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OK, so it's been a long time since we have posted what we thing are good ideas. First, there have been so many obstacles and issues, that just talking about what we wish for has faded. NOT bugs! But features.

Now Chris C. has done a remarkable job with the new survey. His method is much better than just listing them on the board. Your ideas should still go through the proper channels. Just thought getting thoughts on ideas would be fun. This probably isn't the best way to do it -- using one thread. But, I don't want to have 5 MRPs showing up on the left. So, I will give three after. Please comment.

First, my biggest pet peeve and it falls under Jon S's reduce needless clicks. I estimate at least five hours of my life have gone by due to this.

To inactivate a medication in the med list in the script writer, you have two ways to do it. You can right-click and choose inactivate. Or you can click on the button (circled in green). Both give you the "Reason for inactivating" window. I would say I write a reason less than 10% of the time. Things like antibiotics, eye drops, Nystatin cream are things I don't need to document. I don't need "Diaper rash cleared up." But, for something like Seroquel, I do want to write "Ineffective" or "Increased cholesterol." Since we need it sometimes and sometimes not, why not make it so that right clicking does not give the option and clicking on the button which would say "Inactivate with reason."

While we are here, I know that I can click on show the inactive medications or show all, but it would be really helpful to click on a button and have a table of the active and inactive medications side by side with the reason inactivated. It is not helpful to have 15 total meds bunched together or just switching back and forth. It is embarrassing to say, let's try Concerta, and have the parent say, "We tried that six months ago."



By the way, a little known fact: Everyone knows how to inactivate a medication, but there are some good options you may not be aware of when you right-click on a med. One is you can Remove it altogether. So, if you prescribe Ativan and you meant Atarax, you can remove it very quickly. Inactivating it keeps in in that list when it really should be as though you never prescribed it. You can Re-Transmit or Re-Print, which is very helpful.

Next. This drives me bonkers. Please let me know if I am missing something. Seriously, I may be. But, it would be helpful (for me) if when I click on a chart and the last note comes up, it would show the date of the visit at the top and not today's date. It is very misleading.

In your inbox, the patient is always shown as J. Smith. When highlighted the whole name will show in the message below, but there are times that there are other windows on top. It would be helpful to see the whole patient name. Plus safer.

While I am at it, one vote for getting rid of the Re, Re, Re...Is there a way to just make it one Re, when replying?

Finally, may as well put this here: Can we do all names as Last name, First name. For instance, in the main window under View -> Orders, you get a list of all orders alphabetized by first name.

OK, the biggie. And, I will need input on this.

Chief complaints, PMH, Problem list and diagnoses are different things.

1. Past medical history are just that. Things the patient had that aren't active but could affect the patient. Things like Appendectomy 2004 is past medical history (or surgical). It is not a problem, active or inactive. The past medical history must be typed in and is in the right place.
2. Chief complaints: CC are typed in under chief complaints. A chief complaint is defined by what the patient states in their own words. Herein lies the problem. The patient will say Fever or Pain in left shoulder or I get dizzy when I walk to the bathroom. Or Ear pain.

The issue is what is written in the CC is what populates the Past Visit History. So when you look in the past visit history or Past Encounters, you will see:

Fever
Pain in left shoulder
I get dizzy when I walk to the bathroom
Ear pain

This is NOT helpful at all. One will come up with a diagnosis at the end of the "Encounter" and that is what should be listed in the "Past Encounters" So it should say:

Viral infection
Bursitis
Orthostatic hypotension
Acute otitis media

When a parent asks how many ear infections their child has, I can't tell by seeing a list of Acute otitis media mixed in with Ear pain or Fever, etc. I need to know there were five ear infections in the past two years.

So, this would be populated from your diagnosis. Your ICD-9 code. The problem I have always forgotten is what if there are three diagnoses. I forget that FP docs see patients with more than one issue many times. How do you get all three to show up? Is there a primary diagnosis. Or do you just list all three?

