Home Forums Discussions Feedback and Recommendations An "Outcome Oriented Medical Record"

My Wish List:

1. Magic Buttons to glimpse a snapshot of my patient and their disease
2. More tools for managing the database: Expanded search functions including the ability to go back and search a list again, after it is created, and the ability to compare one list against another, seeking those that are on both lists.

Background:
In addition to converting to the Electronic Medical Record we are making two other large changes. We are attempting to emulate the “Medical Home” model of practice, which will make our practice more patient centered, and we believe better structured to compete in the market place of the future. We are also working with our Independent Physician Association, (IPA) to uncover ways for our group to practice both better, and cheaper, with the intent that we will negotiate higher capitation rates based on our outcomes. Before the EMR we had no way to track our outcomes, or effectively change our practice habits.

I believe there are a great many opportunities for us to practice better medicine, and for those better practices to yield a profit for the IPA. We intend to go after a piece of that profit. The often touted, but seldom realized, “Win-Win” situation.

“Magic Buttons”

Imagine that the “Past Medical History” has each entry (be it one word, Dx or paragraph) assigned to a field, (I am too ignorant of computer programming to explain this any more clearly) and with that field you have the option of activating a “magic button”, I will call a “label” , Appendix A, or B etc.

Now your patient, Sally Brown, had a breast cancer operated on 20 years ago, with subsequent radiation therapy, and a recurrence, metastatic to the bone, treated with additional radiation 5 years later, and, thank God, she has been disease free ever since. Her old records, including the second round of radiation therapy, and her subsequent Mammograms, bone scans, and CXR’s are all labeled with the “Appendix A” “Magic Button”.

Sally Brown presents to my office today, with a vague complaint of pain that may be bone pain, and I want to have a quick snapshot of the state of this disease today in my patient. I click on Breast Cancer under Past History and see the “Appendix A” symbol, showing that I have labeled things for this Dx in this Patient. I click on the “Appendix A” symbol and all of the items I have attached are brought up on the single page to give me a “Snapshot” of this patient and her disease at this time.

This would give us the opportunity to finally resolve the problem first described by Weed in 1968, when he proposed moving from the “Source Oriented Medical Record” to the “Problem Oriented Medical Record”. We all know that the POMR has only been partially successful, being too unwieldy and owing to our inability to move away from a “source orientation”. The source orientation is the only practical means for our staff to file lab, x-ray and consults, and it is impossible to file with a “problem orientation” when the same data belongs in the database of multiple problems.

I propose that some sort of “Magic Button” will be the first of a number of innovations that will help us create something I call the “Outcome Oriented Medical Record”. Filing will still be handled by source, and can be found where it should be, no matter why the test was ordered, but when you think of 'Breast Cancer' or 'Diabetes' for this specific patient, a click on the "magic button" will give you a clear image of the status of this problem.

(Note I purposely used the term, “ Magic Button” to avoid ignorantly labeling my idea as a “macro”, or anything else, as such might mislead the computer literate and delay their able to visualize what I am trying to describe.)

DocM,
Although you already know I'm not totally on the P4P bandwagon for many ethical reasons I love you concept here. Might I add to your concept of the idea of using said button or tab as "linking" of some sort? I too don't want to mislead others who might be helpful in getting this started, but I also imagine in your example that certain tests, labs, and exams, what have you, might really be important and useful to any number of Dx's. And so the idea of these buttons being able to "link" anything that you providers care to link to any given Dx might be very useful.

In this way when you run this patients labs, you may need some of those results for either of her two Dx's of Cancer or DM. So you assign button "A" to cancer and get all the things that you assigned to the cancer Dx. Meanwhile button "B" you assign to her Dx of DM and then set up any and all things you would like or need to see for the DM. Am I getting you and are you understanding what I am suggesting, adding or agreeing with here?

The one issue I can see, like all things that are divided and linked together, the usefullness and the quality of such a thing will only be as good as the system or the person doing the sorting and the linking. But if made fairly easy like with quick buttons and the like, this may prove to be extremely useful and a great improvement from the present system we all use. Personally I think this is a wonderful suggestion that deserves further exploration. Great Idea.

I just had a lightbulb kind of moment on your great idea. What if in various places like in the labs section and others, there would be a quick and easy drop down much like in the final section for creating the invoices with the Dx codes. So as you are reviewing a lab, you could put any number of Dx's with it so then that lab will link up and show up for your review anytime you hit the button the corresponds with the Dx's that you previously set them up as??? Obviously for those of you who know your favorite 50-100 ICD-9 codes, perhaps as you type it would give you more and more limited choices and make it quick and easy.

