Wow, check out the new Job Aids

I was just about to log off when I went for a last look at the CIS EV Info site. I clicked on Job Aids and found a terrific list of new text instructions covering a variety of tasks. These are printable, easy-to-use reference guides.

Hooray for that CIS Training Team!

PowerPoint posting malfunction

I don't know why, but the hosting site for my PowerPoint slide sets has been down for the last few hours. I can't get any info as to when they will be back up. They seem to be real players in this field, so I hope this is only temporary. Sorry for the inconvenience of not being able to see any of the old or what I wanted to post today. I will be posting later...

Assuming Authorship and Adding an Attestation

So today I thought I was going to appear the prophet to a new hardcore PowerNote user when, lo and behold, the authorship process whereby one clinician starts and another assumes the note for their own completely changed. Not to get too deep into the weeds, it had been the case that, if a note, e.g. Physician Discharge Summary, was started early in the hospital course, that, in order for the authorship to be updated and displayed properly in the Clinical Notes folder, the new author would be wise to copy to new note and the earlier author would delete the old note. In trying to teach this to a colleague today, we found that, if the saved (Active) note is opened from the Documentation--> Existing tab, a dialogue box offers Read Only or Edit. I don't know when it happened, but by simply clicking Edit, the authorship is transferred and all is well and good.

So for the hospitalists that I've presented to over the last couple of days, I blew it and hope not to have bungled your workflow.

I redeemed myself by demonstrating how to Modify a note when an attestation statement is needed. For example, if you provide supervision for a resident, or an NP or PA, for that matter, a signed note can be modified with an attestation statement easily dropped in as an addendum.

Check out the slide sets and let me know if I've mislead you elsewhere!


Uploaded on authorSTREAM by nrk99


Uploaded on authorSTREAM by nrk99

Quick Tips from the Past

Over the last couple of days, I've had a chance to spend time with a number of the hospital medicine docs. This is a terrific group of highly motivated CIS users who, on the whole, know how to use the system as efficiently and effectively as any. But I learned a couple of things from them today. First, I should never assume that old tricks lose their meaning. And second, much of what we know now about PowerNote documentation will hold true when we go to Enhanced View.

In response to a couple of great questions that I've answered in the past, but in another context, I've attached two slide sets: one a single compact slide on the use of Copy to New Note, a useful but potentially hazardous means of doing serial documentation; the other reviews how to select and default the Document Type, aka folder location.

I must remind you that, in order for a note to be considered clinically meaningful and legally legitimate, it must be updated and revised with integrity. The copy function is best used when passing off a note, e.g. Physician Discharge Summary, that is started by one physician and adopted by another. This allows for authorship to be assumed by the doc who has done the copying. On the other hand, when a progress note is copied one day to the next, you MUST make sure that the overnight events, vital signs, labs, and impression and plan are relevant and current. I can assure you that an auditor will catch on and this can bring serious consequences. I won't dwell on this, since I'd rather be advising you on how to make documentation easier.

I hope these are helpful. I've got more where these came from, so if you've got some basic questions about documentation or chart navigation, just ask.


Uploaded on authorSTREAM by nrk99

Uploaded on authorSTREAM by nrk99

Following a blog, maybe even this one

You might guess that, having started this blog, I also like to follow a few myself. I think it's a pretty cool technology and an easy way to keep an eye on a wide range of topics and opinions. I've set up my home web browser to open to iGoogle, a neat web tool that the 21st century's reincarnate of General Motors offers.

In Google's words:

Google offers the ability to create a personalized iGoogle page that gives you at-a-glance access to information from Google and across the web. On this self-designed page, you can choose and organize content such as the following:

• Your latest Gmail messages
• Headlines from Google News and other top news sources
• Weather forecasts, stock quotes, and movie showtimes
• Bookmarks for quick access to your favorite sites from any computer
• Your own section with content you find from across the web
  

On my page, I follow the NYTimes, my gmail inbox, a few Health IT blogs, the NEJM along with a few other medical entries, and a couple of book lover blogs. I tend to surf for new ones periodically, x-ing out the old and adding the newly found.

It's easy to follow a site from iGoogle, be it blog, newspaper or other website that changes content frequently. For most blogs, including this one, look for the "Subscribe To Posts" and choose where you would like updates to be presented. In my case, I choose "Google Homepage", though there are a number of other "feed" readers on the web. Oftentimes, you will see an icon in the www address bar (see the Subscribe To Posts orange icon below) that you can then click in order to get the updates.