Finally, there is the problem list. These are not PMH. These are not past encounters. They are either active or inactive problems. Currently, the problems are populated, ironically, from the diagnoses and show up in the Summary Page. I have NEVER looked there. It helps with the printout of the chart. Problems should show up somewhere on the encounter, so you can either see them or click on them and have them populate the Assessment. Or you can inactivate them. I don't know how many times that I have re-diagnosed a VSD on a nine-month-old. Sure, it can be in PMH. But, sometimes it scrolls off. And, I don't generally look there.

Thoughts?

One solution would be to have click boxes with predefined statement "course of treatment finished" "increased doseage" and perhaps default by the med or not



This used to be in the box just below that date, now you have to click to see which date was last

Not sure I can answer #3, much of it depends on how you chart.
Certainly the summary is clunky and out of the way. Not sure I have a solution to that.

I know that posting suggestions here won't likely get them into chart. It is just good because a) you know if others are having same issue, b) we may come up with a workaround.

Or maybe everything is 100% perfect with AC.

I would be willing to bet that only five users have ever been frustrated by the pop up screen when inactivating medications.

BERT, I agree with ALL of your pet peeves !!!!

LOL. Maybe I should rename it.

It's a few more seconds but I start each CC in AC with today's date. Sometimes I pull up a patient's visit and think it's new but it's old and this instant reminder helps me click ctrl-N to open a new chart. Agree with you on having to put a reason to inactivate a med. It's really helpful when someone asks why we stopped a maintenance med like an antidepressant and I can give the reason.

Hi Lane,

Finally, I have someone I can have a convo on these two topics. I think? On the CC, great idea putting in the date. Your MA could do it, except mine has no calendar in her brain, lol. I also go back and put OTITIS MEDIA L, so it shows up perfectly in past medical history.

As to the inactivation, I think you could have two options. The first would be to use the inactivate button:



I think I use a reason less than I don't. Reasons would be for changing Abilify to Seroquel. Stopping Paxil. Zantac to Prevacid, etc. No reasons would be deleting hydrocortisone 1% or amoxicillin. etc. In psyche it would be huge to put in reason.



To be honest, I have always thought it would be incredible to be able to use that information to temporarily bring up a window showing:

Medication on: | Start date No longer on: | Stop date: reason

You could quickly glance and see what meds they have been on even inactiving or deleting meds not needed from that window such as antibiotics or whatever.

I know we can go back and forth, but it is just not the same. I have to decide if I want to use Lamictal or Seroquel, when they have already been on Lamictal and I stopped it due to SJS and Seroquel caused a severe metabolic syndrome or weight gain. It is embarrassing to state, "Let's start Abilify," and they have either been on it or had a severe choreathetosis in the past.

Thanks Lane,

I miss the day sof workarounds to try to make AC better. My putting in the final IDC-9 code in the CC I have always though got around the problem of putting the CC in the past visit field.

"I have been having a foot for the past ten days when I feel off a trampoline SIMPLY DOES NOT BELONG PASIT ENCOUNTER OR VISITS.

Putting date and ICD-9 diagnosis fixes this. Your date, which I never thought of is brilliant.

What I disagree with on Amazing Charts is the following. While I think it is great to do surveys and find out what changes help the greatest amount of people, I also think ideas pointed out such as Lane's which is an obvious improvement to the program (AND I DARE SAY IS LIKELY EASY TO FIX IN CODE) would be helpful.

Let me weigh-in on a couple of these.
1. Bert, I entirely agree that it would be helpful to simplify the "inactivation" process for medications.
Many prescriptions are intended to be short term and shouldn't even require removal (e.g when I write for a bowel prep). Wendell's idea of a click-box makes sense; it might even make sense to have the option to click it when you write the prescription, so inactivation occurs when you next open the chart. Whatever makes for the fewest needless clicks...

Does AC have complete control over that "page" of the EMR, or does Surescripts or some other entity mandate certain verbiage or appearance there?

