2010: The Year of the Ambulatory EMR

With the turn of the fiscal year 2010, the medical informatics and IS teams launched into an ambitious agenda for the CIS Ambulatory project. As you know, CIS was first launched in BMC back in 2004 with the introduction of computerized provider order entry (CPOE). This was followed by a host of other functions including PACS (picture archiving and communications system) for viewing radiographs, and physician documentation. In 2005, CIS-Office was implemented to varying degrees across the BMP practices with emphases including medication management and historical data entry. The EMR project then turned to documentation in the outpatient setting wit hthe BAPO and BMERF primary care practice sites receiving much of the attention.

In order for CIS to continue on its successful course, we will be devoting much of the coming year to adding and enhancing tools for the ambulatory world. At present there is a large multidisciplinary team that is designing the ambulatory CPOE tool in order to faciliate use of evidence-based caresets, to expedite appropriate charging and billing process and to improve the documentation of medical decision-making.

For those clinicians who use eScription for documentation, a voice recognition dictation tool with human editors in the background, a pilot is soon to be launched whereby clinicians will migrate to Dragon voice recognition for dictation. This projection promises a significant cost savings when compared to our current dictation system. Dragon also allows the user to edit and finalize documents in real-time without having to wait for transcription nor without having to login to another system (ESA). The critical effect that I anticipate is a newly vitalized engagement, especially among the specialists who have not become proficient with the core of the EMR: Problem/Medication/Allergy/Procedure & Surgical Hx Lists.

Other major projects that have begun and will continue through the year include:

• transition to ePrescribing in order to receive federal incentive reimbursement
  
• Patient Centered Medical Home
  
• Patient Portal
  
• MPages (dynamic patient chart viewing)
  
• PowerInsight dashboards and reporting modules
  
• Formulary and drug benefit management
  Sorry for the long hiatus from posting. As you can see, we've been pretty busy gearing up for a number of exciting projects. Here's to a great year!
  

CIS Results to Endorse coming to all on Dec. 1

A lot is going on these days in EMR land. Anyone who makes it over to the blog must now by know that we will soon be sending electronic results to all users ordering labs from an ambulatory or daystay encounter. That means that we will be able to discontinue the duplicative delivery of paper reports once practices develop a new baseline in workflow. For most practices, the transition has taken a matter of days. Given the variation in practices across BMP, we expect to be able to discontinue paper delivery by the first week of January pending any unforeseen issues with the RTE process.

As I write this, I am watching my Outlook account creep very slowly through the mail merge I set up for the distribution of videos that I have previously sent as well as posted here on the blog. While I still can't deal with hearing my own voice, I've heard that the videos are both useful and the right length: short.

I expect the BMP RTE project to be very successful, but there are a few remaining issues that will need attention:

• It is imperative that the ordering clinician's name be clearly written on the lab requisition. After a virtual inquisition by IS and the lab, we found that labs are delivered to a default attending, e.g. medical director of a clinic, if the ordering clinician, be they resident, PA, NP or otherwise does not explicitly declare themselves on the order.
• An area up for review with our vendor is the need for physicians and others to be able to review labs without actually signing them. This is particularly useful when the proxy tool is employed in cross-coverage. The ability to review, and thereby signify that a lab was "seen" with action deferred to the ordering clinician, is crucial for practice workflow and patient safety.
• The inability to cc another physician is a significant limitation that we will have to live with for the meantime. While I have been in the habit of forwarding relevant results to other BMP physicians, such an expectation for practices much busier than mine would be an unfair encumbrance. Keep in mind that practices outside of BMP to whom you cc results will continue to receive them in printed form.
  

The electronic delivery of Result to Endorse will be a major step towards the paperless medical record. The more we orient ourselves to the electronic record as a data repository and as the focal point for data input and communications, the better the patient record, and, ultimately, our patients' health, will be.

Influenza PowerNote

As I lie here listlessly for the 5th day in a row, I am pleased to report that there is a PowerNote that would be useful to document my visit to a physician were I to have the energy to drag myself out. There are now Influenza PowerNote templates for office and hospital, pedi and adult.

As for me, no need for any diagnostic acumen. My 14 year old son had a positive rapid influenza A/B test last week and, given the reports across the country and that I received the seasonal flu vaccine well over a month ago, I'm stuck waiting for H1N1 to leave me the heck alone. Fortunately, the symptoms are low key enough to allow me to avoid an office visit or other CDC-derived suggestions elements you will find in the templates. However, a constant headache with low grade temp and myalgias have kept me supine 95% of my waking hours.

You could probably fly through a routine flu visit using this template. The diagnoses at the bottom actually populate the note with a SNOMED code, saving you a step in the finishing of a note.

And for those of you who wash your hands compulsively as I do when at work, don't play the fool and forget to do the same at home.

Worthwhile reading

For those of you who who are not familiar with David Pogue at NYT, he is a terrific blogger on personal technology. Peter Lindenauer pointed out yesterday's post to me. Pogue interviews David Blumenthal, the fed's health information czar. It's a worthwhile read.

Pogue Interviews Blumenthal

Pap Tests

If you didn't notice on the CIS announcement screen, effective this past Tuesday, 10/13/09 the much-needed Clinical History data will be included with the Cytology Pap Test results in CIS. This has been a major issue for those of us providing gynecological care.


As a related aside, we are pursuing the delivery of Pap and all other pathology test results to the Inbox as well. I anticipate this being accomplish in the next few weeks. In addition, we will soon be releasing all results ordered in the ambulatory setting to all ordering clinicians. Thus far, approximately 2/3 of all folks working in the outpatient world have requested electronic transmission of results. Based on this successful expansion of the EMR as well as to ensure the quality and safety of results delivery, we will be rolling out Results to Endorse to all BMP providers. Keep in mind that you will receive only those results that have been ordered from an ambulatory venue.