Question, how broad or narrow too??? Still great idea.

Give me some examples. I may have an idea, if you are very committed to data mining, and don't mind learning another program.

Let me see if understand this. You would like to link certain lab results, x-ray results and imported documents to certain diagnoses, so that when a patient has one of those diagnoses in their problem list, you can push a button and instantly see the data relevant to that disease state. Is that right?

If so, who determines which data shows up when you press this button? Do you want to define this yourself, manually?

Define one or two specific "hot buttons" for me, i.e. tell me what kind of specific data you would want to pop up.

Do you mind putting the information in your Appendix A yourself, or does the computer have to do this for you?

Absolutely you guys get it. I would use this on a select number of patients and I am the only one putting the "garbage in".
Imagine if the function keys on the top of this keyboard (F1-F12) could be these "Magic Buttons". Any item or maybe even any area highlighted, could be linked. I highlight Breast cancer in the "past med Hx" and hit F1. Then the relevant imported items, hitting F1 (or I suppose, Control-F1). Later when I am seeing the patient, I notice that "Breast Cancer" has the F1 symbol by it. I click it, or HOLD DOWN THE F1 KEY, and I see a page with everything gathered in one spot. If there are 10 mammograms, the most recent is on top, the others staggered behind, so that I can click any one and see it instead.

Brian: Two examples,
I have used the breast cancer patient as an example:
-items from the old records including the original op report and path report.
-subsequent radiation therapy consultations.
-mammograms
-bone scans
-CXR's

Another example would be the complicated diabetic, (maybe lots of distracting illnesses, COPD, Joint Disease or whatever and before you know it you are way behind on the diabetes, so:
-HgbA1C
-UA for microalbumin OR if already spilling protein, then:
-co morbid DX's 357 585 etc.
-last eye exam
-Last foot exam
-Last diabetic teaching

I wouldn't bother to use this for every patient, but if I got confused, and I took a minute to go through the chart to say, "Lets see now, where are we?" Then how wonderful to be able to click F2 on each of those items, and then the next time I am lost, F2 and it is all revealed!

HockeyRef: Don't get me started on "Less Pay for Low Performance" (the lie of P4P). That is also touched on in my lecture!!. The ethics of P4P isn't nearly as shameful as the manner in which we have allowed the third party payers and bureaucrats to take over the controls. The doctors are no longer driving the bus, but are just along for the ride!. This is why the concept of a powerful tool like AC being used in the application of an "Outcome Oriented Medical Record" is for me, so really exciting. We will have such a HUGE potential to practice better medicine AND KNOW OUR OWN OUTCOMES, that we will finally be in a position to negotiate the pay. Freedom to practice the best practices and the privilege of getting paid appropriately. (Damn, maybe I am delusional?)

Your last idea, linking to the icd-9's has merit, but I don't think I want that. For two reasons.
1- Have you ever noticed that lots of important disease are not in the ICD-9 (the 10 is better?) The ICD was first for research and then adopted by the third parties, but was never intended for us, and it really sucks. I don't see a great utility for it here.
2- I am imagining using one of these "Hot Buttons" to gather consults, test results and notes of the patients complaints when I am still trying to figure out what organ system the complaint is centered in, and I am not close to any diagnosis yet.

DocM,
I was just suggesting (guessing?) ICD-9 because you could perhaps assign the ICD-9 to your magic button. Then anywhere you insert that same number like in the imported lab as I suggested, now it links back to the magic button you previously assigned to it. But I see your picture clearer now too, now that you have added to the original post. But as a P4P tool, some way of using ICD-9 (f'ing 10 still being considered?) would bring it all full circle for that purpose.

I would still want to find a way to get one lab or image linked to more than one button, Dx or ICD-9. Here is a lab with multiple tests on it and so it speaks to cholesterol, diabetes and goodness knows what else. So the ablility to have such a thing link to multiple Dx's seems to be very important here, especially in Primary Care where folks are seeing lots of issues in one very complex patient and encounter.

But your idea of breaking it out, in this completely more issue based format certainly hold lots of merit for further examination and experiments. It must be hell for you guys with old fashioned paper charts, flipping back and forth madly. Even with tools like AC, clicking back and forth between screens must get very frustrating at times. Especially when all you really want to do is be able to see this and that at the same time so you can relate this to that or what have you.