This might be nice. You can see each individual medication with this information, but not all at the same time.
In your example, before suggesting Concerta, you would go to the list of "All" medications, see that Concerta was on the "inactive" list, and hit "History" which would tell you when you prescribed it and why you inactivated it.

NewCrop or Surescripts would have nothing to do with it. They have the database but once it is put into AC, it is pure AC.

It is these little things that the we, as the long time users, have come up with (not because we are any better) but because we have used the program longer, that could improve the program.

I know it may not be this easy, but when my programmer won't Amazing Labels, Viper and File Assistant Pro, I would simply say, it would be great if it could do this, and he would write it in 15 minutes.

2.I understand what you are talking about, but I disagree as to the solution. This is often a big issue when people first start to use AC. I explain to them that the default tab to open a chart in AC is called "Most Recent Encounter (MRE)" but that tab is poorly named. It should be called "New Encounter" or "today's note". The MRE is not in front of you on that page; it is where it belongs: at the top of the "Past Encounters" section.

Bert, the alternative that you suggest is to have the NEW note that opens show the last date the patient was seen. To create the note, the doc MUST change the date to the current one, or the note will be created with the wrong date. It is best for this screen to show the current date, as it does, but I think it should be called "New Encounter" or "Today's encounter" to avoid confusion.

I agree with your point that the CC should not be the label that is used as the "Subject" for past encounters.
It would be helpful to have a diagnosis rather than a complaint. The question is: what would you use as that label? Sometimes there is no clear diagnosis reached. As you point out, sometimes there is more than one diagnosis. Would you suggest that AC automatically pull your first ICD code for the visit and put the corresponding text there? Should there be a box so that we can choose and type in the "subject" of the visit?

There has to be a better way. Like you said, it reads wrong. But, I do want to be able to click on Most Recent Encounter and see the last encounter. Somehow, when you save the note, it should then save at that date.

The only issue would be saving the note to your inbox. As it is, I don't look at the date there anyway. Tough call.

Definitely shouldn't be a box. And, it shouldn't be the CC. This is a tough one. But, if one thought about it hard enough. This is the one part I don't have a great answer to other than listing all ICD-9 codes (names) with the first one being the priority. Hovering over the line would show all. But, that would still make it difficult to see all of the diagnoses.

Good news...The next release will offer you the ability to automatically de-activate a med after a user specified number of days...It's been a popular request and as such we've added it to the roadmap for version 9.0 (Q1 2016).

And, please offer the ability to turn off the popup window asking for a reason to inactivate for every med you inactive. As Jon says, "needless clicks"

I too find the initialization of a new encounter a bit confusing and think this experience should be improved. By default when you open the MRE the system should start with a blank encounter with todays system date. Today it defaults to the most recent encounter and you need to click CNTL-N to clear the note other than PHM, SH, FH. MEDs and Allergies. I believe the prior designers intent was to manage some of this with the buttons for "Overwrite all fields" and "Keep existing CC, HPI and ROS" but that only works when you select the option to use a prior visit as your starting point. I would suggest that we provide a user preference that when you start a new encounter the system defaults to a blank encounter with todays date simulating the CNTL-N (new Note) action and save a click by default. If you then want to use a prior encounter you have that option using the drop down. Thoughts?

I never use the Keep existing CC, HPI, etc. But, if it defaults to a completely new encounter, then you aren't able to see the last encounter.

There are many times that you click on a patient in the patient list, and the, as Jon states, the most recent encounter, pops up. You want that. You want to be able to read the entire last encounter.

I find the only problem is that it is confusing to have the most recent encounter, which could be from a year ago, have today's date on top.

IT IS SIMPLY AWESOME that you are responding to these. It is the first time in the history of AC our suggestions are being responded to (at least in this format).

Thanks Chris.

