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

2010: The Year of the Ambulatory EMR

With the turn of the fiscal year 2010, the medical informatics and IS teams launched into an ambitious agenda for the CIS Ambulatory project. As you know, CIS was first launched in BMC back in 2004 with the introduction of computerized provider order entry (CPOE). This was followed by a host of other functions including PACS (picture archiving and communications system) for viewing radiographs, and physician documentation. In 2005, CIS-Office was implemented to varying degrees across the BMP practices with emphases including medication management and historical data entry. The EMR project then turned to documentation in the outpatient setting wit hthe BAPO and BMERF primary care practice sites receiving much of the attention.

In order for CIS to continue on its successful course, we will be devoting much of the coming year to adding and enhancing tools for the ambulatory world. At present there is a large multidisciplinary team that is designing the ambulatory CPOE tool in order to faciliate use of evidence-based caresets, to expedite appropriate charging and billing process and to improve the documentation of medical decision-making.

For those clinicians who use eScription for documentation, a voice recognition dictation tool with human editors in the background, a pilot is soon to be launched whereby clinicians will migrate to Dragon voice recognition for dictation. This projection promises a significant cost savings when compared to our current dictation system. Dragon also allows the user to edit and finalize documents in real-time without having to wait for transcription nor without having to login to another system (ESA). The critical effect that I anticipate is a newly vitalized engagement, especially among the specialists who have not become proficient with the core of the EMR: Problem/Medication/Allergy/Procedure & Surgical Hx Lists.

Other major projects that have begun and will continue through the year include:

• transition to ePrescribing in order to receive federal incentive reimbursement
  
• Patient Centered Medical Home
  
• Patient Portal
  
• MPages (dynamic patient chart viewing)
  
• PowerInsight dashboards and reporting modules
  
• Formulary and drug benefit management
  Sorry for the long hiatus from posting. As you can see, we've been pretty busy gearing up for a number of exciting projects. Here's to a great year!
  

CIS Results to Endorse coming to all on Dec. 1

A lot is going on these days in EMR land. Anyone who makes it over to the blog must now by know that we will soon be sending electronic results to all users ordering labs from an ambulatory or daystay encounter. That means that we will be able to discontinue the duplicative delivery of paper reports once practices develop a new baseline in workflow. For most practices, the transition has taken a matter of days. Given the variation in practices across BMP, we expect to be able to discontinue paper delivery by the first week of January pending any unforeseen issues with the RTE process.

As I write this, I am watching my Outlook account creep very slowly through the mail merge I set up for the distribution of videos that I have previously sent as well as posted here on the blog. While I still can't deal with hearing my own voice, I've heard that the videos are both useful and the right length: short.

I expect the BMP RTE project to be very successful, but there are a few remaining issues that will need attention:

• It is imperative that the ordering clinician's name be clearly written on the lab requisition. After a virtual inquisition by IS and the lab, we found that labs are delivered to a default attending, e.g. medical director of a clinic, if the ordering clinician, be they resident, PA, NP or otherwise does not explicitly declare themselves on the order.
• An area up for review with our vendor is the need for physicians and others to be able to review labs without actually signing them. This is particularly useful when the proxy tool is employed in cross-coverage. The ability to review, and thereby signify that a lab was "seen" with action deferred to the ordering clinician, is crucial for practice workflow and patient safety.
• The inability to cc another physician is a significant limitation that we will have to live with for the meantime. While I have been in the habit of forwarding relevant results to other BMP physicians, such an expectation for practices much busier than mine would be an unfair encumbrance. Keep in mind that practices outside of BMP to whom you cc results will continue to receive them in printed form.
  

The electronic delivery of Result to Endorse will be a major step towards the paperless medical record. The more we orient ourselves to the electronic record as a data repository and as the focal point for data input and communications, the better the patient record, and, ultimately, our patients' health, will be.

Influenza PowerNote

As I lie here listlessly for the 5th day in a row, I am pleased to report that there is a PowerNote that would be useful to document my visit to a physician were I to have the energy to drag myself out. There are now Influenza PowerNote templates for office and hospital, pedi and adult.

As for me, no need for any diagnostic acumen. My 14 year old son had a positive rapid influenza A/B test last week and, given the reports across the country and that I received the seasonal flu vaccine well over a month ago, I'm stuck waiting for H1N1 to leave me the heck alone. Fortunately, the symptoms are low key enough to allow me to avoid an office visit or other CDC-derived suggestions elements you will find in the templates. However, a constant headache with low grade temp and myalgias have kept me supine 95% of my waking hours.

You could probably fly through a routine flu visit using this template. The diagnoses at the bottom actually populate the note with a SNOMED code, saving you a step in the finishing of a note.

And for those of you who wash your hands compulsively as I do when at work, don't play the fool and forget to do the same at home.

Worthwhile reading

For those of you who who are not familiar with David Pogue at NYT, he is a terrific blogger on personal technology. Peter Lindenauer pointed out yesterday's post to me. Pogue interviews David Blumenthal, the fed's health information czar. It's a worthwhile read.