I still see P4P as a labor managment issue that can only be solved by either returning to the old model of trust the doc, especially the primaries, or, by collective bargining. Funny how back when docs could slow down and only see a handful of patients a day to make a decent doctor's living, nobody had any concerns about "performance". But now after years and years of the facsist Henry Ford cranking up the assembly line so to speak, NOOOWWW, they want to bitch about performance???

Isn't that what almost killed Detroit with high speed and low quality control. You really can't have both. Back in my old business as a stagehand, there were the non-union houses whee things were always hurry, hurry, and then there were the union houses where we might have gone at what seemed to be a somewhat slower pace, but there were a lot less injuries, breakage of expensive equipment, and a whole lot less "re-do's" if you catch me drift. "Nobody re-do like we do." Real quality of outcomes will save lots of money but only in the real long run and none of these SOB carriers really care about that. And it means paying a lot more for the lowly office visit at the PCP's office because this is where the rubber meets the road. Why do Office Visits have some of the lowest relative value units of all things. And then even your own IPA's and PO's multiple this insult by having contracts that pay a higher percentage of Medicare for procedures than for OV's. This is all just smoke and mirrors to pick your pockets.

Anyway, Where was all their concern about outcomes while they were all stuffing the fat faces and pockets with all of our money? To this day where is their concern about outcomes as the swap patients back and forth every enrollment period and have MA's and PA's supervise licensed physicians? BULLCCHIT! That money belongs to patients and doctors for good pay for good care, not for some greedy-@$$ Ivy League MBA to pad his golden parachute. Give me a break.

Have a great night. I need to go home...
Good Night and Good Luck,
Paul

Paul I absolutely want to link a lab slip to multiple 'buttons'. I would like to define the buttons uniquely for each patient, (so I am less likely to run out) but I would probably try to conserve neurons on my personal squishy drive by standardizing the top 2 or 3. But I would like to be able to 'stick' the buttons anywhere I want, IE: stick one on Breast cancer in the PMdHx and stick another right there on the V10.3 (Hx of Breast CA) in the Problem List. But if for the moment, I have overlooked all of that, and I am in 'Radiology' and notice the 'mammogram' with the F1 'button' symbol, I can click right on it there, and see all the pertinent entries, without needing to return to the 'Most Recent Visit' to enter the path.

Doc:

I will tell you that some of the things you are looking for may be coming your way in version 4.0. However, that is probably still months away.

In the meantime, I was brainstorming to come up with a way to do what you are suggesting with the present technology. I have tried to break down the task you wish to perform into a few key concepts, thinking that might lead to an interim solution:

1. You wish to be able to store information dedicated to chronic disease states in some specified area. Right now, Jim Blaine is (mis)using the "Alerts & Directives" portion of the Summary Sheet for that purpose. See this post for details. Start at the linked post and keep reading.

2. You want to be able to link from the patient's clinic note entry area to some outside source of data about the patient. The only way we can do this presently is with %fillers, like %Mr, %FNAME, etc. (Go to this post if you don't know what I'm talking about). This technique would only work if you already had predefined fields, somewhere in the patient's file, for the data you wish to retrieve.

3. You might like to have an area where you could store snippets of text, links to images, things that might not fit into a standard-sized Amazing Charts file. The only way to do this is via Imported Images. Bert has posted before about using Excel files as summary sheets in this post.

Once you have created such a file, you can put anything you want into it, name it after the patient, and then drag'n'drop the Excel file into the patient's folder under Imported Items. An Excel icon will appear there and any time you click on that icon, it will open the Excel file and display whatever you put into it.

Note that you can also create links to OneNote files, which can contain links or images that might not fit into Excel.

Well, that was a long post! Chew all that over, and see if there's anything you can use! If anything is unclear, let me know.

BCMD, wow, thanks for all the effort and links. This has really got me thinking. I am still trying to clarify the Magic Buttons for myself. I am very excited about doing things that will help me and others to practice better medicine, and to do a better job, easier. I am interested in seeing where excell could come into this, it is so powerful and relatively easy to use. (preferred Lotus, but ah well.) I am confused about how or where it is to be stored. I need to learn more about how links work, that is really the next big step for me. The (mis)use of the alerts and directives is a great workaround for now, and the tip about printing the summary and allowing the patient to review it while waiting is priceless. We will start doing that right away.

I think Bert kind of keeps his Excel files and AC charts separate (I may be wrong). But, you don't have to.

You can open the patient's chart to the Imported Items tab, and just drag'n'drop a folder from the desktop right into the patients chart and the icon will appear under the imported items tab, where you can re-name it. Or you can press the Import Item button and follow the steps.