CIS Clinician Satisfaction Survey II

Since posting the survey data two weeks ago, I've had a chance to look more closely at the 100 or so pages of typed comments offered by the 250 or so respondents. While the numbers are very useful in order to get a general overview of satisfaction and EMR engagement, these comments are invaluable as we pursue a 100% paperless medical record.

Today, I am posting the survey results again, though this time with bulleted themes drawn from a replete set of texted sentiments. In truth, I've left out some of the more positive comments, primarily in order to give focus to where we, the informatics team, need to concentrate our efforts for improvement. Training and the spread of useful CIS knowledge has been and remains a high priority for us.

I truly appreciate the time and effort that you've put into providing these results, though more so for your willingness to persevere through this veritable culture change in medicine. With our continued collaborative work--among physicians, mid-level clinicians, ancillary staff and the awesome IS squad we are fortunate to have--I am certain that Baystate Health will remain a national leader in the creation of an EMR that promotes the safest and highest quality care for our patients.

CIS Clinician Satisfaction Survey Part 2

CIS Clinician Satisfaction Survey Results

Here is a first view of CIS Clinician Satisfaction Survey. Thanks to all of you who responded. The data captured here is incredibly meaningful and useful. I will likely post further details and commentary in response to requests, needs and calls for improvement.




SurveySummary_10012009

Loss of Precompleted Notes and Macros

Major bummer for a handful of dedicated CIS users. For convoluted reasons, precompleted notes and macros that had been created on now defunct versions of PowerNote can get lost. The probable issue with the loss of the precompleted notes is that they were likely created on older templates that had been revised over time. We've seen folks lose notes that were created on the earliest templates.I am learning that the system can be quite sensitive to changes made in the content and code. Cerner, our EMR vendor, recently recommended:

Ensure that the precompleted note or the macro was not created before a recent content load. If new PowerNote content has been taken since the precompleted note or macro were created, there will be viewing issues. They were created under older content and a different structure for the portions of the note (paragraphs, sentences and terms). Therefore, when trying to use the precompleted notes or macros with a new structure, there is a mismatch and some of the terms that were there before are no longer there or have been moved around. In order to resolve the issues, the macros and precompleted notes will need to be created and saved again.

An alternative explanation may be that the precompleted notes are shared and accidentally deleted by another user. Unfortunately, there is no way to back up precompleted notes. Cerner's answer to the difficulties with macros and precompleted notes is to create a compendium of auto-texts that would serve a similar purpose. These are not dependent on content or template format and can be used across all PowerNote Templates or in Clinical Notes were you to work from that screen.

I honestly wish I had better news.

Creating Proxy Lists

Granting proxy authorization to another clinician or members of a clinical team enables the proxy to perform any activities for which you have granted them authorization, such as signing, refusing and forwarding messages and results.
To grant proxy authorization to another provider or team member, complete the following steps (see pictorial in slide below):

1. From the Inbox menu, select the Proxy Tab and click the Manage button.
2. Click Add.
3. Search for a user by typing last name, first name. Click the binoculars to search.
From the User list select the user that you want to give proxy to. To grant proxy to more than one user use the arrow to move the current user to the additional user's box and continue searching.
4. Specify a Begin Date/Time and End Date/Time. For example, if you will be out of the office for two weeks, specifying the Start Date/Time and End Date/Time ensures the proxy will be able to access your Inbox messages during that period only.
5. To grant permissions to the selected user, highlight Results or other items you want to proxy.
6. Click Grant
7. Click Accept & Next button.

Proxy

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To remove an existing proxy authorization, complete the following steps:
• From the Inbox menu, select the Proxy Tab and click the Manage button.
• All proxies that you have granted are listed in the Proxies Given By Me pane
• Select a proxy.
• Click Remove. The proxy authorizations are removed.
• Click OK.

To view a list of all individuals to which you have granted proxy authorization, as well as specific permissions of each authorization, complete the following steps:

• From the Inbox menu, select the Proxy Tab and click the Manage button.
• All proxies that you have granted are listed in the Proxies Given By Me pane.
• Select the proxy that you would like to view and click Details. The specific permissions that you have granted are displayed.


To view a list of all providers and document types for which you have been granted proxy authorization, complete the following steps:
• From the Inbox menu, select the Proxy Tab and click the Manage button.
• Click the Received tab.
• The users displayed in the Proxies Received by Me pane are authorizations that have been granted to you.
To view detailed information about the privileges granted by a particular user, select user and click Details.

Results to Endorse successfully rolled out

The number of BMP clinicians now able to manage results through CIS has nearly doubled to about 250 since Tuesday afternoon. This accounts for over 2/3 of all BMP clinicians who practice in the ambulatory setting. Thanks go to all of you who are taking this next step towards a paperless medical record.

One of the major goals in transitioning to electronic resulting is to enable practice sites to develop the means to manage results both on an individual and a group basis. The Proxy tool is designed to facilitate this task. Proxy lists are controlled by the individual clinician and work in conjunction with colleagues and staff. It will be up to the practice to define members of proxy lists and to ensure that those designated to monitor results are included in these lists. Each clinician can proxy anyone on clinical staff to be able to view results and process them as determined by practice protocol.

The following outlines three scenarios for Proxy use:

1. Practice A decides that each clinician (physician, NP, PA) reviews, endorses and manages all results sent to their Inbox Results folder. The Proxy tool is employed when said clinician is away from the office, e.g. on vacation, and practice partners and clinical care coordinator are named as proxies to ensure that all results are viewed while the clinician is away. The Proxy tool allows the user to set a finite time period whereby the proxy is in effect.

