Yes, it seems like a never ending journey to get all electronically available results delivered to everyone's CIS Inbox. For months, I've been promising the simultaneous rollout of a new means a assisting in results management known as pools. The thought was that all results would be delivered to both the ordering clinician and members of a predesignated pool. This pool would be designed in advance of the onset of results delivery and would provide an alternative means of reviewing and endorsing labs, either by a covering doc or even by an MA, depending on practice protocol. For example, there are many instances where it is appropriate for normal labs to be signed by ancillary staff who can also create a correspondence letter informing the patient of their results. Abnormals could be left for the physician to later in the event that those results are not otherwise brought to their attention.
It turns out that the pools as described do not function as promised. After consulting with our IT colleagues at Cerner, we realize that we can best manage these results at the practice level by using the proxy tool. This, in fact, is a really good thing. Most clinical sites use the proxy tool for a variety of functions including patient list management, messages, and, in a number of sites, for results management.
In the coming days, I will create a quick video that will review the set up of proxies. I have heard from many of you who are ready to receive results and expect that we will begin delivery on Tues Sept 8. Stay tuned and look for emails related to this soon.
Sunday, August 30, 2009
Thursday, August 27, 2009
Preadmit Orders
I recently received an email from a rightfully frustrated colleague who complained that they had gone to great effort to schedule a daystay procedure, provided the necessary documentation, and entered an intricate set of orders in advance of the appointed time. In spite of these complete efforts, the orders were lost and had to be done over again late at night and over the phone.
The driving issue that led to this circumstance is related to our so-called "encounter logic". I may have mentioned this in earlier posts, though it deserves repeating. Every time a patient interacts with any part of the health system, a new encounter is created. So if a patient calls the office to make an appointment, a triage encounter is created. When the patient reaches the front desk at the time of that appointment, an office visit encounter is created. When the patient goes to the lab, another; to radiology, another; and so on. When a patient is scheduled for admission, say in the event of an elective procedure, a Preadmit encounter is created. This encounter then changes over to the appropriate admit encounter upon arrival to the facility.
In the case above, a transfusion was scheduled and orders were placed. Unfortunately, those orders were placed on an office visit encounter and not on the Preadmit encounter that is created during the scheduling and registration process. The key is to select the proper encounter in order to place those orders. I realize this might seem onerous (at best), particularly since you are able to review a patient's chart regardless of which encounter is opened. But this is more than data collection; the encounter logic facilitates a variety of tasks including ancillary services, charging and billing and patient location.
The following slide set reviews how to select the correct encounter in the event of a preadmit. This instruction also applies to direct admits and the like.
(Remember to click on the icon at the lower right to open to full screen.)
The driving issue that led to this circumstance is related to our so-called "encounter logic". I may have mentioned this in earlier posts, though it deserves repeating. Every time a patient interacts with any part of the health system, a new encounter is created. So if a patient calls the office to make an appointment, a triage encounter is created. When the patient reaches the front desk at the time of that appointment, an office visit encounter is created. When the patient goes to the lab, another; to radiology, another; and so on. When a patient is scheduled for admission, say in the event of an elective procedure, a Preadmit encounter is created. This encounter then changes over to the appropriate admit encounter upon arrival to the facility.
In the case above, a transfusion was scheduled and orders were placed. Unfortunately, those orders were placed on an office visit encounter and not on the Preadmit encounter that is created during the scheduling and registration process. The key is to select the proper encounter in order to place those orders. I realize this might seem onerous (at best), particularly since you are able to review a patient's chart regardless of which encounter is opened. But this is more than data collection; the encounter logic facilitates a variety of tasks including ancillary services, charging and billing and patient location.
The following slide set reviews how to select the correct encounter in the event of a preadmit. This instruction also applies to direct admits and the like.
(Remember to click on the icon at the lower right to open to full screen.)
