Transcription
McMaster EMRs forpediatric residentsV BelostotskyJuly 2019
EMRs (Electronic Medical Records) – Main players EPIC – www.epic.com Meditech – www.meditech.com Cerner – www.cerner.com
HHS – future Needs a modern comprehensive EMR system Currently is deciding whether: to go ahead with Meditech Expanse – implementation in 2021 or proceed with AFP process of competing vendors – implementation 2022 Meanwhile
All apps are accessed via Citrix platform
Once you log in, you will see something like this
Current systems used at McMaster Children’s Meditech – main platform (results, links to other apps) Patient Link (EPIC) – EMR platform for most ambulatory services Sovera – scanning software platform Order sets – Fillable PDFs for admissions and procedures Policy library – useful for medications, infusions Meditech ITS – transcription platform for physicians Clinical Connect – link to regional results and notes eCHN – link to Sick Kids pediatric database (results and notes) Service handover
Policy library
Type keyword and submitClick to openChoose pediatric monograph
Meditech Main platform Allows access to: Notes Lab results BiochemistryHematology: CBC, Coagulation, Blood BankMicrobiology (only place to see those at HHS)Pathology reports Radiology reports and images Current and previous medications Clinic schedules Links to: Epic for ambulatory notes Flowsheets for inpatient data Clinical Connect for external results
Access to notes/letters in Meditech Health records – dictated bylearners on the phone viatranscription service andtranscribed for physician’ssignatures Decentralized – dictated byphysicians and transcribed bydepartmental assistants Ambulatory – available throughPatient Link Viewer (next slide)
Using Meditech to access patient’s record Advantage Contains all MUMC notes and results overthe last 15 years Only place to see microbiology results Disadvantage Need to start Epic (Patient Link) viewerto see notes from recent ambulatory visits Dated interface Unable to do search within patient record
Access to current inpatient data
Patient Link (EPIC) System of Electronic Medical Records Started in HHS in 2016 for outpatient clinics All residents will be trained to use – 4 hours e-session at HGH
Epic Advantage Modern interfaceAllows easy searchUse of templates and smartphrasesUsed by Sick Kids and CHEO Disadvantage Does not display microbiology results Results and notes from 2014 only HHS version doesn’t have speech recognition module
Smartphrases – custom made blocks of text for easy reuse.PNEPNEPHROTICADVICE is:It was explained to parents today that 80-90% of patients will respond to treatmentwith high dose prednisone and will go into remission within a couple of weeks.However, some patients do not respond and will require investigation with renal biopsyto guide management. In addition it was discussed that up to 70% of children willrelapse and so monitoring urine for protein at home is important to detect a relapsequickly. Common side effects of prednisone were reviewed. The family also receivedteaching on how to check the urine at home for protein daily. The family was instructedto bring *** to the hospital should he develop fever or have chest pain, shortness ofbreath or signs of a blood clot such as warmth/swelling/pain in a limb. It was discussedwith family that children with nephrotic syndrome are at slight increase risk forinfection and clotting. The family was in agreement with plan of care and verbalizedunderstanding of teaching. *** is to fluid restrict to 800mls per day and follow a lowsalt diet (no more than 2 grams per day)
Smartphrases Creation istaught atmandatoryEpic accesscourse Tip sheets forSPHs andmany otheruseful tips areavailable onDashboard
Scheduling pageProvider specificscheduleDivision specificscheduleUse whenpatient isbooked under‘service’Content of StickyNote can only beseen by theprovider
Encounter page
Chart review page
Rooming pagePlease enterpast medical,surgical andfamily historyhere. Otherwiseit is not possibleto import it intonotes
Note in Epic - 3 parts Background information Entered by resident/nurse/physician at thefirst encounter For subsequent notes Pulled from the previous notes automatically Typed/dictated again (obviously not ideal) Exam and measurements Ht, Wt, BP, lab results etc can be pulled into template Entered into notes via Smart phrases Progress notes, assessment and plan Entered by physician/learner/nurse Entered into notes via Smart phrases
NoteClick here to selecta pre-made templateor start a blank noteClick here if you want tocopy previous note anduse it as a draft
Note made using a template Anything blue waspulled from somewhereelse (usually Rooming) Anything yellow means adrop down menu tochoose from The rest is free text totype in
Edit prepopulated textHighlight the text which you need to edit and Right clickThe menu box will appearChoose ‘Make Selected Text Editable’You can now edit/delete text
Why are Problem Lists important If physician writes a 5 page detailed note on a new patient butdoesn’t put highlights of this information in the Problem List then The notes for the next and subsequent clinics will not have theoriginal information and it will have to be manually duplicated fromthe first note or the whole original note has to be copied and thenedited If physician puts information in the ‘Overview’ of a Problem then itwill stay there and can go from the first to subsequent notesautomatically
Creating problem list1. Choose ‘Plan’2. Type problem andpress ‘Add’ thenchoose from the list
Overview of the problem1. Click on problem2. Click on overviewto write commentsProblem and Overview comments will be recorded in Epic and can be automatically transferred to subsequent notes.
