Advice for Group Two

So, Group Two's training date is fast approaching. Do you have any advice for them?

Here are a few things I would suggest:
-- Try to start patients two months and under on EMR. Make them your priority in your first few weeks.
-- Learn to navigate your way around Greenway BEFORE training starts. Get with your Super User and set up your preferences, learn how to pull up your schedule, search for a patient and their demographic info, and how to schedule an appointment. This will save you wasting an hour or two of time with your Greenway trainer doing stuff that your super user is more than capable of doing.
-- Don't get too frustrated. If it's slowing you down, go back to paper for the rest of the morning, then try another e-patient in the afternoon.

Did you survive the slowdown?

Those of us on EMR faced a new challenge this week-- a big decrease in speed due to problems with the main server. Luckily we weren't shut down completely, due to Brock's plan for built-in redundancy.
Speed at our office was slow enough that I went back to paper charts for a day. I was surprised to find that it was a real pain to chart on paper again-- way too much writing.
Luckily we're back up to reasonable speeds.
How's everyone doing on EMR?

And for some GREAT NEWS-- Earl is a Dad! His daughter was born on Friday night, 7 pound 2 ounces. Mom and baby are doing great.

One Week of Totally Electronic Patients, Like, Totally

So I like, totally, did a whole week of electronic patients. Like, wow. So, it's like, possible, fer sure. So, like, don't give up, people. I'm going to the mall to celebrate. (My apologies to Moon Unit Zappa).

ROS Issues

We're finding out that using your ROS Admin feature is a little trickier than we thought, and that building ROS into templates might be trickier, as well. If you're having problems with getting the right ROS options to show up, reply in the comments section and we'll try to help you (maybe your problems will help us figure out why we're having problems, too). Kind of like doing functional neuroanatomy by seeing what deficits people end up with after getting a crowbar lodged in their brain...

Some Coding Ideas

We had a conference call this morning with several folk from Greenway to go over lots of issues. One thing that came up is that for many users who are creating notes in Greenway, the codes from the note (diagnosis codes and procedure codes) do not match up with what is showing up on the paper superbill.
We will try to get some specific information about the differences so we can let each office, or maybe each doctor know, and also see if certain templates have incorrect coding information.
We are also going to develop a template with "approved" codes that you could use as a basis to develop your individual templates. In this way, you can be sure to get paid for your visit and keep things sane for the billing office. We'll go over how to start a template from another template later, but just keep that in mind.
We will also have a person or persons responsible for checking templates and making sure any coding errors get corrected, so they aren't spread throughout the system as others begin using the templates. I'm thinking that person needs to be the Template Czar, but we're open to suggestions as to the appropriate job title.
If you are in doubt about coding, try pulling codes through the Plan Wizard from the Wasatch category. Those are the ones from the superbill (although some are incorrect as well!) and should at least be easy for the B.O. to understand, and fix if necessary.

We Need Feedback on the WCP Templates

Earl and I have made two templates based on the Willow Creek parent questionnaires: a 2 week and a 2 month. We formatted them differently (on purpose) to see which people would like better.
The 2 week template incorporates the questions into a paragraph format, although it retains the same order. (One change we will probably need to make is making the breastfeeding paragraph and the formula feeding paragraph be an either/or/both option, so the final note doesn't include a junk paragraph with no selections.)
The 2 month template has the questions in bulleted form with yes/no answers, exactly as they are on the questionnaire. (One change we'll need to make is to provide fields to elaborate on the questions, such as "do you have any questions about breastfeeding" and then giving a place to enter their question).
Please help us out by trying out these two templates (and having your MA's try entering the questionnaire data for you, as well) so we can get a consensus on which style works better for people. Also take a minute to look at the finished product and see how you like the layout. Please send any comments or questions to Earl, Kevin, or as comments on this post.
Once we get some consensus on the best format, we'll go ahead and build the rest of the templates. The quicker the quicker, so try one out today and let us know what you think!

Personal EMR Milestone

Friday was the first time I did every patient for an entire day in Greenway, and I was out of the office by 6:00 (which is normal for me on Friday). As the Beatles said, "I have to admit, it's getting better, it's getting better all the time".

Happy Fathers' Day to ALL!

What better way to spend it than blogging on greenway while waiting for the Father's Day meal with a 38 wk pregnant wife!

It can be frustrating to think about the extra time that this transition takes and how it invades some of our usually personal moments. In those times it is helpful to see the efforts of others interested in the success of this project and also to see how it has helped me become much better acquainted with others i likely would never have known very well in the corporation.