Play around and you'll get the gist. To find iGoogle, go to any Google page and look under "More". It's pretty straightforward, and a bit addictive, once you get the hang of it.

Flash Player and the Blog

I'm hearing and seeing that a number of folks with BH computers (laptops, tablets and desktops) are unable to view slide sets that I've been posting due to a need for Flash Player updates. I am just off the phone with the Help Desk and have verified that they should be called for the fix.

Here are the instructions:

1. Call the Help Desk at 4-3000
2. Select 1
   
3. Have your asset tag number available. This is the number found on the bar code sticker that is found on the computer (and occasionally the monitor). IT will then be able to remotely install the software update.
4. Give me some feedback on the use of the screenshots. More, less, same, none; new topics, more depth, less detail...
   

Family Hx II (see Ask... for pt )

After asking around, hunting & pecking, right- and double-clicking, I found out a little more about the Family Hx tool.

First a glitch: if you enter - or + for a particular problem, you will see double click for more information. Unfortunately, all a double click brings is the full text of the problem in the event that the end is hidden by this very italicized phrase.

As for a right-click trick, do so at - or + and you can Clear the value. Given the general versatility of the right-click throughout the CIS EMR, it seems odd that no other functions are offered.

If you would like to enter more data for a relative's medical history, double-click on + and a dialogue box replete with entry fields will pop up. So were it important, as it often is, to document when a relative developed CAD, breast Ca, colon Ca, etc., the comments box is available. Preferences (Properties in this screen) can then be set to display comments among other details in the Family Hx.

Check the slide set for pics.


Uploaded on authorSTREAM by nrk99

Error Messages and PowerNotes

We are on a long and winding road to perfect documentation. I don't know about you, but I don't know when we'll get there. It's hard work. I'm guessing I've done around 10,000 PowerNotes over the last few years, between office visits, hospital progress notes and correspondence letters. And while it helps to be able to touch type and even more to be able to type about one thing and talk with a patient about another at the same time, it can be stressful stuff. Structured templates, by their nature, rely on two hands, two eyes and two ears, and are necessarily labor intensive.

I can talk about a host of efficiencies that make PowerNotes more manageable until I'm hoarse (and some of you have heard me), but today I'd rather share my sympathy and be a compassionate provider of transparent informatics.

I know from my own experiences, and from your calls, that there is NOTHING MORE FRUSTRATING than getting an error message that freezes the screen or boots you offline. I received a call earlier today from a colleague who reported just this. Fortunately, the two of us had spoken before about this problem and I was able to take a look at the particular patient record.

Many folks know from prior communications that, if you Select All and Insert Selected when entering lab data into a PowerNote, an insufficient memory error fires. In today's case, though, this was not the cause. It happens that the clinician entered the medication profile twice: once when reviewing & reconciling in the beginning of the note and again at the bottom to document modifications to the list. I can't say whether this alone created the problem, though I've got to think it contributed. What I am pretty certain about is that the default display preferences had a detrimental effect. Between loading the list twice and the defaulted over-display of partially useless information, the error message was bound to occur.

Take a look at the slides to see what I mean and how to change your medication profile preferences.


Uploaded on authorSTREAM by nrk99

Take home messages:

1. I hope I helped someone out today.
   
2. If you ever have a CIS technical issue, grab as much related information as possible, i. e. patient name, MRN, document name/type, time/date, and send it to me, Tom or Pat, or call the Help Desk.
3. Avoid using Select All followed by Include all, particularly when entering lab data.
4. Enter the medication profile one time only; if you want to document that you have reconciled the medication list (which you always should) in the midst of the note, select Medication Profile Reviewed. I have discussed this method of documentation with the PBO and have verified that this is as kosher as the full list with regard to billing code status. Feel free to add the medication list at the bottom after modification.
   
5. Change the Preferences in the Medication Profile list. It is cleaner and much easier to read and interpret.
   

Ask once... and I'll do what I can

Tom and I presented at Medical Grand Rounds to an engaged and engaging audience. We were able to field a bundle of terrific questions and present changes in form and additions in function with the introduction of the CIS Enhanced View. As a result of the presentation, there seems to have been an uptick in the hit counter (see bottom left corner below), hopefully a good sign! We've also received a handful of emails with great questions and special requests.

One question/request came from our new chief of heme/onc, Dr. James Stewart, via email regarding the new Family History tool. In response, here is a slide set that introduces what promises to be a real enhancement to our EMR. (Click the play icon and then the full screen icon found at the right bottom corner of the slide window.)