Friday, August 14, 2009
Auto-text re-update (if you read the first version this morning)
Last week, I discovered that I was able to quickly build about 16 procedure forms that Pain Management had requested over three years ago (!) using the auto-text feature. By simply copying and pasting from Word documents, I was able to circumvent the creation of these fill-in-the-blank forms via PowerNote and have them appear as they always had in the paper world. Great stuff that I expect to apply to a variety of form-based requests. However, there is a catch.
When we first introduced auto-text, suggestions were made to begin each shortcut with a designated symbol, e.g. your initials, the letter z, or a period. I certainly didn't jump up and down to get the word out, so a number of folks have used logical abbreviations like "chol" for a cholesterol-related text. For myself, I've been using the letter z pretty seamlessly. Well, when the pain management forms were posted, they were saved across the system such that they will appear for all users of auto-text. Since they are system-based, they can't be deleted from an individual's list of auto-texts. Well, understandably, this created quite a nuisance for a number of folks. Thanks to Julio Martinez, we realized that, if we start the specialty forms with ~, these will sort to the bottom of an alphabetical list and so you will no longer even see these forms unless you are looking.
If you read the first version of this post, I suggested you rename your auto-text shortcuts. You no longer need to do this. Continue saving as you wish, though I'd still recommend starting with a symbol so that you can view your list, or even create a series of lists, each summoned by a particular symbol.
If you want to check out how you might want to create a form, check out what we've done for Pain Management. For the next few days, they will begin with "pm", though by early next week, they will start "~pm". Here's what you do:
Go directly to Clinical Notes, right-click on the open field and select Add, then type pmAxNB to add the Pain Management Axillary Nerve Block form to the page. From there, hit the Insert button on their keyboard in order to overwrite the lines and fill in the blanks.
As always, feel free to post a comment, anonymously or otherwise, or shoot me an email.
When we first introduced auto-text, suggestions were made to begin each shortcut with a designated symbol, e.g. your initials, the letter z, or a period. I certainly didn't jump up and down to get the word out, so a number of folks have used logical abbreviations like "chol" for a cholesterol-related text. For myself, I've been using the letter z pretty seamlessly. Well, when the pain management forms were posted, they were saved across the system such that they will appear for all users of auto-text. Since they are system-based, they can't be deleted from an individual's list of auto-texts. Well, understandably, this created quite a nuisance for a number of folks. Thanks to Julio Martinez, we realized that, if we start the specialty forms with ~, these will sort to the bottom of an alphabetical list and so you will no longer even see these forms unless you are looking.
If you read the first version of this post, I suggested you rename your auto-text shortcuts. You no longer need to do this. Continue saving as you wish, though I'd still recommend starting with a symbol so that you can view your list, or even create a series of lists, each summoned by a particular symbol.
If you want to check out how you might want to create a form, check out what we've done for Pain Management. For the next few days, they will begin with "pm", though by early next week, they will start "~pm". Here's what you do:
Go directly to Clinical Notes, right-click on the open field and select Add, then type pmAxNB to add the Pain Management Axillary Nerve Block form to the page. From there, hit the Insert button on their keyboard in order to overwrite the lines and fill in the blanks.
As always, feel free to post a comment, anonymously or otherwise, or shoot me an email.
Thursday, August 6, 2009
Trouble Connecting to CIS from Home?
Recently, I've had some troubles achieving a stable connection to CIS when at home. This seems to be unrelated to whether I'm on my Baystate laptop or whether trying to log on from my Mac or my kids' PC laptop. It turns out that the PC's dreaded operating system, Windows Vista, has Internet Explorer8 and I was recently told that CIS will not run through on anything higher than IE7. To make matters worse, Vista doesn't allow me to download this older version of Internet Explorer. On my Mac, Safari has been kind of iffy in terms of holding a connection. So...
If you are having trouble logging in from home, whether from a Baystate laptop or your own home computer, the best way to ensure a connection is to use the Firefox browser. If you don't have this on your home computer, download it. If you'd like to download it to your Baystate laptop, give the Help Desk a call and see whether they can facililate this for you. I make no promises, but this seems a reasonable request if you are accessing CIS from home. (Of course, when logging on to CIS, make sure you first login through baystateheath.org.)