And the suggestion for adding a reason for inactivating a med is a good one!! Not a very frequent request from other users but one that just makes good sense and offers value. I think a free text drop down for you to define your most frequent reasons would be most efficient here. We'll put it on the list...no promises for v9.0 but at least it will now get some visibility

I do read the posts here so I'm listening..just not always able to reply all the time. The normal protocol for enhancement requests is via the Recommended Improvements off the HELP tab ..I get 20-30 a week and read every one. I can't reply to all of them but do on occasion. Each are categorized by functional area which allows me to and prioritize those most common. I then use those as the basis for my survey which all users get to vote. The recent survey is the result of the last 2 years suggestions and others that I feel are just conspicuously absent based upon my experience with other products.

But, even if you reply here occasionally. It shows that AC and you are listening and actually working on some of the recommendations/ideas/complaints. That goes a LONG way toward user satisfaction. And, you get direct feedback on your reply.

I guess also if a problem on a scale of 1 to 10 is a 10, then if 100 people mention it, it may be more important than an issue mentioned by three people. But, if that problem is a 10 out of 10, it may be nearly as important.

Thanks again.

I understand....that makes sense....Since you're clicking on the MRE (Most Recent Encounter) you should expect to see just that....the most recent encounter but with the date of the encounter and not today's date. We can change it to display the date of the prior encounter for further clarity...if you try to save it without changing the date you already get a warning so that shouldn't be a problem. As with everything we do it will be a user preference so those wanting it to stay the way it is will still have that option.

Chris:

I have been graciously asked to fill out product ear surveys from time to time for AC and hope that my input has been helpful. I find the comment that you are getting 20-30 emails a week a very telling statement about the AC problems that exist at present. I think that I speak for many other users who appreciate and love Amazing Charts. This program has become a big part of our professional lives now, and we cannot imagine our daily lives without it. As we feel this connection to Amazing Charts, it is only natural to want to see the product improved, much as raising a child that you hope will turn out to be a great person, some day. I realize that there are going to be bumps along the way. I dare say that the programmers and others at AC probably do not comprehend fully the loyalty of the fan base or this underlying desire that we have to see this product continue to improve. It is difficult to hear that certain features may or may not be seen in future product versions, especially when some problems have been longstanding. If NASA programmers can program spacecraft to get to Pluto and beyond, it cannot be that difficult to make improvements in AC, unless it is a financial issue.

Further, I think that it would be helpful for you to post popular requests on the user board for a broader notification. Not everyone reads the board posts, but it appears that a fair number of user do, and the number is growing all the time. This may save you from receiving redundant emails. The more we communicate, the better the overall product is. Thank you.

Chris,
Thanks for joining in this discussion. Some of these points may seem esoteric and detailed but are actually important since they form the basis for how we use the program.

Before I forget, let me second Mel's comments with which I agree wholeheartedly. In particular, " it would be helpful for you to post popular requests on the user board for a broader notification".


Agree that the page can be confusing to new users. With experience, it generally functions well.

These buttons should be deleted. Their function is limited at best and I don't know anyone who uses them regularly.

I think this would be a mistake. Unfortunately, not every note is completed on the day the patient is seen. If the incomplete note is saved to a message box, the date will be incorrect and when it is retrieved, there will be no way to tell when the patient was seen.

If a change is to be made, I would simply re-name the MRE tab. The user experience is only confusing because of that name. This should be called the "Note creation" screen (or something to that effect). It makes sense to a novice user that the default upon opening a chart is the "Note creation screen". It opens to boxes with the date of the visit (today) at the top. If possible, have a "user preference" which is to display the boxes empty (like the current ctrl-N option) OR populated with the most recent information (as it does now). This eliminates the confusion with the minimal amount of change or disruption to current appearance, coding, and work flows.

This is why it is difficult to make changes. There have to be enough people who agree. This isn't a very good one for "preferences." One thing that has always helped me is to compare the electronic chart with a paper chart. So, I open a paper chart and the first thing I see that was last written in is the last note or MRE. It's date is at the top. It can't be edited. When I start to write a new note with a new CC, HPI, etc., I write a new date. If the note is done the following day, it will still have the beginning date. AC has a great feature where it tells you when you try to save a note on the wrong date, "This is a different date. Do you wish to save anyway,? Or something to that effect.