2. Practice B has divided the group into 4 teams. Each team consists of x number of clinicians, medical assistants and/or clinical care coordinators. Each member of the team proxies all other members of their team. Depending on how results are then managed, any of those team members who have been proxied to receive results can view and Skip or choose to take action and Endorse the result. The endorsement action can be performed by any member of the proxy team.

3. Practice C has chosen to pair clinician with medical assistant via proxy such that the clinician wants to review only those labs requiring additional clinical input, i.e. abnormal labs. In this case, the medical assistant can go through the results that have been proxied and endorse all normal results. (At the same time, the MA can be tasked to generate a patient correspondence letter informing the patient of their normal results.) In the event of an abnormal result, the MA has two choices: the first is to click on the Skip button and leave the result present for review by the clinician; the second is to endorse the result and then forward the result to the clinician for second review and definitive action.

I am currently working with our vendor to provide a third option which would enable the proxied party to click on a Reviewed button, thus documenting that the result as seen by the proxy (be it MA or covering clinician) and allowing the result to remain for the ordering clinician to endorse.

Turning off the Paper

As you can imagine, part of the end-game is to discontinue the paper delivery of results. From my experience, regardless of all plans and intentions, you are best off living in a “duplicate world” for at least a week or two whereby you have to process results both electronically and on paper. This is done primarily to ensure that you receive all results that were preliminarily processed prior to going live with electronic results. When your practice is confident that electronic resulting is reliable, BRL can stop the delivery of paper results.

Results to Endorse

Yes, it seems like a never ending journey to get all electronically available results delivered to everyone's CIS Inbox. For months, I've been promising the simultaneous rollout of a new means a assisting in results management known as pools. The thought was that all results would be delivered to both the ordering clinician and members of a predesignated pool. This pool would be designed in advance of the onset of results delivery and would provide an alternative means of reviewing and endorsing labs, either by a covering doc or even by an MA, depending on practice protocol. For example, there are many instances where it is appropriate for normal labs to be signed by ancillary staff who can also create a correspondence letter informing the patient of their results. Abnormals could be left for the physician to later in the event that those results are not otherwise brought to their attention.

It turns out that the pools as described do not function as promised. After consulting with our IT colleagues at Cerner, we realize that we can best manage these results at the practice level by using the proxy tool. This, in fact, is a really good thing. Most clinical sites use the proxy tool for a variety of functions including patient list management, messages, and, in a number of sites, for results management.

In the coming days, I will create a quick video that will review the set up of proxies. I have heard from many of you who are ready to receive results and expect that we will begin delivery on Tues Sept 8. Stay tuned and look for emails related to this soon.

Preadmit Orders

I recently received an email from a rightfully frustrated colleague who complained that they had gone to great effort to schedule a daystay procedure, provided the necessary documentation, and entered an intricate set of orders in advance of the appointed time. In spite of these complete efforts, the orders were lost and had to be done over again late at night and over the phone.

The driving issue that led to this circumstance is related to our so-called "encounter logic". I may have mentioned this in earlier posts, though it deserves repeating. Every time a patient interacts with any part of the health system, a new encounter is created. So if a patient calls the office to make an appointment, a triage encounter is created. When the patient reaches the front desk at the time of that appointment, an office visit encounter is created. When the patient goes to the lab, another; to radiology, another; and so on. When a patient is scheduled for admission, say in the event of an elective procedure, a Preadmit encounter is created. This encounter then changes over to the appropriate admit encounter upon arrival to the facility.

In the case above, a transfusion was scheduled and orders were placed. Unfortunately, those orders were placed on an office visit encounter and not on the Preadmit encounter that is created during the scheduling and registration process. The key is to select the proper encounter in order to place those orders. I realize this might seem onerous (at best), particularly since you are able to review a patient's chart regardless of which encounter is opened. But this is more than data collection; the encounter logic facilitates a variety of tasks including ancillary services, charging and billing and patient location.

The following slide set reviews how to select the correct encounter in the event of a preadmit. This instruction also applies to direct admits and the like.

(Remember to click on the icon at the lower right to open to full screen.)

Preadmit Orders

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Auto-text re-update (if you read the first version this morning)

Last week, I discovered that I was able to quickly build about 16 procedure forms that Pain Management had requested over three years ago (!) using the auto-text feature. By simply copying and pasting from Word documents, I was able to circumvent the creation of these fill-in-the-blank forms via PowerNote and have them appear as they always had in the paper world. Great stuff that I expect to apply to a variety of form-based requests. However, there is a catch.

When we first introduced auto-text, suggestions were made to begin each shortcut with a designated symbol, e.g. your initials, the letter z, or a period. I certainly didn't jump up and down to get the word out, so a number of folks have used logical abbreviations like "chol" for a cholesterol-related text. For myself, I've been using the letter z pretty seamlessly. Well, when the pain management forms were posted, they were saved across the system such that they will appear for all users of auto-text. Since they are system-based, they can't be deleted from an individual's list of auto-texts. Well, understandably, this created quite a nuisance for a number of folks. Thanks to Julio Martinez, we realized that, if we start the specialty forms with ~, these will sort to the bottom of an alphabetical list and so you will no longer even see these forms unless you are looking.

If you read the first version of this post, I suggested you rename your auto-text shortcuts. You no longer need to do this. Continue saving as you wish, though I'd still recommend starting with a symbol so that you can view your list, or even create a series of lists, each summoned by a particular symbol.

If you want to check out how you might want to create a form, check out what we've done for Pain Management. For the next few days, they will begin with "pm", though by early next week, they will start "~pm". Here's what you do:

Go directly to Clinical Notes, right-click on the open field and select Add, then type pmAxNB to add the Pain Management Axillary Nerve Block form to the page. From there, hit the Insert button on their keyboard in order to overwrite the lines and fill in the blanks.

