The iPAD Experience

If you're reading this, you're probably a Baystate doc anxious to try out your new iPAD with CIS, or trying to decide if it's worth buying an iPAD to use when you're rounding. The good news is that it does work, with some limitations. The bad news is that there are still some glitches, most of which are going to require some programming effort to solve.

For starters, you need to have the free Citrix Receiver app installed - go to the iTunes appplication store, it's free. From the secure website, you need to access CIS from the CIS 4.5 upgrade folder. For some reason, the normal link doesn't work, and if you try to access it that way (and fail) enough times, eWorkplace may kick you out, and you'll need to call the Help Desk to get your password reset. I found it helpful to copy the link from the CIS 4.5 upgrade folder onto the desktop, which simplified repeated access. And, you may need to go in repeatedly because the iPAD is still not truly multi-tasking, although there is software promised to make this occur soon.

Battery life was good. I borrowed Dr. Talati's unit for the weekend without the charger. The device was 96% charged when I got the device on Friday around noon, and down to 56% by the end of the day with a lot of use. I tried to charge it with my iPod touch charger, and got a "not charging" error message, so I rounded on Saturday morning with 56% at the start of rounds (8:30 AM) and was down to 17% by noontime. I then discovered that if you turn the iPAD off, it will charge with a standard iPod charger, and was back to 100% by Sunday morning, and down to 70% by the end of rounds roughly 3 hours later.

Compared to the C5 tablets I've used before, the weight was no problem. Finding a safe place to put it, though, is a challenge. I've seen some Velcro wrist straps that would have made life easier, but frankly, what I really want is a lab coat with big enough pockets to accomodate the iPad. (Business opportunity??). I was rounding with housestaff, and there were lots of "oohs and ahs" from the audience. I do recommend locking the keyboard into Landscape position, especially if you're passing the device around or putting it down to avoid contamination when walking into a MRSA room. Otherwise, the constant rotation between landscape and portrait will make your head spin.

Some of the problems I encountered initially relate to where the keyboard display appears and covers up the Citrix signon box. Life is easier once you know the trick of the three-finger click to open and close the keyboard. Screen sharpness on the CIS default page (Inbox for those of us who are inpatient docs) was excellent, but it helps to zoom in a little if you need to reliably open up individual messages. Some of the other buttons (refresh, for example, toolbar buttons, the X to close a patient chart) work well without needing to zoom in or out, even with large fingers. It helps to keep the left side CIS menu closed to maximize screen real-estate. The scrollbar, though, is particularly annoying. The trick seems to be to touch and hold for a second before trying to scroll.

Patient lists loaded up immediately, at least as quickly as they do on a COW (Computer on Wheels - the Windows-based wireless thin clients that we use in the ICU). Web paging worked great.

The interactive flowsheets we use in the ICU (MICU and SICU quickviews) have left-hand navigation buttons, which is fortunate, because the scollbar is annoyingly slow. I suspect this is a wireless/Citrix/transmission issue rather than an iPAD issue per se, because scrolling on non-Citrix apps seemed to be OK. The horizontal scroll seemed even more difficult than the vertical scroll. By the end of the 2nd day, I had adapted to the need to slow down with scrolling, but still not pleased. (Patient people don't choose ICU as a career...) Other slowness issues: opening up radiology images (about 15-25 seconds on average). The right-hand side PACS menu was difficult to use, although two-finger tapping did bring up a useable menu for displaying multiple images. The images are not sharp enough for diagnostic use, and they will pixillate when you zoom. This may relate to Citrix settings on receiving graphics, and I need to investigate if there is a solution, because we saw this initially with wireless computers on wheels (COWS) when they were first deployed. I understand that some PACS vendors are now sending only the relevant pieces of an image at appropriate magnification, rather than sending the whole image, and hoping it doesn't pixillate when you zoom. We don't have that functionality yet. You can certainly see a portable CXR on the iPAD well enough to tell if an endotracheal tube or line is in proper position, but I'd still go to a high-resolution monitor to assess improvement in a pneumonia or ARDS. The iPAD is capable of such brilliant resolution on photos that it has to be able to do better with CXR and other films - I'm hoping this is a data transmission problem that can be fixed.