If you are having trouble logging in from home, whether from a Baystate laptop or your own home computer, the best way to ensure a connection is to use the Firefox browser. If you don't have this on your home computer, download it. If you'd like to download it to your Baystate laptop, give the Help Desk a call and see whether they can facililate this for you. I make no promises, but this seems a reasonable request if you are accessing CIS from home. (Of course, when logging on to CIS, make sure you first login through baystateheath.org.)
Wednesday, August 5, 2009
VNA Forms
July was a pretty sparse month for posting. I guess I have the summer to blame.
We continue to develop new tools that will advance our progress towards a paperless medical record. Recently, electronic versions of the VNA HCFA 485 (certification/recertification) and Physician Interim Orders forms have been created. These forms can now be sent to the Document to Sign folder in the Message Center inbox. We've been piloting this delivery and sign-off process with docs over at the D'Amour Center for Cancer Care (high volume users) and, by all reports, this is going very well. We are hoping to roll this out to all practices shortly.
Here's a preview:
Let me know what you think.
We continue to develop new tools that will advance our progress towards a paperless medical record. Recently, electronic versions of the VNA HCFA 485 (certification/recertification) and Physician Interim Orders forms have been created. These forms can now be sent to the Document to Sign folder in the Message Center inbox. We've been piloting this delivery and sign-off process with docs over at the D'Amour Center for Cancer Care (high volume users) and, by all reports, this is going very well. We are hoping to roll this out to all practices shortly.
Here's a preview:
Let me know what you think.
Wednesday, July 15, 2009
Customization of Clinical Notes folder display
Here's a slide set that should help you optimize your Clinical Notes display by setting up defaults for expanded folders.
Friday, July 10, 2009
More email questions
As you might imagine, I receive a good deal of email containing questions on use and function of CIS. The following is a copy of such an email, one that contained a series of great questions wherein I tried to answer succinctly and honestly.
Feel free to send me your questions or post them here in the comments section.
___________________________________________________________________
My requests for CIS:
1-Please eliminate the warning that appears when we are doing prescriptions refills since it takes too many clicks and time to do refill of medications.
(In progress)
a-Only prescriptions orders available for modify on discharged patient, continue?
(The elimination of this needless alert is in progress)
b- Interaction checking cannot be performed for medical equipment (ex test strips, glucose monitor, lances, alcohol, etc). Please click Ok to continue placing the order.
(This errant form of a decision support alert is in the process of being sorted out and eliminated)
2-Please allow to use more than 1 macro in PE (ex by adding an other window) and if possible in HPI. The advantage is to be more time efficient since I can do w 2 clicks what I am currently doing w 5 clicks.
Note: The way HPI is set at present, you can't see what you had written in the window if you open a new window using macros or CISO old system.
(Macro functionality is “hard-coded” by Cerner. Autotext is the best way to work with this – see the bottom of this post for the JobAid that is also available at the CIS Info Site)
3- Allow for the pharmacy favorite to be put in alphabetical order like before.
(Use the new Favorites Folder system in the Prescription Writer window. This functions like a Windows-based folder hierarchy and will solve the issue. Unfortunately, I am finding that old favorites from EasyScript days are useless, if not corruptive, to the Rx process. You are best off starting new prescriptions and saving them as new favorites.)
4- Default the P/N to hide structure instead of show structure.
(This would defeat the purpose of structured templates since their guiding contents would be hidden from view. To begin free-texting, just click under the paragraph heading in the open field and the structure will be hidden at the same time that the cursor is enabled for free-texting. See my post from 6/26 that includes a slide set done on this very topic)
5-Allow for use of the existing macros in all different types of notes, e.g. ped and adults, by choosing a tab and alternating from macros of ped notes and macros from adults notes.
(Again, Autotext will solve this issue since these are not location or template dependent. The issue with macros crossing templates is that the templates have to “line up” identically with respect to paragraphs and if they don’t you won’t see the macros show up if made on a different template. Autotext can be used anywhere in any note)
6-When doing refills add an option to pick for 30 days supply & 5 refills.
(Redesign in progress)
7-Allow to correct P/N again instead of giving modify as the only option.
