so, it's come to this...

by Michael

Aug 30, 2012

Stupid EMR UI

To better deal with the stress of stupid UI design in EMRs, I'm going to share my pain with you.

Below is the pop up window that Nextgen shows when you are documenting the length of an office visit for billing purposes.

  1. Notice how the units of time are not labeled.1
  2. Notice how you are given the option of documenting office visits to the fraction of a minute. I don't think that even lawyers are greedy enough to charge for 0.25 of a minute.
  3. Notice the plus sign and minus sign. I'm still not sure what these are for. They are not for doing simple addition and subtraction. Hitting those changes the number to either positive or negative. Can you bill for negative minutes?
  4. Notice the options for 200-700 minute visits. Does anyone ever really see a patient in an outpatient clinic for 11 straight hours?

  1. Trial and error will show it is in minutes. ↩

Aug 29, 2012

Procedure note with TextExpander

I do a lot of joint injections so I created a TextExpander macro to quickly write a short procedure note within my visit note. I used TE 4.0 with the new options for fill ins. I have several optional sections that can expand the note depending on the type of injection I do, but at the same time, for the large majority of injections in which I'm not removing fluid or sending the results for testing1, the note is quickly and easily generated without template cruft.

  1. The pink highlighted text are optional sections that can be added by ticking the preceding checkbox.
  2. The amount of injected medication is pre-populated with my normal dosing but can be edited.
  3. The medication is also pre-populated but can be switched to any of the options available in my clinic.
  4. The lab section already has the two labs I always order, and I can easily add anything else that I need.
  5. There are a few pull-down menus in order to make sure the grammar is correct depending on if I'm injecting one or multiple joints.

Arthrocentesis are simple and straight forward procedures. I'm sure this technique would be even more useful in complicated procedures and operations.

The raw code

Procedure note
Informed consent and time out was completed. The %fill:area% %fillpopup:name=popup 8:was:were% prepped with betadine and alcohol in standard fashion. The skin was anesthetized with ethyl chloride. %fillpart:name=lidocaine%The subcutaneous tissues were anesthetized with less than 3ml of 2% lidocaine. %fillpartend%%fillpart:name=fluidRemoved%%fill:amount% ml of opaque yellow fluid with a positive string sign was removed. %fillpartend%%filltext:name=milligrams:default=40 mg:width=3% of %fillpopup:name=steroids:default=Depo-Medrol (methylprednisolone acetate):Kenalog (triamcinolone acetonide) :Synvisc One% and 2 ml of 2% lidocaine were injected into %fillpopup:name=grammar 10:the:each% joint. Hemostasis was obtained. Post op instructions were given. %fillpart:name=labTests%Fluid was sent for %fill:tests%cell count and crystal analysis.%fillpartend%

  1. Shame on you if you don't document what labs you order in the procedure note. ↩

Aug 25, 2012

Updated: Fixing shortcuts in Messages.app

Update

Make a new Keyboard Shortcut in the preferences menu so that "Close Conversation..." is ⌘-W. That will restore ⌘-⌫ to the correct "delete whole line functionality."

Original (August 6, 2012)

I like my keyboard shortcuts to be consistent across applications. Two shortcuts I use frequently ⌥-⌫ (option-delete) to erase the last word and ⌘-⌫ (command-delete) to erase the last line1.

Since upgrading to Mountain Lion, every time I hit ⌘-⌫ in the Messages app, I get a prompt asking if I want to delete the conversation. And every single time it's mentally jarring as normal, expected behavior elicits an unexpected and incorrect response. That shortcut is being used as a built-in for the app:

Wrong shortcut

A few minutes of searching the web led me to the universally accepted answer that "no, there is nothing you can do about it." Even a well written (I assume--tl;dr) piece by Gruber weren't promising.

So I took a chance and tried to change the shortcut by adding another shortcut on top of it in Keyboard Shortcuts in system preferences.

Changing the shortcut

I used ⌃⌥↩ because I can't see myself every using that shortcut. I can't explain why it seems to get duplicated and also show a new shortcut of ⌥⌘⌫. I did notice that when I went back and re-did this a few times (to take screenshots), I kept getting different duplications. One thing that seemed to be necessary is trying to first make the shortcut ⌃⌥⌫, which would make an error sound and not accept, then doing another one would lead to the desired results.

Changed shortcut

Clear as mud, I know.

  1. This is the case for Textedit, Pages, and Safari. I'm willing to bet it's the case for most native and third-party apps since I've never run across this frustration before. ↩

Aug 24, 2012

Weight loss plan

Intro

Every clinic day I see multiple people whom I have the unfortunate task of telling that their health problems are because of their weight. Most are already aware of their obesity and many have at least a notion that their weight is what is causing the specific reason they came into my clinic that day.

While there are thousands of diet books, exercise programs, research articles and poorly written editorials on the etiology of the problem and potential solutions, I have a limited amount of time to try to make a difference.

