Transcript Advanced Template Design - Sammamish Diabetes and Lipid

Advanced Template Design
2007
By
Donald T. Stewart, MD FAAFP
[email protected]
July 2007
Don Stewart
• Family Practice, sole proprietor x 20 years,
employee x 4 years, now going solo-solo
in a micropractice.
• Paper “templates” for visit notes since
1983
• Disease Management templates since
1993
• EMR templates since 1997
• Practice Partner templates since 2001
You
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Physicians?
Nurse Practitioners?
PAs?
MAs or Nurses?
Practice “Tech” people?
McKesson/Practice Partner employees?
Who heard my talk on this subject last
year?
Resources for this Talk
• This Power Point presentation:
– Advanced Template Design 2007.ppt
– Saving Clicks and Keystrokes.ppt
– Printed handouts here today
• Last Year’s Power Points:
– Advanced Template Design.ppt
– Designing a Chronic Disease Template.ppt
• PDF Handout 2006 (a “how to” with lots of extra stuff):
– Advanced Template Programming.pdf
• These will be available:
– On the PP web site soon
– At http://www.SammamishDiabetesAndLipid.org
– Or email me: ([email protected] ) for
copies of all of the above
Concepts Covered Today
• Reusable data elements
– Lab Data Elements
– Clinical Data Elements
• “Natural Language”
• Strategies for designing “Chronic Disease” or
“Consultant” templates
• Minimizing clicks
• If we have time:
– Disease-aware templates
– Drop Down Menus vs Expanding Menus
– Recursive Quick Text
Reusable Data Elements:
Lab Data Elements (1)
• In the past, we could store data as lab
values. For example:
.L: DiabetesDxDate: «DEL»
would allow us to save something we
could bring back later as:
||LAB<DiabetesDxDate>||
Reusable Data Elements:
Lab Data Elements (2)
So, if you enter this in a template:
.L: DiabetesDxDate: «DEL» Summer 2006
It becomes this when recalled:
DiabetesDxDate: Summer 2006
Reusable Data Elements:
Lab Data Elements (3)
• Limitations of Lab Data Elements:
– Lab Names are limited to 18 characters in
length
– Lab data is limited to 19 characters
– You cannot suppress the display of the name
without using conditional logic
– It is hard to limit the choices for what data is
saved
Reusable Data Elements:
Lab Data Elements (4)
• Workarounds (to hide the Lab Name):
|| IF LAB<HasDiabetes> = “True” {The patient
has diabetes.}
ELSE
{IF LAB<HasDiabetes> = “False” { The patient
does not have diabetes.}
ELSE
{Diabetes status is not recorded.}
} ||
Reusable Data Elements:
Lab Data Elements (5)
• Workarounds (to force specific choices)
.L: HasDiabetes: «REQ» «*True» «*False» «*Unknown»
However, users can always type in
something else besides the choices– the
key is to make the choices you want
easier to click on than typing something
else.
Reusable Data Elements:
Clinical Data Elements (1)
• With version 9.x of Practice Partner,
Clinical Data Elements were introduced.
• CDEs have many advantages over Lab
Data Values for storing and reusing clinical
data.
• You can enter CDEs in a note, or through
a graphical interface
• You can “type” data as text, numeric, or
date
Reusable Data Elements:
Clinical Data Elements (2)
• Clinical Element names can be up to 29
characters in length
• Clinical elements can store up to 40 characters if
entered through the GUI, but only 39 characters
if entered with a dot code in a note. Note that
leading spaces count in this.
• CEs can have attributes, which store up to 25
additional characters of information, though in
9.1 only accessable through the GUI
Graphical User Interface
For Clinical Data Elements
Dot codes and Conditional Logic for
Clinical Data Elements
• CEs can also be entered through notes
using dot codes, and can be pulled into a
note through Conditional Logic.
.CE: Dx Date Diabetes: «DEL»
Or
||CLINICALELEMENT<Dx Date Diabetes>||
Leading Character/White Space
Issues
Template Test2 – use this
template to see what was saved
in the two clinical elements
Without white space, 39
characters are saved to each
Adding white space after the
colon
White space after the colon –
Test1 only saves 22 of
characters
Putting white space before the
colon
When you put the white space
before the colon, you don’t
loose any data
Clinical Data Elements and
“Natural Language”
• Using CEs simplifies creating templates
that recall data in a “natural language”
format:
• ||PAT_FNAME|| was diagnosed with
diabetes around
||CLINICALELEMENT<Dx Date
Diabetes>||.
becomes
• Mickey was diagnosed with diabetes
around Summer 2006.
Chronic Disease or Consultant
Templates
What part of the story do you want
to reuse?
Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Patient ID– The Code
PATIENT ID: This «*age*» old
||PAT_SEX|| «*Accomp_By» was referred
by: ||REFSRC1_NAME_FIRST||
||REFSRC1_NAME_LAST||, ||REFSRC1_
NAME_SUFFIX||. || IF PAT_SEX =
"male" {His} ELSE {Her} || current PCP is
|| CLINICALELEMENT<Patient PCP> ||. ||
IF PAT_SEX = "male" {His} ELSE {Her} ||
current complaints are noted above.
Patient ID—How it Prints
PATIENT ID: This 23 yr old male
accompanied by his brother, John, was
referred by: Donald T. Stewart, MD. His
current PCP is LuAnn Chen, MD. His
current complaints are noted above.
Data for Diabetes Presentation
• Date of Diagnosis
– ||CLINICALELEMENT<Diabetes Diagnosis Date>||
• Story of presentation
– ||CLINICALELEMENT<Presentation of Diabetes>||
– ||CLINICALELEMENT<Presentation2 of Diabetes>||
• Initial fasting glucose
– ||CLINICALELEMENT<Initial FBS Diabetes>||
• Initial random glucose
– ||CLINICALELEMENT<Initial Random Glucose>||
• Initial HgbA1c
– ||CLINICALELEMENT<Initial HgbA1c>||
Presentation: Type II
Diabetes—The Code
The patient was diagnosed with diabetes around ||
CLINICALELEMENT<Diabetes Diagnosis Date> when IF
PAT_SEX = "male" {he} ELSE {she} presented with
CLINICALELEMENT<Presentation of Diabetes>,
CLINICALELEMENT<Presentation2 of Diabetes>. IF
PAT_SEX = "male" {His} ELSE {Her} initial fasting
glucose was CLINICALELEMENT<Initial FBS Diabetes>,
initial random glucose was CLINICALELEMENT<Initial
Random Glucose>, and initial HgbA1c was
CLINICALELEMENT<Initial HgbA1c>||.
Presentation: Type II
Diabetes—How it Prints
The patient was diagnosed with diabetes
around Summer 2006, when he presented
with abnormal glucose noted on routine
exam, no prior DKA, and > 20 lb weight
loss. His initial fasting glucose was 176 200, initial random glucose was unknown,
and initial HgbA1c was 8.9.
Past Medications – the code:
The following oral diabetes medications have been used in the
past: ||IF CLINICALELEMENT<Past DM Med 0 Name> = "" {none}
ELSE { CLINICALELEMENT<Past DM Med 0 Name> was stopped
because CLINICALELEMENT<Past DM Med 0 Reason>,} IF
CLINICALELEMENT<Past DM Med 1 Name> <> "" {
CLINICALELEMENT<Past DM Med 1 Name> was stopped because
CLINICALELEMENT<Past DM Med 1 Reason>,} IF
CLINICALELEMENT<Past DM Med 2 Name> <> "" {
CLINICALELEMENT<Past DM Med 2 Name> was stopped because
CLINICALELEMENT<Past DM Med 2 Reason>,} IF
CLINICALELEMENT<Past DM Med 3 Name> <> "" {
CLINICALELEMENT<Past DM Med 3 Name> was stopped because
CLINICALELEMENT<Past DM Med 3 Reason>,} IF
CLINICALELEMENT<Past DM Med 4 Name> <> "" {
CLINICALELEMENT<Past DM Med 4 Name> was stopped because
CLINICALELEMENT<Past DM Med 4 Reason>.} ||
Past Medications– how it prints:
• The following oral diabetes medications have been used in
the past: Amaryl was stopped because of hypoglycemia,
Glucotrol was stopped because of headache, rosiglitazone
was stopped because edema,
The following lipid lowering medications have been used in
the past: none
The following ACE inhibitor medications have been used in
the past: none
The following ARBs have been used in the past: none
Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Complications of Diabetes
• Neuropathy
– Pain, numbness, gastroparesis, orthostasis
• Nephropathy
– Urine Protein, Creatinine, eGFR
• Eye Complications
– Retinopathy, cataracts
• Skin Ulcers
– Location, infection present?