(We needed to pull this because of the medicolegal vulnerabilities it created. Suboptimal design by the vendor that we are hoping will be fixed in the future. See my brief post of 5/27)
8-Allow for an option of autopopulate the statement of problem is reviewed.
(This can be done by a macro or autotext at the level of the Problem List)
9-Allow to deselect prob list, medication in each of the encounters. Sometimes you can only deselect today's results, v/s, medication list and system doesn't allow to deselect prob list in the autopopulate option.
(I’ve not heard this before. When presented the autopopulate window upon opening a template, you should be able to deselect all of any particular section. A specific example would be helpful)
10-Allow to modify document medication by hx even if there is no fresh encounter. I was trying to update some medications list and the system didn't allow me to erase medications from document medication by hx. The message displayed was: Can't modify orders on discharged patient.
(This is a HUGE issue that has since been resolved since the sending of this email. Please let me know if the problem persists.)
11-Allow to pick more than one macro at the same time by hitting control key before they are pasted.
(As stated earlier, Macro function is Cerner code that we cannot change. Autotext, on the other hand, does not have this restriction and can be used multiple times in the same part of the note)
12-Allow to copy and paste results in other window w/n results in P/N again
(sometimes it doesn't allow it). (You can only copy/paste once into each OTHER window. In order to copy/paste more info, you need to open a second OTHER window)
_________________________________________________________________________________________________
_____________________________________________________________________________________
WHAT IS AUTO TEXT?
When documenting in CIS, Auto text will store text you use again and again, such as standard phrases or statements. Each selection of text can be recorded as an auto text entry and be assigned a unique name to identify it. Unlike Macros, auto text can be inserted within any paragraph of any CIS note. There are two ways to create auto text in a note.
CREATE AUTO TEXT OPTION 1
This option allows you to create auto text while in the process of writing a note. From an open note:
1. Select Hide Structure or open a free text box
2. Click on the text field and type in desired text
3. Highlight the text by dragging your mouse over it
4. Right-click on the highlighted text and select “Save as Auto text”
In the Manage Auto Text window that displays:
5. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
6. Enter a description of the text
7. Click on Add Text
8. Click Create
CREATE AUTO TEXT OPTION 2
This method allows you to create auto text ahead of time. From an open note:
1. Select Hide Structure or open a free text box
2. Click the auto text button on the toolbar
In the Manage Auto Text window:
3. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
4. Enter a description of the text
5. Click on Add Text
6. Type the text entry you wish to create
7. Click Create
8. To create additional auto text, click Create again
9. Click Close when done
USING AUTO TEXT
1. Type the first 3 letters or abbreviation of the text
2. The abbreviation will display
3. Left click on it and hit Enter or use the down arrow on your keyboard to select it and hit Enter
The auto text statement will display.
OR
1. Right-click in any free text field and select Insert Auto text
2. Select desired auto text from the Select Phrase to Insert window
Feel free to send me your questions or post them here in the comments section.
___________________________________________________________________
My requests for CIS:
1-Please eliminate the warning that appears when we are doing prescriptions refills since it takes too many clicks and time to do refill of medications.
(In progress)
a-Only prescriptions orders available for modify on discharged patient, continue?
(The elimination of this needless alert is in progress)
b- Interaction checking cannot be performed for medical equipment (ex test strips, glucose monitor, lances, alcohol, etc). Please click Ok to continue placing the order.
(This errant form of a decision support alert is in the process of being sorted out and eliminated)
2-Please allow to use more than 1 macro in PE (ex by adding an other window) and if possible in HPI. The advantage is to be more time efficient since I can do w 2 clicks what I am currently doing w 5 clicks.
Note: The way HPI is set at present, you can't see what you had written in the window if you open a new window using macros or CISO old system.
(Macro functionality is “hard-coded” by Cerner. Autotext is the best way to work with this – see the bottom of this post for the JobAid that is also available at the CIS Info Site)
3- Allow for the pharmacy favorite to be put in alphabetical order like before.
