated the open letter from John Squire concerning the priorities for Amazing Charts. There are some things that seem to be quite fixable but very annoying, as they have never been addressed. These problems have lived a long life on the board, but have never been addressed. Maybe we could send him a priority list of annoying problems we would like fixed instead of using our age-old work around methods.

1. What's with a chart that forces mixed case TALL med names but then incorporates a spell checker that flags them all, and has a bug where mixed case correction cannot be turned of?!
2. We still really need an order reconcile function that works when you bring in the imported items. This can be a big legal liability and we are using a paper work around.
3. I want to be able to change the chart, i.e. filling in important history notes, updates from specialists, surgeries, etc without having to save a new visit.
please continue below...

IN a previous burst of enthusiasm and good will, a AC user survey was conducted in this very forum, asking for and tallying most requested suggestions (if I recall, an improved letter writer was #1 and happily, that did come to fruition.)

I have previously written AC team members with suggestions, but without much result.

But . . if you promise not to accuse me of suffering amnestic psychosis, here are a few of my top suggestions:

1. CLEANED UP ALLERGIES (lower left).Allergies are in a bold and easier to read bigger font, with less emphasis on who documented the allergy and more on the important allergy itself.
Consider making actual medical allergies fonts in red, while "no known allergies" is fonted in green.


2. DIAGNOSTIC/THERAPEUTIC TRIAL - TAB (this is a new tab placed next in row of tabs on the far right top of the Most Recent Encounter screen - the last tab currently in that row is "confidential" - but there is space next to that tab ) This tab doesn't exist now, but would be easily accessible repository for all sorts of frequently encountered clinical data including patient drug experiences ("Topamax made her dizzy", or "trial of Imitrex-no help" also frequently referred to laboratory values could be placed here such as MRI result in the evaluation of a headache as well as other miscellaneous clinical notes such as "began dialysis February 10, 2012". This field (similar to past medical history on the left) would be addressable in between encounters (ie you could add to it) without starting a new encounter and would always remained constant

3. MEANINGFUL PROBLEM LIST ( (MY FAVORITE SUGGESTION!! ) An improved and enlarged problem list would allow for annotations to be placed next to the ICD diagnoses to jog the provider's memory on specifics of of each diagnosis. (ie "Dizziness ICD 780.4" becomes --> Dizziness ICD 780.4 - nonspecific since hit head on door frame Feb 2014"

The actual problem list field would also be enlarged so the entire problem list which could now be reviewed in its entirety during the patient encounter - (for many of us, the problem list is the map to guide us through a patient encounter.) I've actually designed such a "Most Recent Encounter" screen to obtain the extra "real estate" for the enlarged problem list by changing "Search Dx ICD9" from a full field, to a button (circled in green) to the right (anyone interested in seeing the slightly redesigned screen, feel free to PM me)

4. CUSTOMIZE-ABLE STORABLE PRESCRIPTIONS:

This improvement allows a practitioner to formulate, name, permanently store and quickly retrieve custom prescriptions for re-use on multiple occasions. The title for each customized Rx can be accessed from a window on the right (see diagram)

For example, a practitioner might have five different custom prescriptions for prednisone,including , "Prednisone 10mg -Drug allergy" , Prednisone 10mg - Cluster Headache Protocol" "Prednisone10 mg - Acute Asthma", etc . . . .
According to New Crop The capability for such an improvement exists. (again, anyone interested in seeing the slightly redesigned screen, feel free to PM me)

(again, I have JPEGS of screenshots incorporating these ideas if anyone is interested.)

Bruce Morgenstern, MD (Neurology)
Denver, CO

Love those ideas.

Also:
- Inactive diagnosis need to disappear off the drop down. The list is so cluttered it is terrible and deprives us of the basic, problem list of a PAPER chart, (which I have begun to think of wistfully).
- I understand the need to make the note, once signed, set in legal stone, BUT one error on the vitals renders the charting function useless. I am embarassed to say that I have more than one chart where I missed a weight of 120# on a patient of 320# or a weight of 2200# on a patient of 220.0# and from that day on, the graph will always be basically a straight line, with a single outlier. We need to be able to exclude selected results from the graph, permanently.

Lets start a list! (It will make me feel better for a little while!)

Bruce has a good one in item 2 about being able to tie things together with the problem list.

At one of the user conferences I proposed an idea that was similar, and maybe more powerful.