Neuropathy Code using Lab
Data Values
Neuropathy:
«del»|| LAB<SymetDistDysesthes> ||
«del»|| LAB<Mononeuropathy> ||
«del»|| LAB<Distal Numbness> ||
«del»|| LAB<Gastroparesis>||
«del»|| LAB<Orthostatic Sx> ||
«del»|| LAB<Diarrhea> ||
«*EditSymetDistDysesthes»
«*EditMononeuropathy»
«*EditDistalNumbness»
«*EditGastroparesis»
«*EditOrthostaticSx»
«*EditDiarrhea»
Neuropathy-what you see in the
template
«del» SymetDistDysesthes: none
«del» Mononeuropathy: none
«del» Distal Numbness: none
«del» Gastroparesis: none
«del» Orthostatic Sx: none
«del» Diarrhea: none
«*EditSymetDistDysesthes»
«*EditMononeuropathy»
«*EditDistalNumbness»
«*EditGastroparesis»
«*EditOrthostaticSx»
«*EditDiarrhea»
Quick Text to Edit a Line
Neuropathy-if you click an
*Edit…. quicktext
Nephropathy
• Initial Presentation Data
– First Abnormal Microalbumin/Creatinine
– First Abnormal 24 hour urine protein
– First Creatinine over 1.6
• Most Recent Values
– 24 hour urine protein
– Spot urine protein
– Microalbumin/Creatinine
– Blood Creatinine
– Estimated GFR
– Dialysis status
– Nephrologist
Nephropathy—Initial
Presentation
• First run through on how to put this together:
• Nephropathy first abnormal values:
||CLINICALELEMENT<First Abnormal Microal/Creat>||
«*Edit1stAbnMicroal/Creat»
||CLINICALELEMENT<First Abn 24 Hr Urine Protein>||
«*Edit1stAbn24HrUrineProtein»
||CLINICALELEMENT<First Creatinine over 1.6>||
«*Edit1stCreatinineOver1.6»
“Natural Language” conditional
logic
|| IF CLINICALELEMENT<First Abnormal Microal/Creat> = "" {We have
no record of previous abnormal Microalbumin/Creatinine ratios.}
ELSE {PAT_FNAME's first abnormal Microalbumin/Creatinine ratio
was CLINICALELEMENT<First Abnormal Microal/Creat>.}
IF CLINICALELEMENT<First Abn 24 Hr Urine Protein> = "" {We
have no record of previous abnormal 24- hour urine protein values}
ELSE {IF PAT_SEX = "male" {His} ELSE {Her} first abnormal 24
hour urine protein value was CLINICALELEMENT<First Abn 24 Hr
Urine Protein>.}
IF CLINICALELEMENT<First Creatinine over 1.6> = "" {We have no
record of previous creatinine values over 1.6.} ELSE {The patient's
first serum creatinine value over 1.6 was CLINICALELEMENT<First
Creatinine over 1.6>.} ||
“Natural Language,” the way it
prints
Nephropathy:
Mickey's first abnormal
Microalbumin/Creatinine ratio was 146 on
05/17/2007. His first abnormal 24 hour
urine protein value was 2.5 grams in June,
2007.The patient's first serum creatinine
value over 1.6 was 1.8 in February 2005.
Most Recent Renal Values – the
Code
Most recent recorded renal values:
«del»|| LAB<MICROALB/CREAT>[-Date] || «*EditMicroal/Creat»
«del»|| LAB<24Hr Urine Protein>[-Date] || «*Edit24HrUrineProtein»
«del»|| LAB<PROTEIN-UA>[-Date] ||
«*EditProtein-UA»
«del»|| LAB<CREATININE>[-Date] ||
«*EditCreatinine»
|| IF LAB<Race> = "Black" or LAB<Race> = "Hsp-Black"
{LAB<eGFR(BLK)>[-Date] «*EditeGFR(BLK)»
ELSE
{ LAB<eGFR(NBLK)>[-Date] «*EditeGFR(NBLK)» } ||
«del»|| LAB<Dialysis>[-Date] ||
«*EditDialysis»
«del»|| LAB<*Nephrologist> ||
«*Edit*Nephrologist»
Recent Renal Values – How it
Looks
Current Diabetes Sx: the Code
«del»|| LAB<HypoglycemicEpisod>||
«*EditHypoglycemicEpisod»
«del»|| LAB<LowerExtrPains> ||
«*EditLowerExtrPains»
«del»|| LAB<LowerExtrNumbness>||
«*EditLowerExtrNumbness»
«del»|| LAB<Polyuria> ||
«*EditPolyuria»
«del»|| LAB<Polydipsia>] ||
«*EditPolydipsia»
«del»|| LAB<Blurred Vision> ||
«*EditBlurredVision»
«del»|| LAB<Early Satiety> ||
«*EditEarlySatiety»
«del»|| IF PAT_SEX = "male" {LAB<Erectile
Dysfunct>
«*EditErectileDysfunct»}||
Current Diabetes Sx: How it
Looks
HypoglycemicEpisod: frequent moderate
*EditHypoglycemicEpisod
LowerExtrPains: none
*EditLowerExtrPains
LowerExtrNumbness: none
*EditLowerExtrNumbness
Polyuria: none
*EditPolyuria
Polydipsia: none
*EditPolydipsia
Blurred Vision: none
*EditBlurredVision
Early Satiety: none
*EditEarlySatiety
Erectile Dysfunct: none
*EditErectileDysfunct
*EditHypoglycemicEpisod
After Clicking
EditHypoglycemicEpisodes
Current Status—using a table to
present past values – the code
How it shows in the template
What it shows the next time
Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Patient understanding and plan
• Blood glucose level where hypoglycemic Sx noted
– CLINICALELEMENT<Hypoglycemic Sx Level>
• Does the patient carry ID of diabetes?