I just got back a Western Blot IgM on a patient whose Lyme antibody was reactive. We get a lot of those now, and I wanted to look at the date and symptoms. I chose his name from the patient list, and I clicked on it. Beautiful note. Wrong date. Of course, there is the very small, "This patient was seen two weeks ago on such and such a date."

I guess the date at the top could say Seen on June 5, 2015 @ 4 PM. You can't edit the note except for allergies. I agree that all of the other stuff doesn't need to be there including the stepping off point (but maybe others use this). I believe a simple icon which you click on could open the new chart and which point the HPI, ROS and the objective side of the note clear. I don't know why one would want to start any new note with the old HPI, etc. there. But, if so, just have two icons to click on.

As soon as you click on this, you have a new note, fully editable, with a new date at the top. The date that will be saved when you sign off, whether it is today or next week.

I have always thought the perfect way to do it (which also goes back to the paper chart) would be to have a Face Sheet. (I remember back in the day, when 50% of the board was about improvements, many of us shared Excel spread sheets of a good Face sheet. With a paper chart, if you had time and you did things correctly, you would look at the front of the chart, which listed current important historical information.

I always envisioned pulling the chart from the inbox where it would default to something similar to the summary sheet only more organized and better. It would have a very prominent PMH and Problem list with a list of past encounters. Medication allergies would be prominent. A prominent flashing light or something to let you know there was an important comment would alert you to read that you shouldn't bring up a certain point or that you weren't supposed to discuss the visit with one of the parents.

I do not know how many times I have diagnosed a suspicious heart murmur only to tell the parent and find out they have already been to cardiology twice. I know it is listed in PMH, but it just is something you look over. Especially when it is the fourth line and is covered until you scroll. I also always thought it would be cool to have the plan from the MRE show up at the bottom right which somehow was taken from the last visit. Just some thoughts.

I almost think you would need a committee on this.

Actually, I don't see where you even need today's date at the top when you begin a note. I honestly don't ever recall doing a note and wondering what date am I writing it on. I just do the note. I already know the date. If I go back to paper and recall being a resident and writing a progress note, the only reason I wrote the date at the top was for documentation, not so I would know what the date was. As long as the note documents the date at the top left as it does now when you save it as the date it was written that would make the most sense.

I, too, often make the comparison to paper, but this is an example where we want the EMR to be different. For better or worse, we want much of the old information (FH, SH, Meds, Allergies) to be carried over. Obviously not the CC or HPI.

Once again, you do need it if you save the note and complete it on a different day.

Yes, you need it, but you don't need to see it. And, yes, I want the FH, SH and Allergies to be present. But, to be honest, every time I write a note, I don't write that all over again. That is either in the H & P or in the invaluable Face Sheet or whatever you call the beginning of a paper chart.

Bert,

We use this screen to enter today's note, so it would be really confusing if it didn't have today's date there. When looking at patient history, I've long since trained myself to look at Past Encounters.

I love the fact that the chief complaint in the patient's own words is the title of the encounter. I think it makes the history much more readable and the frequent odd contrast between what the patient is worried about and what we code as diagnoses reminds me to keep it real and patient centered.

Seriously? I thought the chief complaint was always in the patient's own words. What do you mean by title of the encounter? Do you mean the first line of the encounter? It should be.

Or, do you want the Past Encounters to be the same as the chief complaint.

Again, I am very confused. When I do today's note, I want it to show today's date. That is the only thing that makes sense. So, if I do a note today, the top of the note or chart should say October 9th. October 9th should be forever associated with the note. Which means that a month from now, if I go into that patient's chart, I would like to look at the MRE (which would be the one from the October 9th). But, it won't say October 9th anymore. It will say November 9th, and I will have no idea what date I saw them without going to Past Encounters. Why can't it say October 9th, and when I type CTRL + N, it change to a new note and a new date?