I asked for "magic buttons" that could be attached at will in the chart, which would allow all of the items with that button to come up on one screen.
Let me explain:

A key sequence, lets say Alt A would be a 'magic button' which could be attached anywhere you typed it. When attached to a problem in the problem list, it would link all of the other items with "Alt A" and allow them to be summoned up on one page. (like paper clips or post-em notes in a chart that you are preparing for a deposition or a case report). You would tag COPD 496 and also CXR, Spirometry and the one consult from the pulmonologist that anything meaningful in the body of the note. The same patient might have a history of breast CA and "ALT B" attached to that DX and the Mammogram, Path report, Oncologist's consult and AGAIN the CXR.

Click on the icon for "Alt A" on your Med History and all of the Pulmonary bits show up. Click on "Alt B" and everything you have assigned to Breast CA shows up for a quick run through, even if it is shared with another DX like COPD.

A patient with renal failure might have "Alt A" for Med History CKD stage 3 and when you click on it you see all of the eGFR's that you have selected. And maybe also biopsies, ultrasound's etc.

I think this would save a tremendous amount of time for weak minded people like myself who can't remember exactly how bad was that breast CA 5 years ago, and is the shoulder pain today tendonitis or should I be looking for Metastatic disease first off.

Maybe this is just a Geriatrics thing. I have a lot of elderly patients with complex medical histories. Anyway, I would love to have a feature like this.

Once again, Martin, let me make a comparison of Epic to AC. One of the big things demanded here is that we add an encounter problem to the main "Problem List". We actually are monitored or "graded" as to how often this is done. So, with every encounter you have a discreet encounter problem list which then, by simply clicking on an arrow moves a problem into the main Problem List. Because we are scored on how often this is done, the main problem list is overrun with things like "foot pain" or "Need for screening for prostate cancer". Fortunately, one may, at a later date resolve those non-chronic problems and clean up the list. Unfortunately, few of the numerous users of this mega medical complex take the time to resolve problems and so the job is left, it seems, to those PCPs like me who cannot stand looking at a cluttered, dysfunctional Chronic Problem List to clean it up. I spend countless clicks removing items that others (usually a specialist) add. But, at least I can remove them.

Secondly, for every problem in the chronic problem list, there is a comment section where we can indeed add helpful information such as "Seizure Disorder...seizure free since 2012, normal brain CT 2010, followed by Neurology". Once again, however, very few of the users actually add any comments so the task trickles back down to the PCP who is considered the Medical Home and you end up spending valuable time going through all of the previous documentation over and over again in order to get a good feel for those problems. Since nearly all of my patients are still new to me, this task becomes overwhelming. The EHR has the capability to lessen this task but it demands that all of the users contribute to the helpful placement of the information.

Certainly the large medical community of which I am now a part differs considerably from the smaller practices using AC, but the ultimate goal still remains that any provider reading a patient's medical record should be able to easily retrieve the vital information in as little real estate as possible. Having information such as you suggest (most recent spirometry in a COPD patient, GFR in a CRF patient, etc.) pop up or be incorporated somehow with the problem in the Chronic Problem list would be ideal and would keep you from having to constantly change screens to find it.

I met J Squire at the AC conference in Ft Lauderdale and personally gave him the link I have posted previously on the mixedcap spell checker issue from wspell (AC dictionary)and the programming instructions needed to happen in AC.

Also gave Chris the director of project management a list of improvements.
No response or feedback from either. That is rather disappointing.

I did take time out of my practice and personnel family time and drove out 120 miles to attend!

Whether EPIC or AC, the patients problem list has exponentially exploded. In the long run this will become a huge problem and therefore a provider problem to resolve as patients will come back and tell us that we do not have these medical problems, especially after they get more access on the portal.

The easiest way I have found to deal with orders management is using the checkout box, It brings in orders tied only to that patient and is much easier to reconcile.

--Noted that many keyboard shortcuts do not work.

--Would add to this list wider windows for Problem list and alpha sorting this window. Agree with Leslie, the comments box in EPIC is useful.

--More fields available that can populate automatically into the plan section using the % such as medications by class (cardiac, pulmonary)

The board of physicians that was recently appointed by AC, may be a forum that can take these comments to AC and be more effective in getting the minor changes made to make AC flow easily.

In the summary area, you can resolve, inactivate or remove diagnosis' at the top. This may solve some of the problems above.

It might be nice to have a click box where the dx is made acute and will resolve automatically unless it is made chronic or renewed.

There are a host of issues with AC, but there have also been a host of fixes. The letter writer is a perfect example(better.) Unfortunately, so is the spell checker (not better.) If you look at the list of fixes. It used to be easier to look up changes between upgrades, now it appears you have to log into the client portal on the main site (the .net/ac site) and look for changes. There are hundreds of them. from just 6.6 and 6.5. Most are in the background but still important. I'm not defending them, just trying to explain how I see it. There are still changes I would very much like to see as well.