Scrolling through labs takes a little time. Graphing the trends was much more satisfactory than scrolling through the table, and my hope is that mPages or other technology would make it easier to access the information in the future. We have an ICU Safety Bundle report that runs from Discern Explorer, and that fit perfectly on the iPAD, allowing a quick check of all of the patients in the unit re: compliance with the "safety bundle" for VAP and CR-BSI prevention, DVT prophylaxis, glucose control, etc. Once again, having mPages or other quick access to data in customized format would seem to be the key to making the iPAD more useful. (For that matter, you could even envision using an iPhone if the displays were arranged for the screen size. I did get my iPOD touch to talk to CIS, but the scrolling was frustrating, and so inefficient that I can't recommend using a smaller screen than the iPAD). Patient lists (rounding lists, billing lists) intended for print looked like bad Xerox copies - ugly! That may have to do with the font chosen for these reports, and the black-on-white display.

Up-To-Date loaded up fine, but crashed when I searched for antibiotic information. The error message I received was "this operation has been cancelled due to restrictions in effect on this computer. Please contact your sysadmin". I blew through that warning screen and got a "Script error, Line 131, Character 3" and "Access Denied". Being persistant, I kept hitting "yes" to the question of "run script?" and eventually got it to work. But, this process had to be repeated each time. More room for improvement....

Should you try to write notes on the iPAD? I would say "Absolutely not". The keyboard covers up part of your templated notes, and it was difficult to go back and correct what you couldn't see while you were typing blind. Definitely not ready for prime time unless you have an external keyboard, or the display is adjusted to show only what you're typing. A templated note with radio buttons might work - perhaps clicking on findings while you're rounding, and then coming back to summarize on a real keyboard would be workable.

The bottom line is that the iPAD is useable for ICU rounds if you're patient (or impatient and gathering data for a blog) but needs a lot more customization within CIS before the average user would embrace it. Relative to carrying a C5 tablet or pushing around a COW, the iPAD is wonderfully portable, and has better screen sharpness. Xrays are still problematic. Scrolling is torture, and your efficiency would suffer when writing notes, or when reviewing a very complex patient due to the scrolling issues. I can see that mPages and some other customization would improve the experience immensely, and I do see a future for the iPAD as an ICU rounding tool. The question to ask yourself is: "Do I really want to be on the bleeding edge?"

New CIS Update

I just hit go and sent out the latest semi-annual CIS Update.  In spite of the difficulties we have had with ePrescribing and ambulatory CPOE, I must say, we get a lot of stuff done.  Baystate is a national leader in EMR implementation and youare all to thank for that.  While the IS and informatics team are indefatigable in bringing CIS to its greatest potential, it's all about you, the "end-user", whether doc, nurse or other clinically engaged CIS user. 

Highlights include:

• 2.2 million PowerNotes written!  
• PPID prevents critical errors
• Medication Reconciliation this summer
• UpToDate provides CME

CIS Trainer Designees

Is it safe to assume that anyone who makes it over to this site already knows that you have received an email telling you who you can contact in the event of a CIS "emergency".  In an effort to provide as many training and information opportunities available to CIS users, Cindy Sessink, manager, Dave Lapierre, team lead, both of IS training, and I have been on a brainstorming binge for the last number of months.  Results so far:

• Redesign IS Training and Information site
• Early development of CME/CEU for CIS training modules
• Designated CIS trainers for BMP sites, clinicians and other users
• Quick Tips and alerts
• Investigation into discussion forum for posting on the Info Site
• Ongoing web-based training (WBT), webinars, and training sessions depending on rollout schedules

Are you reading this post?  I'd love to get some feedback on what works best and what we're leaving out.  I am especially interested in working with web 2.0 tools.  As you know, I am comfortable developing short PowerPoints and videos, depending on the subject matter.  I'm curious to know whether Twitter would be a useful technology to get the word out in the event of a CIS alert/issue, or even the discovery of a new tip.  Baystate Health is considering the opening of Twitter on the network.  In the meantime, however, I am able to use smartphone/cellular transmission.  

Shoot me an email or leave a comment.

Neil

A Few Words of Update

ePrescribing: We are waiting to install new code that, once rigorously tested, will provide formulary/insurance eligibility details and the highly anticipated External Rx History.  Code delivery is likely today or early next week and, once installed, will go through the pre-release gauntlet before you see it towards the second week of June.  We continue to work with our vendor on the pharmacy selection screens. 