Overview of the problem – completedIf the problem list isprogrammed into the clinictemplate, then the overviewof the problem automaticallygoes from the current noteto the next note.Standard questions can beconverted into smartphrase
Smart phrase for Hypertension history
Choosing the smartphrase for Problem Overview1.2.3.4.Click ‘Hypertension’Click ‘Overview’Type smartphrase namePress ‘Accept’
Overview of the problem – not completed
Overview of the problem – completedIf the problem list isprogrammed into the clinictemplate, then theoverview of the problemautomatically goes from thecurrent note to the nextnote.If it is not programmed thenone can use .proboverviewsmartphrase to addproblems with overviews tothe clinic note
Clinic note with problem list
How can learners get physician’ssmartphrases on their own Click ‘Personalize’ and choose ‘Mysmart phrases’Click on ‘Open’In opened window type the name of thephysician and press go
Acquiring smartphrase1. Choose smartphrase2. Click ‘Share’3. Click ‘Accept’
Choosing visit diagnosis from problem listClick this icon tomake particularproblem your visitdiagnosis.Green tick mark willappear.
Moving resolved problems to PMH1. The wheel appears when you put cursor to the right of the problem2. Select ‘Add to medical history’ from the drop down menu3. Then press ‘Resolve’
Steps summary Design/import from a colleague a smartphrase for a particularproblem Add problem to the Problem List in ‘Plan’ section In problem overview insert the required smartphrase Complete the gaps and save Choose visit diagnosis from the Problem List
Problem lists - summary Can be used to choose diagnosis for the visit When the problem is resolved, then it can be transferred to pastmedical history If the problem list is programmed into the clinic template, then theoverview of the problem automatically goes from current note to thenext note
Smart phrases – important points Users create them and can modify at any time They belong to Epic; ‘creator’ can share them with other users orother users in the same organisation can import one’s smart phraseswithout notification We are in the process of implementing the system when residentsrotating through our service import specific smart phrases beforetheir start day.
FlowsheetsCapture discreet dataCan be programmed in a user friendly wayShould be considered as a buildingtool if parameter is important forfuture data capturing or research
Note vs letter Epic interpretation of both terms is probably different to one’s currentpractice Note – medico-legal document summarizing patient encounter Letter – communication of relevant information to other providers Note can become letter with few clicks (as most services do) butusually contains a lot of information not important to the recipientand triggers complains from primary and secondary care providers
Standard outpatient encounter in our service Person who opens the note is the author of the note. Encounter provider andspecialty columns should be present in charts (IT sets it up) Nurses input vitals and review/input medications Residents/Staff put in histories and plans using pre-designed templates Staff physician reviews documentation and signs the note(it can still be edited after signing if needed and signed again) Staff physician creates the letter, chooses recipients and sends the letter Staff physician closes the encounter. Note can not be edited anymore butaddendums can be created at a later stage if needed
Chart Search Open patient’s chart Put the search word in the field Search engine will bring all the placeswhere this word is found: problemlists, notes, meds, labs etc
Keyboard shortcuts Many useful keyboard shortcuts to speed up work exist in Epic.Here are some examples: F1 – Open Help for the current activitySome are similar to MS-Word: CTRL C (copy text), CTRL V (insert text) etcCTRL SHIFT I – opens Patient instructions sectionCTRL SHIFT P – opens Problems list section Full document is available in tips
Viewing genetic results Open chart in Patient Link or Patient Link Viewer (via Meditech)Go to Media tab – all scanned documents are located thereArrange document types alphabetically if needed (click on Document type)Click on ‘Genetics results – Scan’ to open the result
Attaching article to the patient file Print out the articleAttach patient information label from clinic to the first page and send it to SoveraAfter few weeks select Media tab in ‘Chart Review’The article should be available under ‘Correspondence’ Document Type
Epic summary Save your time Design your own smart phrases Use search functionality Before each rotation Check service-specific Epic requirements on MacPeds Import relevant smart phrases
Epic Advantage Modern interface Allows easy search Use of templates and smartphrases Used by Sick Kids and CHEO Disadvantage Does not display microbiology results Results and notes from 201