As always, feel free to post a comment, anonymously or otherwise, or shoot me an email.

Trouble Connecting to CIS from Home?

Recently, I've had some troubles achieving a stable connection to CIS when at home. This seems to be unrelated to whether I'm on my Baystate laptop or whether trying to log on from my Mac or my kids' PC laptop. It turns out that the PC's dreaded operating system, Windows Vista, has Internet Explorer8 and I was recently told that CIS will not run through on anything higher than IE7. To make matters worse, Vista doesn't allow me to download this older version of Internet Explorer. On my Mac, Safari has been kind of iffy in terms of holding a connection. So...

If you are having trouble logging in from home, whether from a Baystate laptop or your own home computer, the best way to ensure a connection is to use the Firefox browser. If you don't have this on your home computer, download it. If you'd like to download it to your Baystate laptop, give the Help Desk a call and see whether they can facililate this for you. I make no promises, but this seems a reasonable request if you are accessing CIS from home. (Of course, when logging on to CIS, make sure you first login through baystateheath.org.)

VNA Forms

July was a pretty sparse month for posting. I guess I have the summer to blame.

We continue to develop new tools that will advance our progress towards a paperless medical record. Recently, electronic versions of the VNA HCFA 485 (certification/recertification) and Physician Interim Orders forms have been created. These forms can now be sent to the Document to Sign folder in the Message Center inbox. We've been piloting this delivery and sign-off process with docs over at the D'Amour Center for Cancer Care (high volume users) and, by all reports, this is going very well. We are hoping to roll this out to all practices shortly.

Here's a preview:

VNA HCFA 485 (Plan of Treatment)

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Let me know what you think.

Customization of Clinical Notes folder display

Here's a slide set that should help you optimize your Clinical Notes display by setting up defaults for expanded folders.

Clinical Notes Folders

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More email questions

As you might imagine, I receive a good deal of email containing questions on use and function of CIS. The following is a copy of such an email, one that contained a series of great questions wherein I tried to answer succinctly and honestly.

Feel free to send me your questions or post them here in the comments section.

___________________________________________________________________

My requests for CIS:

1-Please eliminate the warning that appears when we are doing prescriptions refills since it takes too many clicks and time to do refill of medications.

(In progress)

a-Only prescriptions orders available for modify on discharged patient, continue?

(The elimination of this needless alert is in progress)

b- Interaction checking cannot be performed for medical equipment (ex test strips, glucose monitor, lances, alcohol, etc). Please click Ok to continue placing the order.

(This errant form of a decision support alert is in the process of being sorted out and eliminated)

2-Please allow to use more than 1 macro in PE (ex by adding an other window) and if possible in HPI. The advantage is to be more time efficient since I can do w 2 clicks what I am currently doing w 5 clicks.

Note: The way HPI is set at present, you can't see what you had written in the window if you open a new window using macros or CISO old system.

(Macro functionality is “hard-coded” by Cerner. Autotext is the best way to work with this – see the bottom of this post for the JobAid that is also available at the CIS Info Site)

3- Allow for the pharmacy favorite to be put in alphabetical order like before.

(Use the new Favorites Folder system in the Prescription Writer window. This functions like a Windows-based folder hierarchy and will solve the issue. Unfortunately, I am finding that old favorites from EasyScript days are useless, if not corruptive, to the Rx process. You are best off starting new prescriptions and saving them as new favorites.)

4- Default the P/N to hide structure instead of show structure.

(This would defeat the purpose of structured templates since their guiding contents would be hidden from view. To begin free-texting, just click under the paragraph heading in the open field and the structure will be hidden at the same time that the cursor is enabled for free-texting. See my post from 6/26 that includes a slide set done on this very topic)

5-Allow for use of the existing macros in all different types of notes, e.g. ped and adults, by choosing a tab and alternating from macros of ped notes and macros from adults notes.

(Again, Autotext will solve this issue since these are not location or template dependent. The issue with macros crossing templates is that the templates have to “line up” identically with respect to paragraphs and if they don’t you won’t see the macros show up if made on a different template. Autotext can be used anywhere in any note)

6-When doing refills add an option to pick for 30 days supply & 5 refills.

(Redesign in progress)

7-Allow to correct P/N again instead of giving modify as the only option.

(We needed to pull this because of the medicolegal vulnerabilities it created. Suboptimal design by the vendor that we are hoping will be fixed in the future. See my brief post of 5/27)

8-Allow for an option of autopopulate the statement of problem is reviewed.

(This can be done by a macro or autotext at the level of the Problem List)

9-Allow to deselect prob list, medication in each of the encounters. Sometimes you can only deselect today's results, v/s, medication list and system doesn't allow to deselect prob list in the autopopulate option.

(I’ve not heard this before. When presented the autopopulate window upon opening a template, you should be able to deselect all of any particular section. A specific example would be helpful)

10-Allow to modify document medication by hx even if there is no fresh encounter. I was trying to update some medications list and the system didn't allow me to erase medications from document medication by hx. The message displayed was: Can't modify orders on discharged patient.

(This is a HUGE issue that has since been resolved since the sending of this email. Please let me know if the problem persists.)

11-Allow to pick more than one macro at the same time by hitting control key before they are pasted.

(As stated earlier, Macro function is Cerner code that we cannot change. Autotext, on the other hand, does not have this restriction and can be used multiple times in the same part of the note)


12-Allow to copy and paste results in other window w/n results in P/N again

(sometimes it doesn't allow it). (You can only copy/paste once into each OTHER window. In order to copy/paste more info, you need to open a second OTHER window)

_________________________________________________________________________________________________

_____________________________________________________________________________________

WHAT IS AUTO TEXT?