Uploaded on authorSTREAM by nrk99

Let me know if this is helpful or whether I should include more detail.

Medical Grand Rounds Preview

Tom Higgins and I will be presenting at Medical Grand Rounds tomorrow and I thought to post our slide set to give you an idea of what we will be covering in the event you are not able to attend. The gist of the talk will be focused on changes in form and function of CIS with the rollout of the Enhanced View. As always, I'd be glad to field questions on- or offline.


Uploaded on authorSTREAM by nrk99

A brief return to Health Maintenance

I've been working on a reasonable review of the new Problem and Diagnosis List functions that will be found in CIS Enhanced View. While I'm quite confident the upgraded version will solve a host of problems we've all encountered with the current version, there are some key changes that I want to make sure I explain so that I can refer you back to this site in the event of any difficulties.

So... I see from the poll and I've heard in conversation that there remains some concern about the Health Maintenance tool. I suggest folks go back to December's and the first half of January's posts to check what I've had to say thus far. I've also added a few major links that take on this topic.

Here are a few issues that I've heard about:

• The addition of the Zostavax vaccination- most of us in adult primary care are aware not only of the "availability" of the vaccine, but of the guideline that recommends a single dose for all adults 60 years and older. While the efficacy data are not exactly compelling and the cost of the vaccine is prohibitive, particularly when payers want no part of it, I included this HM element because it seems reasonable to track and is part of the MHQP preventive health set. Take a look at this slide for one way of handling the RED mark:
  

Uploaded on authorSTREAM by nrk99

• Pneumococcal vaccine does not have a Cancel Permanently selection. I will have this added as soon as technologically feasible.

• Consider changing the due date time frame for certain expectations, e.g. Td/Tdap, to "turn red" earlier. So for Td, the expectation could come due at 9 years rather than 10 years, thereby avoiding that booster being delayed in the event that the patient visits during the 10th year only to return many months after the 10 year expectation. As I've mentioned in an earlier post, the next big upgrade of CIS will include an updated and customizable version of HM that will allow the physician to make these changes based on patient needs rather than set code. For now, I'm glad to entertain this question and would appreciate feedback. I believe it would be practical only for those expectations that have long intervals since this could be a set up for over-testing.

• Prostate Cancer screening - get rid of it... This is a not uncommon suggestion and, as I approach 50, I would love to host a lively if not definitive debate here. For now, the PSA and DRE will remain on the HM tool and, like the Zostavax, can be canceled if you so choose.

Stay tuned for Problem and Diagnosis Lists - Enhanced View style.

Can't sleep, might as well post.

It's been a few very busy days and so I haven't had a chance to put together a post lately. I, along with many others, did some testing of the Enhanced View during the week and have found it to be as promised: lots of new features, a cooler and more intuitive interface, and some improvements of longstanding tools.

I'm in the midst of working on the new Diagnosis/Problem List feature. It appears to be a lot cleaner and easier to move a dx to problem and vice versa. There is even a code converter that anticipates out launch of charging and billing at the closing of a note.

Maybe a quick word on available code nomenclature:

SNOMED CT - Systematized Nomenclature of Medicine -- Clinical Terms - this is our preferred choice for entry into the Problem and Diagnosis Lists. The two primary reasons are that they are vastly more inclusive and descriptive, and this system is more amenable to data mining and capture for the purposes of builiding registries and other data management tools. To the first point, SNOMED encompasses most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc.

ICD-9 - The International Classification of Diseases, Ninth Revision - this is the codification system used for billing and charging, though more broadly defined as the code used to classify morbidity data from inpatient and outpatient records, and physician records. Its chief advantage is its universal role in billing schedules.

CPT - Current Procedural Terminology - this code set describes medical, surgical, and diagnostic services and procedures. It is used for billing purposes as an adjunct to the ICD-9 code.

DSM - Diagnostic and Statistical Manual of Mental Disorders - this is the code set that provides diagnostic criteria for mental disorders. As many of you know, it consists of a 5 axis system related to the various aspects of a patient's disorder, from affective to physical to functional. The ICD-9 and DSM use the same diagnostic code numbers, enabling this system to be used for billing and charging.

BOTTOM LINE: Use SNOMED diagnostic codes in your note. The conversion from SNOMED to ICD will be a snap when we are ready to roll out associated charging and billing processes.