(Use the new Favorites Folder system in the Prescription Writer window. This functions like a Windows-based folder hierarchy and will solve the issue. Unfortunately, I am finding that old favorites from EasyScript days are useless, if not corruptive, to the Rx process. You are best off starting new prescriptions and saving them as new favorites.)
4- Default the P/N to hide structure instead of show structure.
(This would defeat the purpose of structured templates since their guiding contents would be hidden from view. To begin free-texting, just click under the paragraph heading in the open field and the structure will be hidden at the same time that the cursor is enabled for free-texting. See my post from 6/26 that includes a slide set done on this very topic)
5-Allow for use of the existing macros in all different types of notes, e.g. ped and adults, by choosing a tab and alternating from macros of ped notes and macros from adults notes.
(Again, Autotext will solve this issue since these are not location or template dependent. The issue with macros crossing templates is that the templates have to “line up” identically with respect to paragraphs and if they don’t you won’t see the macros show up if made on a different template. Autotext can be used anywhere in any note)
6-When doing refills add an option to pick for 30 days supply & 5 refills.
(Redesign in progress)
7-Allow to correct P/N again instead of giving modify as the only option.
(We needed to pull this because of the medicolegal vulnerabilities it created. Suboptimal design by the vendor that we are hoping will be fixed in the future. See my brief post of 5/27)
8-Allow for an option of autopopulate the statement of problem is reviewed.
(This can be done by a macro or autotext at the level of the Problem List)
9-Allow to deselect prob list, medication in each of the encounters. Sometimes you can only deselect today's results, v/s, medication list and system doesn't allow to deselect prob list in the autopopulate option.
(I’ve not heard this before. When presented the autopopulate window upon opening a template, you should be able to deselect all of any particular section. A specific example would be helpful)
10-Allow to modify document medication by hx even if there is no fresh encounter. I was trying to update some medications list and the system didn't allow me to erase medications from document medication by hx. The message displayed was: Can't modify orders on discharged patient.
(This is a HUGE issue that has since been resolved since the sending of this email. Please let me know if the problem persists.)
11-Allow to pick more than one macro at the same time by hitting control key before they are pasted.
(As stated earlier, Macro function is Cerner code that we cannot change. Autotext, on the other hand, does not have this restriction and can be used multiple times in the same part of the note)
12-Allow to copy and paste results in other window w/n results in P/N again
(sometimes it doesn't allow it). (You can only copy/paste once into each OTHER window. In order to copy/paste more info, you need to open a second OTHER window)
_________________________________________________________________________________________________
_____________________________________________________________________________________
WHAT IS AUTO TEXT?
When documenting in CIS, Auto text will store text you use again and again, such as standard phrases or statements. Each selection of text can be recorded as an auto text entry and be assigned a unique name to identify it. Unlike Macros, auto text can be inserted within any paragraph of any CIS note. There are two ways to create auto text in a note.
CREATE AUTO TEXT OPTION 1
This option allows you to create auto text while in the process of writing a note. From an open note:
1. Select Hide Structure or open a free text box
2. Click on the text field and type in desired text
3. Highlight the text by dragging your mouse over it
4. Right-click on the highlighted text and select “Save as Auto text”
In the Manage Auto Text window that displays:
5. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
6. Enter a description of the text
7. Click on Add Text
8. Click Create
CREATE AUTO TEXT OPTION 2
This method allows you to create auto text ahead of time. From an open note:
1. Select Hide Structure or open a free text box
2. Click the auto text button on the toolbar
In the Manage Auto Text window:
3. Enter the abbreviation you wish to use. The abbreviation should be the first 3 letters of the phrase or statement
4. Enter a description of the text
5. Click on Add Text
6. Type the text entry you wish to create
7. Click Create
8. To create additional auto text, click Create again
9. Click Close when done
USING AUTO TEXT
1. Type the first 3 letters or abbreviation of the text
2. The abbreviation will display
3. Left click on it and hit Enter or use the down arrow on your keyboard to select it and hit Enter
The auto text statement will display.