When documenting in CIS, Auto text will store text you use again and again, such as standard phrases or statements. Each selection of text can be recorded as an auto text entry and be assigned a unique name to identify it. Unlike Macros, auto text can be inserted within any paragraph of any CIS note. There are two ways to create auto text in a note.

CREATE AUTO TEXT OPTION 1

This option allows you to create auto text while in the process of writing a note. From an open note:

1. Select Hide Structure or open a free text box

2. Click on the text field and type in desired text

3. Highlight the text by dragging your mouse over it

4. Right-click on the highlighted text and select “Save as Auto text”

In the Manage Auto Text window that displays:

5. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
6. Enter a description of the text
7. Click on Add Text
8. Click Create

CREATE AUTO TEXT OPTION 2

This method allows you to create auto text ahead of time. From an open note:

1. Select Hide Structure or open a free text box
2. Click the auto text button on the toolbar

In the Manage Auto Text window:

3. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
4. Enter a description of the text
5. Click on Add Text
6. Type the text entry you wish to create
7. Click Create
8. To create additional auto text, click Create again
9. Click Close when done






USING AUTO TEXT

1. Type the first 3 letters or abbreviation of the text

2. The abbreviation will display

3. Left click on it and hit Enter or use the down arrow on your keyboard to select it and hit Enter

The auto text statement will display.

OR

1. Right-click in any free text field and select Insert Auto text

2. Select desired auto text from the Select Phrase to Insert window

Great question on system performance

Question by email:

Just had a patient who is Director of IS at (a local hospital). They use the same Cerner CIS system there as we do both in the hospital and in the outpatient clinics (all across the country in 22 states, etc.) with their main “server” in Tennessee. He said to me “is it always that slow”? There were lots of half second to one second pauses etc. I said "yes, (no different than is has been for years)." He said, “they would have me by the … if the system were that slow at (my hospital).

What could possibly be the issue with our product?

Answer:

At Baystate, we "host" Cerner on our own servers whereas the aforementioned hospital system likely uses what is called an ASP version, or application service provider, such that their Cerner products are web-based. Furthermore, the perceived lack of snappy responsiveness is not only because we use our own local servers, but, as a system, we use the Cerner product that allows us to customize its various tools to our needs. These require more time and juice to operate. Customization is neither offered nor available with the ASP version of the Cerner EMR.

As tough as it might seem in its current state, we, as a physician group, would not be happy if we had to use Cerner contents "out-of-the-box". In addition to our customized PowerNotes, there are other fixed designs that would have you scratching your head as to whether there had been enough clinical input during development.

Another likely factor is that this other system is not able to do nearly as much as we do at BH with our EMR. While the rest of the country is struggling to come to terms with the reality of HIT (health information technology), Baystate is in the 99th percentile with regard to EMR adoption and expansion. We are excelling at CPOE, electronic documentation, data storage and retrieval, and the list goes on.

Show-Hide and Alphabetizing Favorites

Interesting week EMR-wise. We had a successful launch of EKG and stress test tracing images to the Clinical Notes as well as delivery of these results to BMP physicians ordering from the ambulatory setting. We're getting closer to making changes to the Table of Contents, as I reported earlier this week. But we also had something of a snafu with our attempted launch of the new Immunization Schedule.

Our intentions were good and, boy oh boy, did the IS team ever perform due diligence in terms of testing this new tool. Sometimes, though, all the testing in the world doesn't mean a thing when it can't be done in real time and space. To make a long night's story short, we ultimately decided to pull the schedule and reverted to the Immunization Profile, which really is just a plain text list of vaccines given.

For adults, the profile is fine, but for kids, whose MO is to be pin cushions through adolescence, the schedule was and will be a colorful enhancement. Expect to see it sometime in the TBD. For those of you whose patients are older than age 20, the schedule doesn't change things much except to lose the list and create a Historical Immunizations tab in the All Results band. All else functions as is including Health Maintenance and View Immunizations in the PowerNote. But for our younger patients, the schedule will provide visual cues and alerts that will improve the delivery of this essential component of care. You'll get the heads up when we are ready to give it another go.

In the meantime, one of my partners in crime, Pat Brown, created a couple of nice slide sets that I thought might be useful tips.

Turning off the Show-Hide structure opt...

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Alphabetizing favorite medications

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CIS Table of Contents (Menu bands)

This week will mark the end of the third month since the changeover to the unified version of CIS. Over the course of this time, we've had to overcome a variety of unexpected setbacks, but have also benefited from a host of changes that, when frustrated, go unseen in the midst of a rushed patient care session. Your voices have been heard and in response to suggestions made regarding the user interface, the Table of Contents (or Menu bands) will undergo an overhaul of a sort.

When we first made the changeover on March 24, a single TOC was designed for use by all. In the coming days, you will see a different arrangement, depending on where you spend the majority of your time. If, when you login to CIS, you see the Message Center with the Inbox, you will see the Ambulatory view as listed below; if you see the Message Center alone, yours will be the Hospital-based view; if you live in the ED and can login to FirstNet, then it's obvious what you'll be seeing.

Suggestions for modifications were culled from emails and less than formal conversations and were also sought from medical directors in order to better define site-specific designs. Check the lists below for what to expect in the coming days.

Ambulatory View

• Overview
• Documentation
• Clinical Notes
• All Results
• Laboratory (NEW)
• Micro
• Health Maintenance
• Histories
• Immunization Schedule (coming your way June 24)
• Growth Charts
  
• Diagnosis/Problems
• Medication List
• Allergies
• Orders
• Tasks
• other necessary, though not frequently used, bands

Hospital View: the patient chart will default to open to the Orders screen

• Overview (take a closer look at the Since Last Time tab for new labs, results, documents since last date/time stamp. This can be helpful to look for new consults, etc.)
  