And, then there are the little successes like all the doctors and staff in our office looking at how the advantages of the system can outweigh the difficulties in transition.

Here is an email to Karla which may help some with templating stuff theyr'e working on:

On Sat, Jun 14, 2008 at 9:59 PM, Karla Feindt <kafeindt@yahoo.com> wrote:

I tried to do your create note/progress note option on a pretend patient. I couldn't figure out the ROS Admin or where the option to create or save exam types is located....ooohhh I just read a little further and saw you will cover that in another post...I will have to be patient :)

ROS Admin is pretty easy but it would probably be easier to show you than describe it to you; basically you highlight the categories on the left, then windows will open on the right. If an item is in light gray it will be an option but will not show up as a default "admits" or "denies"; you can click on that individual item (either in ROS admin or in your actual note) once and it will show a (-) sign, meaning "denies", twice for (+) "admits", and three times to make it neutral again. Your defaulted ROS should show up in any note, although mine is giving me trouble right now and I'm waiting to hear from Greenway.

Also, if I am creating a line that will nbe used in multiple different template, is there a way to save it in a library, copy/paste it? Can you use your DIAGNOSES AND PLANS FOR MERGE to put into our own templates? Is there a way to use this create note/progress note process but then have pretyped plans where all I have to do is click on one thing and my whole URI plan will come up, or another and my usual entire OM (bronchiolitis, VGE, etc) plan would come up so I don't have to do multiple clicks in the plan section?

There is definitely a way to save it in the library; I would have to go to a template to see how, but I'm also forwarding this to Earl, who can tell you the exact way to do it. As far as linking diagnoses and plans, you can create a template that doesn't have HPI or PE but has diagnoses, and you can link specific order, labs, meds and instructions to each diagnosis. I have one that's pretty complete that you're welcome to try. Under select template, change the user to Kevin Lash, and select the template named "diagnoses and plans for merge". It can overlay into any type of note.

I hope these questions make sense. I plan to attend the Wed AM meeting, but sometimes rounds interfere with best laid plans... Hope all is well with you. After this exhausting template creation work, I am goin to bed, at least until the next patient calls... Thanks for all your work on this blog, Karla Feindt

I hope you can come one of these Wednesdays- I think it would really jumpstart your template work and save you a lot of time.

Thanks,

Kevin

The DUH! Moment of the Day

I stumbled on a totally obvious but hugely time-saving little trick today. I like having a full ten charts "open" at one time (you can tell they're open because the names are on the tabs along the botom of the page on the "Patient Charts" page), but the last thing I want to do when I'm walking in the office late after rounding is stop and one-by-one open those charts so they're ready to go.
So, you can open all ten charts AT ONCE by pulling up your schedule (click on the EKG button at upper left) and click on each chart you want open to highlight it (it will change color). Then click on the open chart icon on the left hand side of the toolbar (the normal way you've been opening patient charts). You'll see all ten charts open up along the bottom. When the tabs are there, you can switch from one chart to another without closing or opening the chart.

I've noticed a couple of problems with the WCP 2 week template-- one is that I didn't put in the normals as the defaulted response, so I went ahead and did it. When you check the EM coding, it might tell you the physical exam isn't coded. We're working on this, but it will still code for the correct well child visit so don't worry.

Consults Can Be Tracked Through Order Tracking

Our trainer, Nick Irwin, was kind enough to set up dummy CPT codes for subspecialist referrals. This allows you to track them through the Order Tracking function to check and see if a patient has actually gone, or link it when you get a referral letter back from the specialist.
To do this, in your PLAN section, find "Orders", then ">Add New", then to the right of that click on "Favorites".
A new window will pop up. DON'T CHOOSE "CONSULTS" from across the top-- instead, look down the categories in the column on the LEFT and choose the last box, which says "Consults" in white letters. Then just check the box of the consult you want to order, and it can be tracked. There are a few we didn't think of (Ped. Surgery and Lactation are the ones I noticed) that we will add in. If you have others, please e-mail me lash.kevin@gmail.com and we'll put them in.