I hoped I helped you to sleep if you too are awake at the wrong hour of day.

Checking for Sneak Peeks and Updates

A quick plug for updates and sneak peeks: Check out the CIS Enhanced View Information Site and click on the View link in order to see what is coming your way. There is a terrific slide show that compares the current to the future state of CIS.

• Patient search
• Refresh/As of
• Schedule view
• Family History
• Procedure History
• Overview Summary Tab
• Medication List

Uploaded on authorSTREAM by nrk99

More to come, but this is a great introduction to the new look and feel. (A big thank you to Sandy Gagnon!)

Quarterly Reports

I'm going to veer off the path a bit this evening to talk about the quarterly reports that are sent out to departmental chairs, division chiefs and medical directors. I suspect that a number of you are hear of these results and have been encouraged by them. Others of you might not be so sanguine.

It is fair to say that being a reports analyst can be a thankless job. In fact, in spite of hours of work and an elegant product, Mark Proulx has had to juggle email replies containing critique of all kind, from the constructive to the undignified. In spite of this, the reports reveal the remarkable progress we have made with CIS utilization.

As you know, Baystate Health's goal is to become paperless by the end of this decade. While this might seem a fantastical goal, the truth is that Baystate has recently been recognized as being in the top percentile of over 5000 US hospitals in terms of adoption and integration of the electronic medical record. We are on a trajectory of success.

The so-call quarterly metrics reports that we generate for distribution and review are reports, and just that. They are sent as a means of revealing areas of both engagement and reluctance. They are not measures of merit, productivity or compensation. Understandably, the included calculations ought to be straight forward: see a patient, create a PowerNote, next patient... and so on. Well, now that I have an insider's view, I know that it just ain't that simple.

Think of these reports as the final product of an intricate cascade of technical events. Much like the coagulation cascade, if a single factor is missing or defective, the outcome may be useless. And so we see unders and overs, distortions and disappearances.

If a document is created on the wrong chart encounter, the visit will be counted, but the PowerNote won't. If the patient is in your schedule, but is seen by a PA, NP or another doc in the practice, then the visit may be attributed to you, but the signed document will be attributed to its author. It's even more painful when hundreds of scheduled visits occur, yet zero documents are counted, a rare though frustrating occurrence. And how about the few who had ZERO scheduled visits and ZERO documents reported? That really is a particularly unpleasant outcome. We have been giving careful examination to reports just like these.

Dictated notes confound the calculations to an even greater degree. In an ideal world, all notes would be easily and efficiently created online using structured templates, aka PowerNotes. Why, you're asking? Because it widely understood that using a structured template improves documentation as well as patient care. Decision support, health maintenance cues, and medication review are just a few reasons why templates are often better than handwritten or dictated documents.

Unfortunately, structured templates have not caught on for a host of reasons, most related to the entry of data. While we continue to refine them, a number of physician practices, primarily in the specialty world, use dictation. Dictated documents do indeed upload into CIS. However, capturing these documents for reporting is tough. This is due to the fact that the aforementioned cascade is made more complex by additional factors and interfaces. We are much closer to achieving accurate calculations, but we continue to learn from the shortfalls.

Yesterday, I worked with a team of IS analysts to redefine the logic used to track and calculate the number of documents as well as the number of times the chart is accessed for prescriptions, results reviews, and other routine events. I expect that our next reports will be provide better data. The numbers look great and we are hoping to be able to share better looking news at the end of this quarter. In the meantime, if you've got questions about how the data are collected and reported, feel free to email me or to use this blog as a forum for commentary.

EV Peek: Reminders

While I've had reasonable exposure to the Enhanced View interface, I had a chance to really get into the Message Center this morning. I've been touting the new look and tools, but not until today did I really get a good feel for how it drives. I can't tell you much about Pools since they are yet to be built, but Proxies are very cool. The proxy tool is highly customizable such that you can select from a long laundry list of chart elements to proxy to others. This can be useful for managing messages, labs, documents, etc., and can improve clinic/office workflow depending on how responsibilities are shared. It's design is much simpler than the current one.

Reminders can be set to display instantly or at some later date/time and remain in your Message Center Inbox until cleared. It can also be set up to return at a later date. For example, you've got a patient that needs a follow-up imaging study in 6 months. You might post a reminder to yourself and forward it to your staff assistant to have the test scheduled 6 months from now. That "shared" reminder can serve as a message to staff and can then be cleared from your inbox once the necessary deeds are done. At the same time that this reminder message is generated, you can also set a due date for the reminder to return to your inbox to again alert you to the need for the follow-up test. This type of reminder is saved to the "Recipient's Inbox", as seen in the slide below.