OR
1. Right-click in any free text field and select Insert Auto text
2. Select desired auto text from the Select Phrase to Insert window
Thursday, July 9, 2009
Great question on system performance
Question by email:
Just had a patient who is Director of IS at (a local hospital). They use the same Cerner CIS system there as we do both in the hospital and in the outpatient clinics (all across the country in 22 states, etc.) with their main “server” in Tennessee. He said to me “is it always that slow”? There were lots of half second to one second pauses etc. I said "yes, (no different than is has been for years)." He said, “they would have me by the … if the system were that slow at (my hospital).
What could possibly be the issue with our product?
Answer:
At Baystate, we "host" Cerner on our own servers whereas the aforementioned hospital system likely uses what is called an ASP version, or application service provider, such that their Cerner products are web-based. Furthermore, the perceived lack of snappy responsiveness is not only because we use our own local servers, but, as a system, we use the Cerner product that allows us to customize its various tools to our needs. These require more time and juice to operate. Customization is neither offered nor available with the ASP version of the Cerner EMR.
As tough as it might seem in its current state, we, as a physician group, would not be happy if we had to use Cerner contents "out-of-the-box". In addition to our customized PowerNotes, there are other fixed designs that would have you scratching your head as to whether there had been enough clinical input during development.
Another likely factor is that this other system is not able to do nearly as much as we do at BH with our EMR. While the rest of the country is struggling to come to terms with the reality of HIT (health information technology), Baystate is in the 99th percentile with regard to EMR adoption and expansion. We are excelling at CPOE, electronic documentation, data storage and retrieval, and the list goes on.
Friday, June 26, 2009
Show-Hide and Alphabetizing Favorites
Interesting week EMR-wise. We had a successful launch of EKG and stress test tracing images to the Clinical Notes as well as delivery of these results to BMP physicians ordering from the ambulatory setting. We're getting closer to making changes to the Table of Contents, as I reported earlier this week. But we also had something of a snafu with our attempted launch of the new Immunization Schedule.
Our intentions were good and, boy oh boy, did the IS team ever perform due diligence in terms of testing this new tool. Sometimes, though, all the testing in the world doesn't mean a thing when it can't be done in real time and space. To make a long night's story short, we ultimately decided to pull the schedule and reverted to the Immunization Profile, which really is just a plain text list of vaccines given.
For adults, the profile is fine, but for kids, whose MO is to be pin cushions through adolescence, the schedule was and will be a colorful enhancement. Expect to see it sometime in the TBD. For those of you whose patients are older than age 20, the schedule doesn't change things much except to lose the list and create a Historical Immunizations tab in the All Results band. All else functions as is including Health Maintenance and View Immunizations in the PowerNote. But for our younger patients, the schedule will provide visual cues and alerts that will improve the delivery of this essential component of care. You'll get the heads up when we are ready to give it another go.
In the meantime, one of my partners in crime, Pat Brown, created a couple of nice slide sets that I thought might be useful tips.
Our intentions were good and, boy oh boy, did the IS team ever perform due diligence in terms of testing this new tool. Sometimes, though, all the testing in the world doesn't mean a thing when it can't be done in real time and space. To make a long night's story short, we ultimately decided to pull the schedule and reverted to the Immunization Profile, which really is just a plain text list of vaccines given.
For adults, the profile is fine, but for kids, whose MO is to be pin cushions through adolescence, the schedule was and will be a colorful enhancement. Expect to see it sometime in the TBD. For those of you whose patients are older than age 20, the schedule doesn't change things much except to lose the list and create a Historical Immunizations tab in the All Results band. All else functions as is including Health Maintenance and View Immunizations in the PowerNote. But for our younger patients, the schedule will provide visual cues and alerts that will improve the delivery of this essential component of care. You'll get the heads up when we are ready to give it another go.
In the meantime, one of my partners in crime, Pat Brown, created a couple of nice slide sets that I thought might be useful tips.