How to Import a Template

For those of you who haven't imported a template yet, here's what to do.
-- click the "download file" button if you have been sent the template in an e-mail attachment and save the file to your desktop. If you open the file, it will just look like gibberish, so don't worry.
-- Go into Greenway and click on "Chart", then "Template Admin."
-- on the lefthand side of the window under "Options", down at the bottom it will say "import". Click on that.
-- a new window pops up (after a minute) that says "Select Clinical Templates". Click on the word "Browse" that is to the RIGHT of the words "File System".
-- a window should pop up that has all the contents of your desktop. Double click on the icon that has the file you want (for example, it would say "WCP- 2 weeks" to import my last template).
-- on the left under "Browse File System", the name of the file will then appear. Click on the name and it will change to blue, bold type, and will also appear over on the right box as well. Then click on the box in the lower right-hand corner that says "Start Import", and it will put that template in your list of templates.
--You can then click on that template to open it, or choose it from your user list when you are seeing a patient. You can also make adjustments or changes to the template and save it as your own without changing the template for everyone else.

Users who have some good templates to use include Earl Judd, Maggie Hull, Darin Bosworth, Teresa McNaught, and yours truly. Try them out by selecting them from the user list, and then if you want to import them contact the person by e-mail so they can send it to you.

Did I get everything right, Earl?

First "Willow Creek" well check template

I have completed my first attempt at putting the Willow Creek parent observation questionnaires into a full well check template. I resisted the urge to add other elements to the HPI simply for the sake of consistency; I did format the ROS, PE, Diagnoses and Plans to what I thought would be typical for a 2 week visit, although the exam may be a little long.
Please give it a go and tell me what you think.
You can find it under my username after you choose Select Template. It is called "WCP- 2 weeks".
If you want to actually import the template, send me an e-mail lash.kevin@gmail.com and I can attach it to my reply. It will eventually end up in Tank Template or some other place that's easy to find.

Great News for Willow Creek, St. Marks and Draper

We are going to take the patient questionnaires for the well child checks that are used by Willow Creek, St. Marks, Draper (I think) and a few other docs here and there, and put them pretty much word-for-word into templates that can be used for Well Child checks. This should speed things up enormously, since the MA will be able to enter the data (and should only have to enter any abnormal values, since the normals will be defaulted). Then the doc can complete the (age-appropriate formatted) PE, the Diagnosis page (pre-populated with the most likely diagnoses) and (diagnosis-specific) Plan, including the likely vaccines already selected.
Give us a week or two to get this done, but I hope we'll get a lot of use out of these templates.
And you will owe us a seriously great dinner for our free templating work!

Growth Curve Tip

As we switch to electronic well checks, that first visit gives you a less-than-useful giant dot standing all by itself on each section of the growth curve. We have asked our MA's to go back and enter the growth parameters from the previous Well Check to that at least we have two data points and a curve in between. It's much more effective for showing to the parents and for assessing the interim growth.
All the MA (or the doctor!) has to do to enter previous vitals/growth data is go to the Vitals section, click on the Wizard, then click on Add Vitals. Enter in the values, and be sure to change the date in the bottom right-hand field to the date that the vitals were obtained. Then click Add Vitals and close the window. They should then appear on the growth curve that you access from the Facesheet.

My full DAY!

Though our office hasn't had triaing yet, we have worked hard to get the docs familiar with problem lists and past history to date so as to be better ready for the big day.

Today, I managed to work with Jill and get through all but my last patient electronically. Our office still runs slower so tidying up at the end of the day was a little rough but it isn't as bad as i thought it might be.
The last 3 days have been crazy with 14 yo's bolting from the building scared of their shots, Kabuki syndrome (what's that?) and other wierd stuff. That continued today with strange diagnoses but i was able to get almost all the PMH entered for my autistics, aortic stenosis, etc.

I do bail on a few if i can't get the PMH entered before entering the room.

I'm really getting better with handwriting - hang in there with it. It isn't any faster than typing but it is more convenient sometimes.

I try to make sure i open the note and then go back to the growth chart before entering hte room to not have to try and do that in front of the patient - especially when it takes 20 secs.

The families are quite patient and the kids of course love the colors and the fact that their pediatricaiin would have a COMPUTER!

More later from our end
Earl

How do I deal with the time crunch?

I would love to hear how everyone is juggling the time crunch. It is still taking longer to see patients, but I have a pretty full schedule and don't want to cut back on patients. How are you handling this?