• Orders
• Documentation
• Clinical Notes
• Diagnosis/Problems
• Histories
• Medication List
• MAR
• MAR Summary
• Allergies
• All Results
• Laboratory
• Radiology
• Micro
• Interactive Flowsheets
• I/O
• Handover
• other necessary, though less frequently used, bands

ED View: the patient chart will default to open to the Orders screen

• All Results
• Laboratory (NEW)
  
• Radiology (NEW)
  
• Allergies
• Clinical Notes
• Diagnosis/Problems
• Documentation
• Facesheet/Insurance
• Forms
• Histories
• Immunizations
• Medication List
• Micro
• Orders
• Patient Information
• Reference Text
• PowerNote ED (in anticipation of ED electronic documentation)
• other necessary, though not frequently used, bands
  

Imminent Improvements

Now that we've settled into the unified view of CIS (note the intentional avoidance of the word "enhanced"), the informatics team is able to circle back and make some changes to the interface that ought to improve your experience. First on the list is the rearrangement of the Table of Contents (or Menu) bands. These changes will be based on position (ambulatory-, ED- or hospital-based). Without going into too much detail, we will move the Documentation and Clinical Notes higher up the list and give lab results its own band to save you a few clicks. For ED docs and those who spend most or even part of their time in the hospital, the default opening page will be Orders rather than the Overview page. For ambulatory-based docs, you will see the removal of hospital-oriented entries like Med Rec and MAR Summary. Expect these changes to be evident in the next week or two.

We are also actively seeking a results to endorse solution that will enable a system-wide rollout towards the end of the summer. In order to make this happen smoothly, we are creating pools, (think "group proxies"), that will facilitate custom workflow design in every practice. While the usual routine in a primary care setting is for doctors to review results and communicate with patients accordingly, others choose to delegate this review and be made aware of abnormal results. My first thought is to create a results pool for each of the BMP practices. Pools will be posted at the same time that RTE will arrive in the clinician's Message Center inbox. A result can be reviewed and endorsed by the physician and will then drop off both their list as well as the pool's list. In the event that the protocol is for the medical assistant to endorse normal labs, then those results will also fall off the pool list as well as the ordering clinician's results list. It will be the responsibility of the practice to determine the proper protocol so as to avoid inadvertant endorsement of results that go unseen by the ordering clinician.

Other improvements:

We continue to work with Cerner to optimize the function of the Prescription Writer. If you haven't heard, two key points are to 1) Cancel/Reorder any meds that were last written with EasyScript. Thereafter, the Renew function will work well; and 2) when in doubt, fill in the Duration field. This will facilitate the easy completion of the Rx. Remember to click on the big downward yellow arrow found in the middle divider bar if you are unsure of what field needs completion to execute a script.

Med Rec is still in a tough spot, though we expect it to improve over the next few months.

We have a new Health Maintenance Redesign working group. The plan is to review current guidelines and bring the HM tool in line with the evidence and recommendations of sentinel task forces.

PowerNotes Index on CIS Info Site

We continue to make the CIS Information Site the so-called "source of truth" for the what, where and how-to of CIS for all users. We will be posting an index of all PowerNotes that have been created thus far, organizing their titles by venue, that is, by the variety of areas in which they might be used. While I tried to define these divisions as broadly as possible, I would not be surprised if found additional ways of cross-referencing these templates. Let me know what you think.

PN Index

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RTE not ready for prime time

As a result of a logistical error yesterday, the Results to Endorse function was “turned on” for all ambulatory practice sites. For those of you who had not previously received these results, measures have been taken to discontinue this electronic delivery immediately. While electronic results to endorse remains a system goal for all BMP practices, yesterday's delivery was premature. We are currently in the midst of creating associated tools designed to streamline anticipated changes in workflow and expect to introduce these in the coming weeks. I expect that we will be able to formally roll out results to endorse for all ambulatory laboratory orders early next month.

In the event that you have received these laboratory results for the first time, you can discount them as your means of results review and expect that your usual protocols remain in place, i.e. paper reports. To clear them from your Message Center Inbox, double-click on the first report-->scroll down to view all results-->click OK & Next until the last result.

Health Maintenance Working Group

The original intent of Health Maintenance tool was to account for both established clinical guidelines and local community practice. Since its initial posting, guidelines and practice have changed such that there is a need to re-evaluate the current design of the tool. I am interested in pulling together a group of interested docs to review the current design and determine the contents of a revised version. I’d like to kick off the project with an informal meeting within the next month. Given the nature of the work, I think we can accomplish much of the task thereafter via email, blogging or other electronic means.

The goals of this project include:

• Selecting and reviewing the latest clinical practice guidelines
• Reviewing the literature for some of the more controversial screening measures
• Determining the appropriate HM elements
• Determining appropriate time intervals
• Reviewing and editing verbiage of the alerts

Secondary goals include:

• Piloting various electronic means of communication: email, blog, wiki, twitter, web-conference
• Previewing developments in HM too

I expect that, if we are successful with the electronic communications, there may only be a need for an introductory meeting and possibly a final meeting for sign-off. Please let me know whether you would be interested. At minimum, I’d like a group of 4-6 docs to take part in this project.

I’m looking forward to a lively and fruitful discussion.

Correct Function a vulnerability

After a great deal of thought and investigation, the Clinical & Medical Informatics team has decided to remove the Correct function from CIS documentation as of May 27, 2009. The team has consulted with HIM (Health Information Management) and Baystate Health Risk Management. All entities agree that, until the proper notation regarding any updates appear in corrected documents, the Correct function should not be used. The tool will be re-introduced when its function is modified to meet best practice.

Health Maintenance...again

So I've think the IS team has struck paydirt. After hours, days and weeks of techno-struggle, it seems the Health Maintenance performance dilemma has been solved. In fact, it may finally be working as designed (see 4/22 post).