Monday, June 22, 2009
CIS Table of Contents (Menu bands)
This week will mark the end of the third month since the changeover to the unified version of CIS. Over the course of this time, we've had to overcome a variety of unexpected setbacks, but have also benefited from a host of changes that, when frustrated, go unseen in the midst of a rushed patient care session. Your voices have been heard and in response to suggestions made regarding the user interface, the Table of Contents (or Menu bands) will undergo an overhaul of a sort.
When we first made the changeover on March 24, a single TOC was designed for use by all. In the coming days, you will see a different arrangement, depending on where you spend the majority of your time. If, when you login to CIS, you see the Message Center with the Inbox, you will see the Ambulatory view as listed below; if you see the Message Center alone, yours will be the Hospital-based view; if you live in the ED and can login to FirstNet, then it's obvious what you'll be seeing.
Suggestions for modifications were culled from emails and less than formal conversations and were also sought from medical directors in order to better define site-specific designs. Check the lists below for what to expect in the coming days.
Ambulatory View
When we first made the changeover on March 24, a single TOC was designed for use by all. In the coming days, you will see a different arrangement, depending on where you spend the majority of your time. If, when you login to CIS, you see the Message Center with the Inbox, you will see the Ambulatory view as listed below; if you see the Message Center alone, yours will be the Hospital-based view; if you live in the ED and can login to FirstNet, then it's obvious what you'll be seeing.
Suggestions for modifications were culled from emails and less than formal conversations and were also sought from medical directors in order to better define site-specific designs. Check the lists below for what to expect in the coming days.
Ambulatory View
- Overview
- Documentation
- Clinical Notes
- All Results
- Laboratory (NEW)
- Micro
- Health Maintenance
- Histories
- Immunization Schedule (coming your way June 24)
- Growth Charts
- Diagnosis/Problems
- Medication List
- Allergies
- Orders
- Tasks
- other necessary, though not frequently used, bands
- Overview (take a closer look at the Since Last Time tab for new labs, results, documents since last date/time stamp. This can be helpful to look for new consults, etc.)
- Orders
- Documentation
- Clinical Notes
- Diagnosis/Problems
- Histories
- Medication List
- MAR
- MAR Summary
- Allergies
- All Results
- Laboratory
- Radiology
- Micro
- Interactive Flowsheets
- I/O
- Handover
- other necessary, though less frequently used, bands
- All Results
- Laboratory (NEW)
- Radiology (NEW)
- Allergies
- Clinical Notes
- Diagnosis/Problems
- Documentation
- Facesheet/Insurance
- Forms
- Histories
- Immunizations
- Medication List
- Micro
- Orders
- Patient Information
- Reference Text
- PowerNote ED (in anticipation of ED electronic documentation)
- other necessary, though not frequently used, bands
Friday, June 19, 2009
Imminent Improvements
Now that we've settled into the unified view of CIS (note the intentional avoidance of the word "enhanced"), the informatics team is able to circle back and make some changes to the interface that ought to improve your experience. First on the list is the rearrangement of the Table of Contents (or Menu) bands. These changes will be based on position (ambulatory-, ED- or hospital-based). Without going into too much detail, we will move the Documentation and Clinical Notes higher up the list and give lab results its own band to save you a few clicks. For ED docs and those who spend most or even part of their time in the hospital, the default opening page will be Orders rather than the Overview page. For ambulatory-based docs, you will see the removal of hospital-oriented entries like Med Rec and MAR Summary. Expect these changes to be evident in the next week or two.
We are also actively seeking a results to endorse solution that will enable a system-wide rollout towards the end of the summer. In order to make this happen smoothly, we are creating pools, (think "group proxies"), that will facilitate custom workflow design in every practice. While the usual routine in a primary care setting is for doctors to review results and communicate with patients accordingly, others choose to delegate this review and be made aware of abnormal results. My first thought is to create a results pool for each of the BMP practices. Pools will be posted at the same time that RTE will arrive in the clinician's Message Center inbox. A result can be reviewed and endorsed by the physician and will then drop off both their list as well as the pool's list. In the event that the protocol is for the medical assistant to endorse normal labs, then those results will also fall off the pool list as well as the ordering clinician's results list. It will be the responsibility of the practice to determine the proper protocol so as to avoid inadvertant endorsement of results that go unseen by the ordering clinician.