Here's what I'm doing: I'm running my normal schedule. In the morning I go over which patients I want to see on EMR, and which ones I want to use charts.
My first priorities for EMR patients were:
1- new patients (so they won't have a chart really)
2- 2 week and 2month well child visits (same reason)
Then I started expanding to other well child checks. I still haven't made my own well child templates, but I'm familiar enough with the ones that Earl and Maggie did, as well as how my routine differs from them, that I think I'm ready to dive in now. I wouldn't have been able to do that a month ago, however, and the "Tank Template" well child templates are very good. Thanks again for taking all the time to set them up!
Once I figured out how to do sick visits quickly (especially once I made some shorter exam types and my diagnosis/plan template) sick visits are actually easier for me to see.
One big problem is entering in all the past medical, family and social history. We have been working on a shorter version for Southpont (it's named Southpoint FP, toward the bottom of the categories list on the left hand side when you're in PMFSH) that will have a corresponding questionnaire to hand to patients. The idea is to have the questionnaire be identical in order to the items on the PMFSH so that an MA or a front desk person, or a provider, can quickly enter them in. We're not quite there yet, because Greenway alphabetized them, which totally changed the order. When we get that one polished, I'll share it on this blog. It will also have a Spanish questionnaire that can be transferred into the English chart.
So on some days, I've been able to crank through pretty well. Today, for instance, I saw all patients electronically (but only worked half a day due to training). I have noticed that if patients come late or if I have a complicated patient and get really behind, then I'm sunk and just switch to charts for the rest of the day.
I have also saved the box that my tablet came in to take home charts and I've finished charting some patients at home, especially so I can enter in PMFSH.
On many patients I've just entered one or two pertinent points of past history, or I've just skipped it altogether, since we still have a paper chart.
I think I"m pretty close to being able to do all electronic charts. Now watch tomorrow be a disaster:)
By the way, we had a very good training session with Nick today. We're going to work a little bit on templating tomorrow.

Acute Visit Tips

I'm finding that it's easier to do acute visits in Greenway without using a template. I made an acute visit template (you can find it under my username), but the HPI gets me bogged down and steers me away from getting right to the heart of the matter.
So here's what I do:
Click on CREATE NOTE, and then on the PROGRESS NOTE option from the drop-down list, but DO NOT CHOOSE A TEMPLATE!
CC: Click on the WIZARD icon (the magic wand with sparkles in the upper right hand corner of the toolbar) and type in the chief complaint. I also like to type in who is bringing the patient "Here with Mom" and maybe allergies and meds "NKDA; taking tylenol" so they show up prominently in the note.
HPI: To do this without a template, just click on SKETCH PAD in the tool bar. This will open a blank sheet of notebook paper to type or write out your HPI. I like doing it this way, because I can follow the way the patient/parent tells me the story.
PFSH: you do this the same way you normally do. We still don't have this very well fleshed out in most of our charts, but that's a topic for another day :)
ROS: I click on the category that I want to open ("constitutional", for example) and then click on the "C" box. This will open a table with several symptoms in gray. I have organized these in my Review of Systems Admin (under the "Chart" heading on the upper toolbar) to have the categories I want. I prefer to have everything unchecked, so I can go through and hit just the symptoms I want by clicking once for a negative, twice for a positive, or a third time to turn that item off again. I will typically hit four or five systems, but just in a way that makes sense and doesn't clutter the note or take too much time. For the system that is the main focus of the HPI, I click on the "H" box to indicate "see HPI".
VITALS: should have been entered by the MA. If they weren't, click on the WIZARD at the upper right of the toolbar. A new window opens, then you click on ADD NEW VITALS at the upper right. Enter in any values you want to (remember all values are in English, not metric), then click on the ADD VITALS box at center bottom. Then click on the X in the upper right hand corner to close the window.
PE: If your exam is very short and focused, just click on SKETCH PAD and type or write your exam. If it is a more thorough exam, click on the WIZARD again in the upper right hand corner and choose the categories you want to include, or better yet, if you have saved EXAM TYPES you can just click on the TYPE icon just to the left of the Sketch Pad, and a drop down menu will let you choose from your preset exam types. I would strongly recommend putting in some Exam types for yourself, since the exam seems to be the part that bogs you down the quickest. I'll cover how to do that in another post. If I need to change an exam element from my presets, it's usually easiest just to click on the category an go to text view, then click at the end of the sentence to get a cursor. From there I usually backspace to delete the unwanted text and just type in what I want to say without jumping through the hoops of the presets.
IN-OFFICE PROCEDURES: If you do Rapid Streps, UA's or other office procedures that will need a result entered in during the visit, you can click on the WIZARD and choose from the options, or just click on the SKETCH PAD and free text in the result.
ASSESSMENT: Click on WIZARD and add a diagnosis from the search box. This can be a little tricky. The easiest way is to choose a diagnosis from the Wasatch superbill by clicking on the down arrow in the CATEGORY box and selecting *WASATCH. The ICD-9 NAME box then automatically opens and you can scroll down until you find the diagnosis you want, then click on it and click on OK. Other categories that have been helpful to me are A-COMMON PROBLEMS or rarely, the subspecialty categories (usually too detailed and just don't seem to have what I want). My other trick is to click on SEARCH and then click on CODE instead of DESCRIPTION. You can then open a Google search on the internet and type in the diagnosis and the words "ICD-9"; for example, "inguinal hernia ICD-9". You can usually find one or more sites that will give you the ICD-9 code. You then type in the code number back in the Greenway search box and click SEARCH and it should give you the ICD-9 name on the left hand side. You can change the "LOCAL NAME" if you need to to get more specific, then click OK and it will add the diagnosis to your note.
You can also click the little pencil and paper icon to the right of each diagnosis you enter to add a text box explaining your diagnosis or giving a differential, for example. Clicking on the far right icon will add that diagnosis to the patient's problem list.
PLAN: Again, you can either click on the SKETCH PAD and free text it, or you can click on the WIZARD to prescribe meds, order labs or consults, add instructions and set up disposition.