I give you fair warning that it can take up to 45 seconds or a minute if you are loading a patient record with a great deal of information for the first time since the fix. Go back to it in the future and it should load quickly, finally relying on the HealthFacts tool I've alluded to in previous posts.

Now that the Health Mainteance tool appears to be functioning again, I will be looking for folks to join in a working group to consider a revamp, taking into account the various practice guidelines and latest evidence. Anyone interested knows how to find me... or I'll come find you.

Report from Kansas City

Tom and I have been here in KC at Cerner headquarters for the last few days at the Cerner Physician Community conference. As you might imagine, Prescription Writer has been a hot topic and a source of pain across Cerner's clientele. While I think we've had some improvements in function since we went live with it in March, it still requires considerable reworking until there is uniform satisfaction. A few lessons learned:

• the addition of sentences for the sig have helped to fill in required detail fields
• though promised to be an efficient transition, data from EasyScript should be ditched
• Consider delete all old favorites from EasyScript
• Rather than using Renew for refills of Rxs written on EasyScript, use Cancel/Reorder to reformat the Rx and allow Renew next time around
• Build new Favorites within the new Ambulatory Meds favorites folder and, if you have the patience to do so, build a specialty- or class-based subfolder structure within that larger folder
• DO NOT CHANGE your Home folder from the Durable Medical Equipment (DME) catalog to anything else. You risk losing this catalog if you move it.

Our pleadings for a return to an EasyScript user interface have been heard. While we can't expect to see a return to this anytime soon, I will be part of a working group with the Cerner engineers who are working on this important project. They demonstrated a mock-up of something similar to EasyScript and so I am hopeful.

That's it for now.

Health Maintenance trial fix

I mentioned a week or two ago that we are working on improving the loading time of Health Maintenance. Today we ran a "proof of concept" trial to see whether our strategy would work. While I haven't heard from more than just a couple of folks, it seems that the HM tool is loading more quickly.

It was quickly discerned by these docs that the creatinine expectation loads as though never satisfied. As this was just a test run, the creatinine deficiency will not be part of the fix. Once Josh is able to write new code to shift the Health Maintenance tool back into gear, you will find that the creatinine measure will accurately load re: expected vs. satisfied. However, not all that is accurate is precise! The creatinine will show as expected if it had not been done in >365 days, but whether displayed as satisfied or expected, will show the current date and not the date it was last performed. This might have to be the compromise we choose to live with until a real fix comes with future Cerner upgrades.

The bottom line is that you will be able have this health maintenance measure flagged and be logged accurately (and precisely) in the diabetes registry; you will just have to make sure that it has the correct date when running your screen. For the most part, I would assume that virtually all HbA1c measures have an associated creatinine, so that would be a place to start.

Prescription Writing Woes

Sorry for another long absence. Last week, we spent three days with folks in from Cerner headquarters in Kansas City to hear out and evaluate our disappointment with the Prescription Writer, Medication List and Medication Reconciliation tools. For the most part, we were pleased with the team's receptivity, though less than excited about what can be fixed quickly. The long and the short of it is that we will not see any major changes in the layout and appearance of the Prescription Writer for the time being. However, we will be putting together some documentation to help you optimize the function of what currently exists.

One crucial discovery I have made over the last week is that, in spite of being promised a seamless transition from EasyScript to Prescription Writer, many of the refill/renew and favorites woes are derived from an obvious lack of seamlessness. In fact, I am beginning to untangle myself from the older scripts and will also be building new Favorites folders. This is a major drag since I have about 350 favorites that came over from Easy Script. The problem is that all those extra terms in the sigs and all those problems with renewing and changing doses are a direct result of using old commands to create new prescriptions.

My advice is this: when renewing a med that was originally written in EasyScript, DO NOT use Renew. USE Cancel/Reorder. This will rid of the old version of the Rx, allow you to make changes to the dose and the sig , and should present the mandatory fields in a somewhat more logical fashion. It is definitely worth it. Then, save the new Rx as a Favorite if desired. This new favorite, whether written in the office or on discharge from the hospital, will end up in the Ambulatory Meds favorite folder where you can then organize a brand new folder set based on disease states, medication classes, organ systems, whatever you like. The favorites that fall outside of the Ambulatory Meds folder are all imports from EasyScript. Feel free to delete them as you build new ones.

Keep your eyes peeled for emails and updates on the CIS Info site. We will be getting out details for change in the coming days.

Folder Structure of Clinical Notes

You've probably noticed by now that the folder structure (or hierarchy) of the clinical notes has changed. While it is not likely to be dramatic change to most patient charts, it may cause some head scratching for patients who have been in and out of the hospital and to many different clinical sites. The main gist is that the folders are no longer organized by location. There are now three major folder headings:

• Requests, Authorizations, Contracts & Consents
• Patient Care Documentation
• Non-BH Medical Records Scanned

Patient care documentation will consist of PowerNotes, dictated documents, results, reports, forms, etc and will be organized by specialty. This restructuring will facilitate improvements in organization and importation of clinical documentation whether created in CIS or scanned into the system.

This redesign will not only improve the filing process of documents, particularly those that are used both in the ambulatory and inpatient settings, but will allow for streamlining of the soon-to-be-introduced scanning initiative. While I'll have more to say about this in future posts, this is a major next step in Baystate's journey to the paperless medical record.

Health Maintenance Performance

As many of you know and have reported, the performance, i.e. speed, of the Health Maintenance tool has been absolutely lousy for the past few months. While we thought we had improved function a couple of months ago with the introduction of a new tool meant to speed up the loading of data, we soon found this had no effect. The idea was that this tool, called Health Facts, would cache individual patient data so that each time you went to HM, the only data that would need to load would be those that had not previously hit the page. Well, whether that tool works or not, Health Maintenance remains slow and dysfunctional.

