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:

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

New CIS Homepage

This is the text I sent in an email earlier today to the BMP primary care practice sites' medical directors and practice managers. While the first bullet regarding the split screen may not hold true for you, all else is generalizable and so I thought to post it for the wider audience as well.

A few highlighted points about the new CIS Primary Care Physician/NP/PA Homepage:

Ø All providers will have the “split screen” such that the Message Center menu will reside at the left side of the screen and the office schedule will fill the page

o Double click on a Message Center element and the contents of the selected folder will populate the area where the schedule sits

Ø Message Center in Enhanced View = Inbox of CIS-Office

Ø Proxies will need to be reassigned

Ø Messages will operate in similar fashion to pre-EV and office policy and protocol should continue accordingly

Ø Orders folder does not change re: review and co-signature

Ø The Sign & Review folder in CIS-Office becomes the Documents and Saved Documents folders in the new CIS. Saved Documents are those that have been started and saved, but not yet signed by the author

New items:

Ø Consults, Reminders, Notify Receipts

o The use of these new tools will depend on workflows determined by individual practices and providers.

o Consults, in particular, should not be used as the sole means of referring a patient to a consultant. The soon-to-be introduced Pools will facilitate the development of effective workflows for electronic consultation requests.

Ø Results

o The delivery of Results does not imply or create a requirement to manage results electronically at this time. As part of the so-called build of the Enhanced View, the Results folder will be available for all practices/providers for viewing and results management if so desired.

o If your practice currently receives paper results, this routine will continue until your group has chosen to stop their delivery.

o It is the choice of the individual practice to determine the timing and transition strategy to a paperless electronic medical record.

o Scanning of paper documentation will begin by incremental rollout beginning in the late spring. This integration will be instrumental to creating a paperless EMR.

As always, feel free to contact me with any questions. The coming week promises to be both challenging and exciting. Having “lived” with the Enhanced View for the last few months, I am confident that it will live up to its moniker.

Neil

On March 24, CIS Enhanced View=CIS

Here is a slide set that tries to summarize what you should know about the functional improvements and changes with the Enhanced View. Get to the CIS Enhanced Information Site today to find review and training materials.


Uploaded on authorSTREAM by nrk99

Medication List - writing a prescription

Transparent Informatics: writing prescriptions quickly and efficiently on Prescription Writer will take time and practice. Oddly enough, there are a couple of crucial tricks to getting them done without losing your mind. For instance, make sure that you select Dose as well as Duration in the Details section lest you risk your sanity. I can't say for sure why we are not prompted to select these two elements. Dose refers to the "1 tablet" part of the sig and, if you add Duration, e.g. 30 days, you will not be forced to go back and enter the unit, e.g. tablet, from the bottom of a scroll down list. I know that doesn't make much sense, but do it any other way and you will know what I mean.

I am being as honest as I can be here. I really do think the Enhanced View is a major step forward for CIS, particularly for the ambulatory setting. However, I also agree with all those who have raised concerns about the Prescription Writer. It is Change with a capital C. I've been working for a few hours on the following video and hope it clarifies the prescription writing process. Let me know what you think of the video and whether it needs more help.

Medication List 5 - Prescription Writing

Health Information Management Post

A special posting at the request of the folks behind the scenes who help to ensure that our documentation is of the highest integrity. HIM plays a significant role in bringing a level of sophistication to our PowerNotes, helping the health system not only meet coding requirements, but improve the structured templates to facilitate the best means of recording clinical events.

FYI: the information pertains to Hospital-based documentation

A note from Health Information Management –

We would like to thank you for your work and strides with documenting in CIS.
As you are know the details provided in your documentation regarding diagnoses, therapies and procedures - will paint a picture of the patient’s severity of illness, and describes the quality of care provided.

Great documentation will accurately reflect your great work.
Take credit for the excellent care you provide.

We would like to inform you about the “Diagnosis Specificity” field within most CIS progress note templates.
• By utilizing this field you will (with just a mouse click)–
o Identify acute exacerbations of certain chronic conditions
o Document site and stage of decubitus ulcers.
o Stage the level of chronic kidney disease
o Define Diabetic related conditions
Terry Gosselin - Lead Coding Compliance Analyst phone #322-4302

…AND something everyone can appreciate –by using this field you can eliminate a potential post discharge query from coding staff!

REMEMBER…If it is not documented…it did not happen…or did not exist.
So be as specific as possible when documenting.

Thank you!
Jennifer Cavagnac - Senior Documentation and Coding Analyst phone #322-4366
o Provide information useful to case management, quality review, resource utilization, coding, research, and other clinical staff.

Edit in Line Mode - DO NOT USE!

This is a note from the "Senior Navigator Strategist" at Cerner regarding a problematic option in the Medication List:
We recommend to not turning ON Edit on Line mode (EOL), as turning this preference ON will limit the amount of order details screen that the Physician or other clinician can view during the ordering/prescribing process. Currently, one is not able to modify multiple orders with common order details when the mode is activated. It is possible to do one of the following, but not both at once: either edit on the line mode, or edit multiple orders with common order details. However, in order to perform the latter, make sure that the edit on the line mode functionality is turned off by right-clicking on an order and making sure the Edit on Line mode is unchecked.

Bottom line: if your prescribing efforts seem to be completely whacked, right click on an order and make sure that the Edit on Line does not have a check next to it.

Web-Based Training for Enhanced View

Since I last posted, a host of new training materials have been launched and should be available to you whether at work or home. The latest includes the beginnings of a compendium of WBTs, or web-based training modules, similar to what was used when we first went live with CIS a few years back. If you remember, these are texted instructions (no voiceover) and so, technically speaking, should be straightforward to access when logging in from home. They consist of click-through screens with some "try on your own" areas within each module. Here is the link to the so-called Master List. Keep in mind that you will need to login to the Baystate site and navigate to the CIS Enhanced View Information site if you want to access these remotely (the link below won't work).

Web-Based Training Modules - The Master List

In addition, many of you have accessed the newly posted webinars. These are pre-recorded instructional sessions done over the past couple of weeks. While we've had some technical difficulties related to the Baystate firewall, I think we've got the problem figured out and list all the links here today.

(An enormous thanks go to the CIS training team led by the formidable Dave Lapierre!)

Webinars:

1. General Overview
   
2. Documentation
3. Prescribing
4. Documenting Medication Compliance
5. Medication Reconciliation for Providers
6. Message Center
7. Histories
8. Patient Instructions for Discharge

All of the above are relevant to physician/provider users of CIS except for Documenting Medication Compliance (inpt and ambulatory RNs and MAs) and Patient Instructions for Discharge (inpt RNs).

NOTE: as of 5:30PM today, I am not yet able to access these webinar links outside of the firewall. I can assure you that this will be figured out sooner rather than later.

UPDATE: I'm on my iMac at this very moment and, after downloading the GP4 program, I am able to seamlessly listen to the pre-recorded webinars. No need to enter an access code; just cancel out of that mini-screen. You might then see another dialogue box or two-just ignore them. So for all you mac users, it's a simple download and then click to use the GP4, not the Java.

UPDATE AGAIN: The first Webinar, General Overview, takes about 30 seconds for the audio portion to begin. I thought this was a problem with the software; it was only my lack of patience that was problematic!

More on the Medication List - Using Start & Stop Columns

So I think I'm onto something for the tracking of meds in the Medication List. In fact, and in spite of first impressions, I think tracking meds for refill will be easier and more accurate in the Enhanced View. Take a look at the video and tell me what you think. I tried to keep down the time and still provide a meaningful description.

Medication List 4 - Start & Stop Columns