– LAB<Carries DM ID?>
• Does the patient carry glucose?
– LAB<Carries Glucose?>
• Does the patient carry glucogon?
– LAB<Carries Glucogon?>
• Does the patient have a diabetes-aware buddy?
– LAB<BuddyAwareDMCare?>
• Who is the buddy?
– CLINICALELEMENT<Buddy Aware Hypoglycemic Care>
Patient understanding - code
Hypogylcemic Plan:
The patient notices the symptoms of low glucose when his glucose level is
less than ||CLINICALELEMENT<Hypoglycemic Sx Level>||.
«*EditHypoglycemicSxLevel»
|| IF PAT_SEX = "male" {He} ELSE {She} IF LAB<Carries DM ID?> = "yes"
{carries or wears identification that he has diabetes} ELSE {does not carry
or wear identification that he has diabetes} IF LAB<Carries Glucose?> =
"yes" {, carries glucose} IF LAB<Carries Glucagon?> = "yes" {, carries
glucagon}. || «*EditHypoglycemicPlan»
|| IF LAB<BuddyAwareDMCare?> = "yes" {The patient has people close to IF
PAT_SEX = "male" {him} ELSE {her} who are aware of the symptoms of
hypoglycemia and who know what to do to help, should he develop those
symptoms. These people are CLINICALELEMENT<Buddy Aware
Hypoglycemic Care>} ELSE {The patient does not have anyone close to IF
PAT_SEX = "male" {him} ELSE {her} who is aware of the symptoms of
hypoglycemia and who knows what to do to help, should he develop these
symptoms. IF PAT_SEX = "male" {He} ELSE {She} was advised to seek
out several people to assume this role.} || «*EditBuddyAwareHGCare»
Patient understanding – when
the template opens
History Section Templates
• Past Medical History
• Family History
• Social History
• How you set these up takes special
consideration, since this is a place where
you can store important data to be
imported into your notes
Hiding the Title of the History
Sections
• You can use the Special Features, tab
Records 2, to hide the title of the History
Sections
• Uncheck the “Include title when inserting
clinical data” box.
• This is useful if you want the title to print in
a different font or size than the rest of the
section
Hiding the title of the History
Section Templates
Make your own title
The “History” Quick Text
Past Medical History
• Surgeries: Approximate Date, perhaps the
location, perhaps who the surgeon was,
complications
• Medical Hospitalizations: Date, location,
outcome, who the physicians were, significant
procedures or tests done
• Psychiatric or Substance-related treatment
• Transfusions
• Significant past medical illnesses or
conditions
• Significant environmental exposures
Past Medical History
Uses
• This is a great place to enter, for example,
the details of a cardiac cath or bypass
surgery that will be important in the
patient’s future management.
• It might be a great place to put a
paragraph that updates the status of a
patient with Crohn’s disease or RA.
Past Medical History
Uses
• The point is that this section can be pulled
into your notes any time you want, can be
as large as you want, and can be
formatted however you like.
• You should update it regularly and be sure
to include the date of last update
Family History
• This can be a tremendous practice-builder and
patient relationship builder for anyone in primary
care. Lots of important social history included
here.
• Important to include:
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Date updated
Approximate ages of family members or age at death
Significant medical problems and health status
Names of children (tremendously helpful in primary
care), where they live, and what they do
Family History
Additional Information
• Status of parents, if elderly, quite
important – where they live, who checks
on them, what responsibilities the patient
has for their care.
• Number of grandchildren
• Which siblings live close, and which ones
are far away.
Saving Family History in Clinical
Elements
Clinical Elements for Family Hx
Clinical Elements for Family Hx
• || IF CLINICALELEMENT<FH Colon CA> = “” {We have no
information of a family history of colon cancer.}
ELSE
{IF CLINICALELEMENT<FH Colon CA> = “none” {The patient has
no known family history of colon cancer. }
ELSE { The patient has a positive family history of colon cancer in
IF PAT_SEX = “male” {his} ELSE {her} CLINICALELEMENT<FH
Colon CA>. }
} ||
Social History:
What makes the patient unique as a person
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Where were they born?
Where did they grow up?
Where do they live, and for how long?
Who do they live with?
How far did they go in school?
What is their family and marital status?
What is their occupation?
What do they do for fun?
What are their goals? (retire, move, etc?)
What unusual stresses are they experiencing?
Thank You for Coming
Questions, Demonstrations, Examples?
For early copies of this presentation, email
request to
[email protected]