PCP versus Specialist, Doc versus Doc, AC versus Users; each has their own ranking for a ranking of the importance of the urgency in the need for repair. You can't please everyone. Sometimes you can't please anyone. It's no different than in practice.

Then there is the need to meet MU standards. Think of it what you will, it is necessary to bring in new clients and that's where the money is. We are not gouged for support as are many EHR's.

No one would disagree that this is a hard time for EMR manufactures: They seem increasingly barraged with questionably useful government mandates that (arguably - (but not from me)) seek to replace professional thought and judgment with increasingly Byzantine and complicated rules and checklists; and that these mandates are, ironically, almost counterproductive to the goal of an elegant, efficient and intuitive patient record.

That said, the goal of this thread seems to be to articulate and consolidate basic user-generated requests -ones which are popular, and which could be easily implemented by AC, even while it struggles to keep up with government mandates.

I for one believe that among these could certainly be:

1. clearer, more easily-read color coded allergy warnings

2. Some type of field or tab that could act as a repository for frequently required & accessed information, and that this field could be addressable and alterable in the chart without initiating a new patient encounter

3. Some type of problem list which would be easily accessible, easily annotated, and allow for retiring of inactive problems

4. Customizable user-generated Sigs/instructions for prescriptions- which would eliminate the need to ever rewrite the same prescription once it has been written the first time - NewCrop tells me the Scriptwriter already has this capability.


. . .So I agree that Amazing Charts has its work cut out for it keeping up with government mandates, but perhaps, under its new leadership, it would consider devoting a small component of its resources to product improvements that are shown to be both frequently requested and easily implemented

Bruce Morgenstern, MD (Neurology)
Denver CO

For me, it's refilling prescription requests where the pharmacy's name for the patient is somehow different from my AC name.

I don't want to constantly be changing patient names. I do want to be able to match a refill request to the chart that I in all my professional experience believe is the same person. I want the POWER to do that, even if I kill someone.

So I deny the request with a note that will send a new eRx, which I do. Then I get an unhappy patient who is told that the request was denied. The pharmacy can't seem to understand my two step procedure. Then staff has to get on the phone with the pharmacy, who finally finds the new Rx in their system.

All because the match of names is not exactly the same.

While I realize that there are many difficult programming problems facing AC, some of these issues are simply not that tough. As far as the spell checker, AC just has to spring for a better spell checker.

Just do something.

That is one of my pet peeves also, the inability to readily click on a eRx request from a pharmacy because name or medication does not match up exactly and the requirement to totally retype/rename the patient or med in AC, why can't it be like quest labs when I get a lab result that doesn't exactly match a name it then gives me the option to pull up a patient list and with a click assign it to a patient in my AC database. I am pissing off the local pharmacies as now I send virtually all scripts eRx to them but do not respond to eRx requests from them

The problem of reconciling incorrectly spelled names on Script renewals certainly does seem to resonate with a number of users.

SO . . . if you had the opportunity to meet with an AC programmer and design an interface which solves this problem, what would you as and end-user, recommend as a fix? Propose an option, which would be maximally user-friendly, relatively easy for AC to design and implement, and not significantly impede AC's already existing functionality for others?

Bruce Morgenstern, MD (Neurology)
Denver, CO

decision tree in verbage, does name match yes/no if no then pull up patient list in ac database allow user to choose correct name and reassign, does medication match yes/no if no pull up patients medication list allow user to choose correct medication and reassign

I may be misunderstanding you koby, but when I get an eRx request from a pharmacy that does not match the patient name, I run my cursor over the first name, hit delete, and then the correct name (from AC data) pops up on the line below, I then match up the names and I get the correct med to e-prescribe as it matches up to the AC med list. Sometimes it may be the brand or the generic, but this extra step has helped match up the names and meds for me.

Jimmie thanks for the heads up, I haven't tried responding to eRx's for a while now so will give that method a try.

Hi koby,

Usually (at least for me) if the name does not match, it is due to the patients middle initial being present in the first name field. Backspacing over the middle initial will allow the name to match.

Gene

then again have a patient who has Rx for verapamil er 240 mg in his active Rx list, got eRx for refill verapamil hcl er 240 mg, came across as unmatched and would not allow me to choose it

then again have a patient who has Rx for verapamil er 240 mg in his active Rx list, got eRx for refill verapamil hcl er 240 mg, came across as unmatched and would not allow me to choose it