Uploaded on authorSTREAM by nrk99

A reminder can also be saved to the patient's chart rather than to your inbox. A typical situation when this would be useful is in posting a note to yourself to do something, say a comprehensive diabetic foot exam, on the patient's next visit. This functions like a sticky note should and, while it hangs in the chart as a reminder, does not clutter your Message Center inbox with less crucial cues.

More feature reports to come

Here ye! Here ye! New Alerts to the Inbox

I am pleased to announce, especially to those of us who provide primary care, that alerts will be sent to your CIS Inbox when patients are discharged from the hospital and when patients are transferred to and from a critical care unit, including Med/Surg ICU, CVICU, PICU and NICU.

You hopefully know that PCPs have been receiving alerts to the Inbox for the last couple of years when patients have been seen in the ED and when admitted to the hospital. All alerts will share similar verbiage as well as the same unavoidably ugly font.

Doe, Jane was discharged from BMC (or BFMC/BMLH) on Date-Time. You are receiving this notification because you are listed in CIS as the patient's primary care physician. If you are not this patient's primary care physician please contact the Admissions Department to have them remove the relationship.

[Substitute seen in ED/admitted/transferred for discharged and you'll get the idea.]

As for other Inbox deliveries, the hospital medicine service forwards copies of H&P and discharge summaries to PCP inboxes via the Request Endorsement function. While this adds an extra click or two to the signing process, the automatic delivery of PowerNotes to the PCP can save time and improve patient care.

Look forward to the development of documentation that will arrive from the ED when patients are seen and discharged for outpatient follow-up. We are working with the Emergency Depts at all three hospitals and hope to have this start rolling by the end of calendar year 09. The BMC ED is doing an amazing job of EMR acculturation since the rollout of CIS ED/FirstNet, a slick tracking system that improves communications and efficiencies throughout that madhouse. They've also seamlessly transitioned to 100% computerized order entry and are game for more. We are aiming to do the same for BFMC & BMLH EDs over the next year.

Thank you, Patti & Yvette!

Today's entry is an easy one for me. The work has been taken care of by two terrific members of our IS team.

Patti McConnell of our supreme training team has redesigned the CIS Enhanced View Info site that you can access by clicking on the link here or on eWorkplace. It now has the look and feel we've been working towards and is only the beginning of what will become an advanced web-based learning center for CIS.

Yvette Carter of our equally outrageous technical team whipped off a quick slide set earlier today that summarizes most of the new features found in the Enhanced View. Given its comprehensive simplicity, I thought to heist it for posting here today. I think it offers more food for thought as we get ready to roll with EV.


Uploaded on authorSTREAM by nrk99

More on CIS Enhanced View

Phew... I just came home from a day-long synagogue board retreat. In an effort to prevent my wife from saying yes to another community responsibility, I stepped up last summer when things were looking pretty bright for the coming year. Well, what a difference an economic crash makes. Suddenly, I find myself in the mix of change management in all corners of my life. (I don't think I need to give the gory details of "managing" two teenagers.)

While I can't say that change is always easy, there's no doubt that it can be good. And the IS and informatics teams are doing all we can to make the change to CIS Enhanced View better than good. With time and attention, I think you will find yourself with an EMR that truly is enhanced. The training sessions that the team is currently holding for staff superusers are going extremely well. Each and every clinical site will have at least one person who will have an in-depth introduction and understanding of the Enhanced View and will be the first line of response when we rollout on March 24. And as you've heard here and elsewhere, physician superuser classes will be held in early March. Get to a session if you can.

Yesterday, I posted a brief intro to the Message Center. In the coming days, I'll get a little deeper into the tools. Messages, reminders and consults will foster communication not previously practical via CIS. Take advantage of the new Pools feature and foster new ways to manage messages and results by all members of the clinical team.

As for documentation, we continue to create PowerNote templates to meet the needs of primary and specialty care clinicians. Two new features that we will be introducing are Free Text and Auto Text. Free Text allows for text entry directly into the "final version" view of a document. Simply click into the note and type. No more need to scroll back and forth or stretch open the text box. Auto Text is similar to using macros, using abbreviations to populate the note with text. For example, "The patient is brought in by ambulance" could be entered into the note by typing BIBA or by selecting from a list as is done with macros. More to come in future posts.