Dragon VR dictation:  A couple of weeks ago, I sent an invitation out to all clinicians who have the option to dictate their notes to enroll in the Dragon Voice Recognition rollout.  Since January, we have been piloting this technology on a limited basis.  We have learned a great deal including the fact that this technology is not everyone's cup of tea.  The accuracy rates are high, especially when one speaks quickly and clearly, but it takes a measure of both patience and commitment to master.  Right now, the plan is to give this software to those interested who currently have higher dictation costs and see where that next step takes us.  I am hopeful that we will be able to offer this technology to any and all-comers over the next year or two.

MPages:  We are currently piloting this new screen with six docs and their MAs.  The MPage is what the Overview tab should have been in the first place.  The best description is that it looks and almost acts like an iGoogle page.  All elements found in the menu to the left are flattened out on a single page in widget format.  These widgets can be moved around and defaulted to display as opened/closed.  So it's easy to not only see a patient's meds or problems, but also easy to just right into that section of the chart to make any changes or additions.  So far, the MPage has met a great deal of enthusiasm.  We are trying to determine a number of things:  satisfaction, ease of use, opportunities for workflow redesign, i.e. staff entering patient health information traditionally entered by docs. 

The iPad!:  Kishi Talati, our new assoc. med. dir., got his hands on an ipad and, Mac-geek that he is, has begun to master this new device for use on the Baystate network.  Look forward to news about this and the possibility of taking advantage of this and other Apple connectivity.

Cancel DC Renew Complete... What's the diff?

I am frequently asked how best to manage the Medication List. So often, we find meds that are duplicated, obsolete, or have simply run their course and no longer belong on the list. What's the best what to clean up the list? Well, there is no right and wrong for dc’ing meds. This is the way I like to think about it:

• Renew (think magazine subscription): The renew start date picks up at the last stop date
• Cancel/Reorder (think dose increase): the reorder start date is today and the canceled Rx is no longer in play, i.e. this is used for any dose/sig/pharmacy routing change
• Cancel/DC (think flushing the meds): this is the general way to dc any med, rendering it inactive and no longer visible on the active meds list
• Complete (think Z-pak): this is the way to dc a med that had a finite course, like an antibiotic.
• Maintenance v. Acute: maintenance will leave the med on the active list regardless of whether the stop date was reached. I find this useful, even in acute situations, to allow tracking at a follow-up visit. For example, I gave that Z-pak for acute otitis in March and the patient comes in today when I can ask about efficacy and tolerance. On the other hand, using the acute setting allows the med to complete and fall off the list of active meds. Many would argue that this is the proper and best way to manage the Medication List. We have left this up to the user.

Thanks to Rob Smith for the succinct question this morning!

Mac workaround identified

Many many many of us realize that, in spite of the institutional dominance of Windows-based PCs, Mac really is the way to live. Unfortunately, this can create connectivity issues when trying to connect to Baystate's network. In the past, I've suggested that using the Firefox browser might help. But since the release of the Snow Leopard OS, this is no longer surefire.

Well, I learned something new after co-presenting at medical grand rounds last week. Ted Hartenstein, 4th year med-peds resident, said he found that if you log in to the network via baystatehealth.org and then, instead of clicking on the eWorkplace prompt, click on the ESA prompt. Let this begin to load, but rather than entering in your EN# and password, X out and return to the eWorkplace icon and open the application for login. I've already checked on my own Mac and have heard from a few previously disgruntled Mac users that they are now gleeful.

Thanks Ted!

Patient-Centered Medical Home PowerNote

Many of you are already aware of the NCQA Patient-Centered Medical Home project that has been underway since last summer. While the definition of PCMH is pretty vast (see pp. 1-2 Standards and Guidelines for Physician Practice Connections®—Patient-Centered Medical Home (PPC-PCMH™)), we are working to develop tools that will enable you to more effectively meet the level 3 criteria for NCQA certification.

A group of us (Diane Russell, Julie, Gentes, Glenn Alli, and I) have been working on a Medical Home PowerNote template that provides cues for optimal documentation of a variety of chronic medical conditions. While the template itself is essentially just a "refurb" of the Med Office Note template, the HPI and Impression & Plan have been juiced up with both monitoring and treatment terms for each of the following conditions: Type 2 diabetes, HTN, hyperlipidemia, CAD, CHF, asthma, and chronic pain.