Don't forget to save and hold periodically as you go along.
These instructions take about three times as long to read as it will actually take you to do the note!

One last trick: I have prepared a template that just has common diagnoses and plans specific to those diagnoses. You will find it if you click SELECT TEMPLATE and change the USER to Kevin Lash. Then click on DIAGNOSES AND PLANS FOR MERGE. This will populate a list of common diagnoses for you, whether you have been working in another template or just going from the wizards. Check the boxes that are appropriate, and when you go to plan you should have the logical (at least in my mind-- a little scary, I admit) labs, medicines, and discharge instructions for that diagnosis. You have to scroll down past a list of all the labs first, but then you should get to the specific stuff. This template will layer over well checks or acute visits and should save you some time.
In another post, we'll talk about how to import this template into your User so you can begin to customize your own instructions.

Be brave and give it a try!

Group One-- How's It Going?

So, for all of you in EMR Group One, how are you doing? How many Lenovos have been tossed through windows or off of tall buildings? How many patients per day are you seeing electronically, and which ones?
Here are my brief answers:
-- The most I've done was a complete morning with all patients charted electronically. But that afternoon my first three patients came late, and I gave up. I have noticed that I'm having to devote enough mental energy to EMR that I'm less flexible in dealing with late patients, complicated patients, or stressful days. When those happen, the EMR is done for the day.
-- I am getting pretty fast on sick visits without using a template. I will do a separate post detailing how I do it.
-- Earl and Maggie did a great job on the "Tank Template" Well Child Checks. These are a great place to start, especially on 2 week and 2 month well checks.
-- I had a hunch that templating would be the key to getting Greenway to work for me instead of me for it. We all use "mental templates" for our various visits-- for example, I do each kindergarten visit more or less the same, and even strep throat visits follow a mental template for me (not consciously, but we're all creatures of habit). Now I need to tailor templates so that the chart reflects how I think, instead of making myself think in the way the template does. Then I'll feel at home with Greenway.
-- We're still having speed issues at Southpoint, even though Brock and Bruno have spent an insane number of hours trying to speed it up. Waiting for a screen to refresh really gets in the way of having GW work for you.
-- I am finding myself wanting to do more patients in Greenway, because it's starting to become a habit now. I just need to get faster at it.

Post a comment to let me know how you're doing...

Why did Kevin start this blog?

OK, it's not like I don't have plenty to do. But as we're into our sixth week of EMR implementation, I've figured out a few things that might save some of you some time. I'm sure you have, too, but we just don't have a great way to share those tricks.
Also, I've felt several times in these past weeks that I just needed an e-place to vent a little. This blog can be that, too.
So, here are the rules:
--If you are a Wasatch Peds doctor or mid-level and want to post, e-mail me kevinlash@wasatchpeds.net to get permission. I've invited some of you whom I thought would be more likely to want to post.
--I would love to know the things you've figured out to make Greenway work for you. Or a great template that you've been working on and why you like it.
-- I would also like to hear about what doesn't work for you and why.
-- If you have a question, like "Why can't I get Greenway to do this?" or "How do I do that?" this would be a great place to post it. We'll try to put our heads together and figure it out, or contact Greenway to do it.
-- Life is also about art-- share your feelings, humor, or nervous breakdowns with us.
-- I do reserve the right to moderate comments, or to restrict access to the blog if necessary. Please no flaming or trolling!
-- If you are a doc somewhere who is considering an EMR and want to read through our experiences, feel free.
-- I will also invite some of our Greenway contacts to post here.

Ready, set, BLOG!