Pogue Interviews Blumenthal

Pap Tests

If you didn't notice on the CIS announcement screen, effective this past Tuesday, 10/13/09 the much-needed Clinical History data will be included with the Cytology Pap Test results in CIS. This has been a major issue for those of us providing gynecological care.


As a related aside, we are pursuing the delivery of Pap and all other pathology test results to the Inbox as well. I anticipate this being accomplish in the next few weeks. In addition, we will soon be releasing all results ordered in the ambulatory setting to all ordering clinicians. Thus far, approximately 2/3 of all folks working in the outpatient world have requested electronic transmission of results. Based on this successful expansion of the EMR as well as to ensure the quality and safety of results delivery, we will be rolling out Results to Endorse to all BMP providers. Keep in mind that you will receive only those results that have been ordered from an ambulatory venue.

CIS Clinician Satisfaction Survey II

Since posting the survey data two weeks ago, I've had a chance to look more closely at the 100 or so pages of typed comments offered by the 250 or so respondents. While the numbers are very useful in order to get a general overview of satisfaction and EMR engagement, these comments are invaluable as we pursue a 100% paperless medical record.

Today, I am posting the survey results again, though this time with bulleted themes drawn from a replete set of texted sentiments. In truth, I've left out some of the more positive comments, primarily in order to give focus to where we, the informatics team, need to concentrate our efforts for improvement. Training and the spread of useful CIS knowledge has been and remains a high priority for us.

I truly appreciate the time and effort that you've put into providing these results, though more so for your willingness to persevere through this veritable culture change in medicine. With our continued collaborative work--among physicians, mid-level clinicians, ancillary staff and the awesome IS squad we are fortunate to have--I am certain that Baystate Health will remain a national leader in the creation of an EMR that promotes the safest and highest quality care for our patients.

CIS Clinician Satisfaction Survey Part 2

CIS Clinician Satisfaction Survey Results

Here is a first view of CIS Clinician Satisfaction Survey. Thanks to all of you who responded. The data captured here is incredibly meaningful and useful. I will likely post further details and commentary in response to requests, needs and calls for improvement.




SurveySummary_10012009

Loss of Precompleted Notes and Macros

Major bummer for a handful of dedicated CIS users. For convoluted reasons, precompleted notes and macros that had been created on now defunct versions of PowerNote can get lost. The probable issue with the loss of the precompleted notes is that they were likely created on older templates that had been revised over time. We've seen folks lose notes that were created on the earliest templates.I am learning that the system can be quite sensitive to changes made in the content and code. Cerner, our EMR vendor, recently recommended:

Ensure that the precompleted note or the macro was not created before a recent content load. If new PowerNote content has been taken since the precompleted note or macro were created, there will be viewing issues. They were created under older content and a different structure for the portions of the note (paragraphs, sentences and terms). Therefore, when trying to use the precompleted notes or macros with a new structure, there is a mismatch and some of the terms that were there before are no longer there or have been moved around. In order to resolve the issues, the macros and precompleted notes will need to be created and saved again.

An alternative explanation may be that the precompleted notes are shared and accidentally deleted by another user. Unfortunately, there is no way to back up precompleted notes. Cerner's answer to the difficulties with macros and precompleted notes is to create a compendium of auto-texts that would serve a similar purpose. These are not dependent on content or template format and can be used across all PowerNote Templates or in Clinical Notes were you to work from that screen.

I honestly wish I had better news.

Creating Proxy Lists

Granting proxy authorization to another clinician or members of a clinical team enables the proxy to perform any activities for which you have granted them authorization, such as signing, refusing and forwarding messages and results.
To grant proxy authorization to another provider or team member, complete the following steps (see pictorial in slide below):

1. From the Inbox menu, select the Proxy Tab and click the Manage button.
2. Click Add.
3. Search for a user by typing last name, first name. Click the binoculars to search.
From the User list select the user that you want to give proxy to. To grant proxy to more than one user use the arrow to move the current user to the additional user's box and continue searching.
4. Specify a Begin Date/Time and End Date/Time. For example, if you will be out of the office for two weeks, specifying the Start Date/Time and End Date/Time ensures the proxy will be able to access your Inbox messages during that period only.
5. To grant permissions to the selected user, highlight Results or other items you want to proxy.
6. Click Grant
7. Click Accept & Next button.

Proxy

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To remove an existing proxy authorization, complete the following steps:
• From the Inbox menu, select the Proxy Tab and click the Manage button.
• All proxies that you have granted are listed in the Proxies Given By Me pane
• Select a proxy.
• Click Remove. The proxy authorizations are removed.
• Click OK.

To view a list of all individuals to which you have granted proxy authorization, as well as specific permissions of each authorization, complete the following steps:

• From the Inbox menu, select the Proxy Tab and click the Manage button.
• All proxies that you have granted are listed in the Proxies Given By Me pane.
• Select the proxy that you would like to view and click Details. The specific permissions that you have granted are displayed.


To view a list of all providers and document types for which you have been granted proxy authorization, complete the following steps:
• From the Inbox menu, select the Proxy Tab and click the Manage button.
• Click the Received tab.
• The users displayed in the Proxies Received by Me pane are authorizations that have been granted to you.
To view detailed information about the privileges granted by a particular user, select user and click Details.