We are pretty happy with the design and believe that, if you know how it works, you will be too. Here is a video I created covering the essentials. Given the length of the template, this was tough to keep under 5 minutes. I suspect that if you are familiar with PowerNote use, though, this will be old news.

(If you are unable to see the video in full view, use the following link: Medical Home PowerNote)

ePrescribing comes to CIS

In the coming weeks, CIS 's prescription writing tool will be upgraded to perform ePrescribing (electronic prescribing) in accordance with the federal government's health information technology strategy.  By way of CMS incentive programs, Baystate ambulatory practices will reap financial benefit from the implementation of this new technology.  From the prescriber's perspective, the process doesn't change all that much.  There are a couple of enhancements that, if all goes as planned, will improve the experience of the Prescription Writer.  Formulary and Pharmacy Benefit Management (PBM) information will be readily available at the time of writing.  What I hope to be even more useful is the new External Rx History.  This tool allows you to download all prescribed medications over the last two years regardless of whether the scripts were handwritten, auto-faxed or ePrescribed.  As you can imagine, this will help monitor compliance with refills.  Even better, you will be able to track for controlled substances.  All prescription details, including dates, refills, sig, prescribers, and pharmacies, will be viewable at the point of service.

Eileen Giardina created a fantastic and comprehensive web-based training program that is available on the CIS Info site.  Definitely take the time to review this entire module.  Because this link is "behind the firewall" and requires you to be logged into the BH network and in order to give you a quick overview of the major enhancements, I've created the following web-based video.

Improved Health Maintenance Tool

Coming soon to CIS is a a much enhanced Health Maintenance design.  There is one fix and two very much needed additions to the utility: comments will hold to a single expectation rather than across the page as in the past till now; the ability to customize timeframes for particular HM expectations; and the opportunity to add custom expectations for particular patients.

I've created a short slide-driven video that reviews these major features.  While there's always more to know about anything on CIS, this should get you started.  The link should work regardless of whether you are on the network.  If you are interested, I am glad to send you a QuickTime version that you can download onto your desktop for repeat viewing.


New Health Maintenance Module

A Pictorial Explanation of the Inpatient Folder Structure

Thanks to Tom Higgins for this succinct display:

Folder Structure Inpatient

Dragon Dictation Pilot

We have begun our Dragon dictation pilot this week.  11 physicians went through an in-depth training session last week and are into their first few days of use.  I've created these primer-level CIS videos for supplementary training. I'd love to know if you find them helpful.

Click on the links below to be brought to screencast.com where you should be able to view them on any BH computer.  If you have any trouble viewing from here, I created these videos on QuickTime and have the MPEG-4 files on my desktop if you want a copy.  Keep in mind that you'll need this Apple freeware that is bundled with iTunes. 


Don't forget to click on the FULL SCREEN button


Move Your Dragon Templates to the Favorites Tab

Beginning PowerNote with Autopopulation

Disable Autopopulation

Problem List Management

Entering Current Medications

Updating Medication List

Setting the Default Folder for PowerNotes

CIS Physician Advisory Group

Back in 2004, Peter Lindenauer gave me a call and asked that I join a group he was convening that would help develop the vision for CIS. If you know your paleontolgy, you'll know that this was during the Jurassic era when internists saw their patients through the course of their care, whether in the office or the hospital.

We now know through carbon dating (however contested by the Kansas state board of education) that since 2004, there was a dramatic evolutionary shift of the punctuated equilibrium sort*. This shift yielded two subspecies of physicians, homo ambulatorus and homo hospitalus. I don't want to launch into a potentially divisive debate nor forget that there are vast populations of geographically versatile species (phylogentically speaking homo medicoversatilus, with innumerable subspecies). Rather, I'd like to call attention to the vast lands that this variegated collection of creatures roam outside of the hospital.

As I've mentioned in a previous post, 2010 promises to be a very productive year, particularly in the ambulatory environment. Not wanting to review these goals again (see post from 12-14-09), I just want to let folks know that I will be convening a group of about 20 docs from the five major departments (med, OBGYN, peds, psych, surg) with the primary intention of keeping a larger audience up to date. The meeting will be on a quarterly basis and will provide a high level overview of current developments and future projects.

One could say that "advisory group" is a misnomer. I'm choosing it because I am interested in the feedback I expect to receive and am also hopeful that this group will bring back information to a wider audience of colleagues. I don't expect that to be done on an official basis, but rather by generating some excitement by word of mouth. I will also try to post agendas and minutes for those meetings. Stay tuned.




