Advanced Template Design 2007 By Donald T. Stewart, MD FAAFP Don. S@Sammamish. Diabetes. And. Lipid. org 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 • • Physicians? Nurse Practitioners? PAs? MAs or Nurses? Practice “Tech” people? Mc. Kesson/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. Sammamish. Diabetes. And. Lipid. org – Or email me: (Don. S@Sammamish. Diabetes. And. Lipid. Org ) 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: Diabetes. Dx. Date: «DEL» would allow us to save something we could bring back later as: ||LAB<Diabetes. Dx. Date>||
Reusable Data Elements: Lab Data Elements (2) So, if you enter this in a template: . L: Diabetes. Dx. Date: «DEL» Summer 2006 It becomes this when recalled: Diabetes. Dx. Date: 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<Has. Diabetes> = “True” {The patient has diabetes. } ELSE {IF LAB<Has. Diabetes> = “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: Has. Diabetes: «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 Test 2 – 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 – Test 1 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: ||REFSRC 1_NAME_FIRST|| ||REFSRC 1_NAME_LAST||, ||REFSRC 1_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 Lu. Ann 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<Presentation 2 of Diabetes>|| • Initial fasting glucose – ||CLINICALELEMENT<Initial FBS Diabetes>|| • Initial random glucose – ||CLINICALELEMENT<Initial Random Glucose>|| • Initial Hgb. A 1 c – ||CLINICALELEMENT<Initial Hgb. A 1 c>||
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<Presentation 2 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 Hgb. A 1 c was CLINICALELEMENT<Initial Hgb. A 1 c>||.
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 Hgb. A 1 c 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, e. GFR • Eye Complications – Retinopathy, cataracts • Skin Ulcers – Location, infection present?
Neuropathy Code using Lab Data Values Neuropathy: «del» || LAB<Symet. Dist. Dysesthes> || «*Edit. Symet. Dist. Dysesthes» «del» || LAB<Mononeuropathy> || «*Edit. Mononeuropathy» «del» || LAB<Distal Numbness> || «*Edit. Distal. Numbness» «del» || LAB<Gastroparesis>|| «*Edit. Gastroparesis» «del» || LAB<Orthostatic Sx> || «*Edit. Orthostatic. Sx» «del» || LAB<Diarrhea> || «*Edit. Diarrhea»
Neuropathy-what you see in the template «del» Symet. Dist. Dysesthes: none «*Edit. Symet. Dist. Dysesthes» «del» Mononeuropathy: none «*Edit. Mononeuropathy» «del» Distal Numbness: none «*Edit. Distal. Numbness» «del» Gastroparesis: none «*Edit. Gastroparesis» «del» Orthostatic Sx: none «*Edit. Orthostatic. Sx» «del» Diarrhea: none «*Edit. Diarrhea»
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>|| «*Edit 1 st. Abn. Microal/Creat» ||CLINICALELEMENT<First Abn 24 Hr Urine Protein>|| «*Edit 1 st. Abn 24 Hr. Urine. Protein» ||CLINICALELEMENT<First Creatinine over 1. 6>|| «*Edit 1 st. Creatinine. Over 1. 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] || «*Edit. Microal/Creat» «del» || LAB<24 Hr Urine Protein>[-Date] || «*Edit 24 Hr. Urine. Protein» «del» || LAB<PROTEIN-UA>[-Date] || «*Edit. Protein-UA» «del» || LAB<CREATININE>[-Date] || «*Edit. Creatinine» || IF LAB<Race> = "Black" or LAB<Race> = "Hsp-Black" {LAB<e. GFR(BLK)>[-Date] «*Edite. GFR(BLK)» ELSE { LAB<e. GFR(NBLK)>[-Date] «*Edite. GFR(NBLK)» } || «del» || LAB<Dialysis>[-Date] || «*Edit. Dialysis» «del» || LAB<*Nephrologist> || «*Edit*Nephrologist»
Recent Renal Values – How it Looks
Current Diabetes Sx: the Code «del» || LAB<Hypoglycemic. Episod>|| «*Edit. Hypoglycemic. Episod» «del» || LAB<Lower. Extr. Pains> || «*Edit. Lower. Extr. Pains» «del» || LAB<Lower. Extr. Numbness>|| «*Edit. Lower. Extr. Numbness» «del» || LAB<Polyuria> || «*Edit. Polyuria» «del» || LAB<Polydipsia>] || «*Edit. Polydipsia» «del» || LAB<Blurred Vision> || «*Edit. Blurred. Vision» «del» || LAB<Early Satiety> || «*Edit. Early. Satiety» «del» || IF PAT_SEX = "male" {LAB<Erectile Dysfunct> «*Edit. Erectile. Dysfunct» }||
Current Diabetes Sx: How it Looks Hypoglycemic. Episod: frequent moderate *Edit. Hypoglycemic. Episod Lower. Extr. Pains: none *Edit. Lower. Extr. Pains Lower. Extr. Numbness: none *Edit. Lower. Extr. Numbness Polyuria: none *Edit. Polyuria Polydipsia: none *Edit. Polydipsia Blurred Vision: none *Edit. Blurred. Vision Early Satiety: none *Edit. Early. Satiety Erectile Dysfunct: none *Edit. Erectile. Dysfunct
*Edit. Hypoglycemic. Episod
After Clicking Edit. Hypoglycemic. Episodes
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<Buddy. Aware. DMCare? > • 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>||. «*Edit. Hypoglycemic. Sx. Level» || 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}. || «*Edit. Hypoglycemic. Plan» || IF LAB<Buddy. Aware. DMCare? > = "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. } || «*Edit. Buddy. Aware. HGCare»
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: – – 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 • • • 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 Don. S@Sammamish. Diabetes. And. Lipid. Org
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