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:

Uploaded on authorSTREAM by nrk99

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.

Quick Review of Co-signing and adding Attestation in new CIS

Quick post with slide set today.

Remember to click on the icon in the bottom right corner directly adjacent to "authorSTREAM" to open to full screen and do the same when you want to return to normal screen when done with viewing.


Uploaded on authorSTREAM by nrk99

Back to blogging

It has been quite a couple of weeks for all of us, no doubt. I have learned a tremendous amount, not only about the new CIS interface (some would call it the Enhanced View), but also about fielding both constructive and... let's just say, not-so-constructive critique. As I hope you've experienced and heard, the CIS team has done an unbelievable job of preparing, deploying and supporting what it takes to make for a system-wide rollout. As we now know, there are deficiencies to the enhancements and folks have not been shy to point them out. I can personally say that I have logged dozens of issues with Cerner, most pertaining to the new prescribing process and the problem/diagnosis lists. While we can do some of the fixes locally, I believe we have the attention of Cerner and will be able to make some improvements over the coming weeks.

You may have heard about or participated in a webinar I ran today during the noon hour. I hope it was useful and plan to do another one next Wednesday at noon. I will be focusing on the Medication List and Prescription Writer and, if we have time, will touch on documentation.

I've made these three videos to review the Procedure/Surgical Hx function. One is for entering a surgical procedure, another for an obstetrical delivery and the last for a routine colonoscopy. They run 3-5 min each.

Surgical Hx This view appears to be truncated for no particular reason. I think you'll get the idea though (and it takes 2-3 hours to make these!)

Obstetrical Hx

Screening Colonoscopy