We've been told by Cerner that Health Maintenance "works as designed". So we now know that the design is faulty. What we have found out is that the tool is designed to find every clinical event that satisfies the health maintenance measure. (A clinical event is any result that we are counting, e.g. LDL.) So, while this isn't such a big deal for an event that occurs every 10 years (tetanus) or even every year (mammogram), a serum creatinine can occur dozens, even hundreds, of times in the lifetime of the patient (data exists for the past 5 years). We have found that there are patients who have had hundreds of these events and that the tool records each of these events to a so-called table. What would be considerably more reasonable would be that the last posted value be used to satisfy the HM expectation and so avoid slowing down the process of displaying the HM elements.

So the bad news is that, and we (meaning, Josh Wherry of IS fame and uber-talent) have haunted Cerner as much as is feasible. The system designers are aware of our dissatisfaction, but, because of evolving software code, are unable to make the fix for us.

But the good news is that we have a clear understanding of the bad news and that Josh has written a work-around piece of code. This will enable the HM tool to work effectively and efficiently until we are able to take on updated code from Cerner later this year. The fix, though, will involve a single hitch for it to work.

Without getting into any more detail than I already have, once this work-around is tested and then brought to a computer near you, one test will display in somewhat funky fashion: the creatinine. The test will show as an above-the-line expectation if not resulted within the past 365 days, but will not display the last date that it was actually performed. Conversely, if the creatinine had been done in the last 365 days, such that the expectation has been satisfied, the date noted below the line will read incorrectly.

The better news is that the correct date of the creatinine, and presumably the performance of HM in general, will present "as designed" by the end of this year without the need for Josh's work-around.

Thanks Josh!

Procedure/Surgical Hx Free Text

Q: Is there any way to free text a surgical procedure anymore? I have a patient who just underwent what the operative report says was a transobturator midurethral sling. ...and I searched transobturator, urethral, midurethral and came up with nothing.

A: There have been a number of requests for docs and other clinical folks to be able to enter procedures and surgeries that just don't seem to be searchable through the Histories tool. You might recall that we have this option in the Problem List, among other places, though discourage people from using free text since uncoded data are not especially versatile. This is the say that such entries would not be easily converted from one tool to another (Problem to Diagnosis List, for example). Also, we have trouble tracking and mining uncoded data for registry and research purposes. That said, when I received the above request, I contacted my IS buddy, Julie Gentes, and, with the flip of a switch:

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Prescription Writer and the Medication List

My two favorite topics... well, not really. So far, we have had a couple of teleconferences with senior Cerner analysts to share some of the major issues reported thus far. For one, "real estate", the amount of space given to view relevant information, is inadequate. While the old Med Profile seemed less than optimal to many, the new Med List is difficult to read and doesn't take good advantage of potential space.

I remember a time when many of us felt that EasyScript was difficult. With Prescription Writer, the cumbersome task of writing a prescription requires lots of practice and a little luck to boot. It pains me to hear that folks are reverting to paper prescriptions and so the repair of these tools is priority number one.

I am confident that we have been heard by Cerner. Though I can't pin a timetable to the improvements, I believe the practice and process of monitoring and prescribing medications will get better over time.

Below is a slide that Sandy Gagnon of the IS training team put together today. It is a great way to see the Medication List in single-spaced layout. Thanks Sandy!

Uploaded on authorSTREAM by nrk99



And, if anyone is interested, I led a webinar on the Medication List and Prescription Writer last week that can be reviewed via this link: Medication List Webinar

Procedure Titles and Codes

I've been asked how the Procedure Hx selection can be made easier when there seem to be hundreds of choices that seem to account for all the esoterica and none of the run-of-the-mill. So I went back to my screen and cracked open the the couple of folders listed in my Favorites section and took a look. There, I found system-tracked entries as well as my favorites from the retired Procedure Profile tool. I then went to the search box and started hunting around. The following table contains 22 of the most common procedures performed, including 2 entries for retinal exams.

Procedure	Code	Terminology
Diagnostic Colonoscopy	269810011	SNOMED
Colonoscopy, flexible…with or without collection…	45378	CPT4
Bone Density scan	456435014	SNOMED
Echocardiogram	1229672017	SNOMED
Carotid Artery Doppler assessment	1488435015	SNOMED
Diagnostic ultrasound of abdomen and retroperitoneum	2838019	SNOMED
CT of Chest	262405017	SNOMED
PFT- pulmonary function tests	1223095017	SNOMED
Polysomnogram	100605013	SNOMED
Upper GI endoscopy…diagnositic…with or without specimens	43235	SNOMED
Myocardial perfusion imaging…at rest and/or stress (exercise and/or pharmacologic)	78465	SNOMED
Exercise stress test	375609014	SNOMED
Exercise stress echocardiography	375982017	SNOMED
MRI of lumbar spine	361784019	SNOMED
MRI of cervical spine	361781010	SNOMED
Cardiac catheterization	70051019	SNOMED
Percutaneous angioplasty of coronary artery	1219586014	SNOMED
Percutaneous coronary intervention	2535176014	SNOMED
Percutaneous transluminal balloon angioplasty with insertion of stent into coronary artery	2694928017	SNOMED
Percutaneous transluminal coronary angioplasty, multiple vessels	141011017	SNOMED
Dilated retinal eye exam…(DM)	2022F	CPT4
Examination of retina	410663011	SNOMED

When searching for these and other Procedures, make sure to have the dropdown windows read Contains and Terminology. I have my terminology selected at SNOMED and CPT4. In order to make changes to that selection, click on the Show Advanced Options term.