(*Eldredge, Niles, and S. J. Gould (1972). "Punctuated equilibria: an alternative to phyletic gradualism". In T.J.M. Schopf, ed., Models in Paleobiology. San Francisco: Freeman, Cooper and Company, pp. 82-115. )

Medication Not Effective

Med Not Effective

Filing Documents and the Folder Structure

I've been speaking with folks from HIM who are concerned about the filing of a variety of inpatient documents, including those of your service. To give you some background, the so-called folder hierarchy was designed, tested and retested over about 2 ½ years before it was put into the live environment a number of months ago. While it might seem confusing to some, there is an overarching logic to its build that accounts for the filing of documents of all types and from all sources. This is to say that, implicit in its design is consideration of the type of document (dictation, PowerForm, PowerNote), the author of the document (physician, nursing, social work, ancillary service), the document's associated department/division, and, most importantly, the venue of origin. This last determinant is the crucial one to keep in mind.

So, if a patient is seen in the hospital, there are a limited number of folders to place a document. In the case of a consultation, the initial document, whether dictated or done by PowerNote, must be placed in the Consult Notes folder. Those notes created on follow-up visits in the hospital are Progress Notes and so should be filed in that folder. The easiest way to think about this is to consider the design of the paper hospital chart: the initial consult note is placed under the Consultation tab and all subsequent notes are placed along with all others under the Progress Notes tab. Other hospital-based folders include Admission/History and Physical and Discharge/Transfer Notes.



Other folders designed for physician use, i.e. those that are labeled by specialty, are for the ambulatory world. So if a patient comes in to your office for a pre-operative evaluation, this note should be filed in the Medical Consultation Program folder. Were you to see that same patient for a follow-up visit, that document should also be filed into the same folder. That folder is essentially the office chart for the program/division.



Additionally, operative and procedure reports will be filed in the Operative Notes and Procedure Notes folders, respectively, and without consideration of whether the event occurred during a hospital, daystay or ambulatory encounter. Associated consult, progress and follow-up notes, though, are filed in folders as described above (Consult & Progress Notes folders for inpatients and Specialty Office Notes folder for ambulatory patients).



We are working to educate folks about the proper filing of documents, particularly in the inpatient setting. When notes get placed in specialty folders designed for the ambulatory environment, there is a great risk of those notes not being found on review by colleagues, consultants, ancillary services and administration, e.g. HIM coders.



I hope this clarifies a murky subject.

Happy New Year!

On the evening of December 30th, the Office of the National Coordinator of Health Information Technology (ONC HIT), led by Dr. David Blumenthal, released the "Interim Final Rules" regarding Meaningful Use of the electronic health record. Apart from a world filled with acronyms, (CIS, ONC, HITECH, ARRA, MU, EMR, EHR to name an elementary few), it appears that health care reform is integrally linked to HIT. While we've been blanketed by media impressions of the federal wranglings towards reform, it seems to many that the path set by the separately signed congressional bills are better understood as health insurance reform. On the other hand, the ONC is setting an agenda that has its origins in the ARRA (the American Recovery and Reinvestment Act) which earmarked as much as $36B to invest in and incentivize for improvements in health care delivery in the United States. In large part, these improvements will be facilitated by the institution of robust electronic technology that will not only create the building blocks for information input and storage, but will streamline the exchange of health information across local, state and federal boundaries.

The Interim Final Rules that were released on Wednesday night is actually a 556 page document that details the criteria for "eligible professionals" and hospitals to receive reimbursement for the implementation of electronic health records. Also outlined are regulations for quality reporting via PQRI and the need to create the means for interoperability between systems and institutions. As with any hefty document, operations and accounting regulations take up a chunk of weight as well.

After reviewing this document, I am proud to say that Baystate's CIS implementation has anticipated much of what it takes to achieve Meaningful Use status. As I posted a couple of weeks ago, a number of our FY10 projects will further advance our efforts to achieve MU as well as other institutional goals that will improve the quality and depth of care we provide to our patients.

Check out David Blumenthal's NEJM discussion released shortly after the publication of the mega-document. He does a nice job of distilling the essential elements of the ONC's efforts and defining some of the more commonly used terms in this ever-growing sector of medicine.

Launching HITECH