Other improvements:
We continue to work with Cerner to optimize the function of the Prescription Writer. If you haven't heard, two key points are to 1) Cancel/Reorder any meds that were last written with EasyScript. Thereafter, the Renew function will work well; and 2) when in doubt, fill in the Duration field. This will facilitate the easy completion of the Rx. Remember to click on the big downward yellow arrow found in the middle divider bar if you are unsure of what field needs completion to execute a script.
Med Rec is still in a tough spot, though we expect it to improve over the next few months.
We have a new Health Maintenance Redesign working group. The plan is to review current guidelines and bring the HM tool in line with the evidence and recommendations of sentinel task forces.
We are also actively seeking a results to endorse solution that will enable a system-wide rollout towards the end of the summer. In order to make this happen smoothly, we are creating pools, (think "group proxies"), that will facilitate custom workflow design in every practice. While the usual routine in a primary care setting is for doctors to review results and communicate with patients accordingly, others choose to delegate this review and be made aware of abnormal results. My first thought is to create a results pool for each of the BMP practices. Pools will be posted at the same time that RTE will arrive in the clinician's Message Center inbox. A result can be reviewed and endorsed by the physician and will then drop off both their list as well as the pool's list. In the event that the protocol is for the medical assistant to endorse normal labs, then those results will also fall off the pool list as well as the ordering clinician's results list. It will be the responsibility of the practice to determine the proper protocol so as to avoid inadvertant endorsement of results that go unseen by the ordering clinician.
Other improvements:
We continue to work with Cerner to optimize the function of the Prescription Writer. If you haven't heard, two key points are to 1) Cancel/Reorder any meds that were last written with EasyScript. Thereafter, the Renew function will work well; and 2) when in doubt, fill in the Duration field. This will facilitate the easy completion of the Rx. Remember to click on the big downward yellow arrow found in the middle divider bar if you are unsure of what field needs completion to execute a script.
Med Rec is still in a tough spot, though we expect it to improve over the next few months.
We have a new Health Maintenance Redesign working group. The plan is to review current guidelines and bring the HM tool in line with the evidence and recommendations of sentinel task forces.
Monday, June 15, 2009
PowerNotes Index on CIS Info Site
We continue to make the CIS Information Site the so-called "source of truth" for the what, where and how-to of CIS for all users. We will be posting an index of all PowerNotes that have been created thus far, organizing their titles by venue, that is, by the variety of areas in which they might be used. While I tried to define these divisions as broadly as possible, I would not be surprised if found additional ways of cross-referencing these templates. Let me know what you think.
Friday, June 12, 2009
RTE not ready for prime time
As a result of a logistical error yesterday, the Results to Endorse function was “turned on” for all ambulatory practice sites. For those of you who had not previously received these results, measures have been taken to discontinue this electronic delivery immediately. While electronic results to endorse remains a system goal for all BMP practices, yesterday's delivery was premature. We are currently in the midst of creating associated tools designed to streamline anticipated changes in workflow and expect to introduce these in the coming weeks. I expect that we will be able to formally roll out results to endorse for all ambulatory laboratory orders early next month.
In the event that you have received these laboratory results for the first time, you can discount them as your means of results review and expect that your usual protocols remain in place, i.e. paper reports. To clear them from your Message Center Inbox, double-click on the first report-->scroll down to view all results-->click OK & Next until the last result.
In the event that you have received these laboratory results for the first time, you can discount them as your means of results review and expect that your usual protocols remain in place, i.e. paper reports. To clear them from your Message Center Inbox, double-click on the first report-->scroll down to view all results-->click OK & Next until the last result.
Thursday, May 28, 2009
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.
Wednesday, May 27, 2009
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.
Monday, May 18, 2009
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.
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.
Friday, May 15, 2009
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:
That's it for now.
- 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.
That's it for now.
Tuesday, May 5, 2009
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.
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.
Monday, May 4, 2009
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.
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.
Thursday, April 23, 2009
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.
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