I need something short, memorable, and effective.

So this is what I tell patients:

The Plan

  1. Exercise is great and I certainly encourage it, but you won't lose any weight doing it, and you'll probably gain. Exercise if you want to, but that's not what we're going to concentrate on.
  2. I don't care how big your bones are or how slow your metabolism is, if you eat few enough calories you will lose weight. Fat is stored energy. Take in little enough energy into your system and you'll use up the stored energy.
  3. Weird diets are not sustainable. The social, economic and taste-preference factors in our life are way too powerful.
  4. Anything you drink that has calories, stop. Like Sprite? Drink diet Sprite. Like Coke? Drink Coke zero.
  5. Make the exact same food in the exact same way and portions that you always do. Then cut out a 10% pie slice of it off of your plate and throw it into the trash can before you start eating. Throw away the first 10% of your food at every meal.
  6. After 1 month, start throwing away 20% of your meal. Continue to throw away an additional 10% every month until you consistently are decreasing your weight.
  7. You will be hungry.

Benefits

  1. No more expensive than what you are already doing.
  2. Can continue to eat the same foods you already like and know how to make.
  3. The hungry pains are mild and you will have enough time to adapt.

Outro

I'm not sure how effective this is for other people. It's what I do and it works. I think we get "too smart by half" when it comes to weight loss with our modern vs. paleo vs. vegan vs. diet du jour theories.

Aug 23, 2012

Using Keyboard Maestro to log into Nextgen

It takes me about 45-60 seconds to log into my EMR due to human frailty, distractions and a shit EMR. To speed up the process, allow me to do other things with that time, and keep my anger in check, I set up Keyboard Maestro to login for me:

The video makes it look easy. In reality, due to vagaries of the Citrix Viewer and variable speed of the network1, I had to make a lot of Until loops to continue to check for the right window being ready and at the front before starting the next phase of the log in.

  1. At 6:30 am, the network is fast, but when everyone starts to log in at 8am, the thing slows to a crawl. ↩

Aug 22, 2012

We should not suffer bad EMRs

Dr. Richard Just clearly lays out a few of the problems that physicians are having with EMRs, but his apparent conclusion and the conclusion of the headline of the article are wrong.

He appears to think that while the current offering of EMRs are poor, we need to "suffer" through them.

Quite the opposite is true in fact. We should not support companies that make harmful products because of the promise that one day they will be beneficial any more than we would give a patient an experimental drug on the promise that one day the company will figure out a different drug that works.

False dichotomies are frequently raised in the discussion of EMRs. For example, unreadable handwritten progress notes are compared to legible electronic notes as an example of how EMR notes are better. However, we are all fully aware of the uselessness of many of the legible but copy-and-pasted notes1 in our medical era or the problems with notes "disappearing" as in Dr. Just's example. The fallacy is that notes have to be either in a certified EMR or handwritten.

In my hospital, hand-written progress notes are still the norm, but when I round, I type my notes into my laptop, using lots of custom macros and scripts to aide in the process, and put the printed note into the chart. It's certainly no Hitech, Cchit, MU EMR, but it is fast, reliable, secure, and legible. Even better, no note has ever magically disappeared because the vitals were not already entered.

As a nerd, programmer, and the one ultimately responsible for the safety of my patients, I declare that the EMRs I have been exposed to are unacceptable and at the same time that there are many electronic, technophilic ways to improve patient care.

I relish the day that I can purchase a quality EMR that makes my work better and my patient's healthier. Until that time, I will not waste money supporting shit but will continue to make my own tools.

Supporting bad products, bad technology companies, and bad med-tech policies, regulations, and laws only delay, and hopefully not destroy, the time when we will one day have something worthy of our profession. Your patients deserve better.

  1. Just yesterday, I saw a patient in consult in which every single physical exam for the last year documented "stippling in the back of the throat, with erythema and purulent exudate". ↩

Aug 19, 2012

Mou.app OS X

As a good nerd, I'm a big fan of Markdown and Dropbox. As a lazy nerd and a bit of a control freak, I love being able to blog directly from Dropbox with Scriptogram.

Recently, Mou.app was the first app to incorporate the ability to post directly from the app to Scriptogram and your Dropbox account.

Simply put, you get a simple plain text editor screen. You type your blog post and see the markup in a live preview window, then hit a keyboard command to to send the file to your Dropbox folder and to Scriptogram.

Those who already are familiar with Scriptogram will be happy to know that you don't have to go to the website to sync.

Mou is currently in beta and thus free to try. I've already donated $10 to the cause.

Aug 19, 2012

I have a dream

Last night I dreamt that Tim Cook hired me to help create an EMR that doesn't suck.

I need therapy.

Aug 17, 2012

Stupid billing situations #1

The bureaucracy and politics of modern healthcare is insane. Nothing illustrates this better than the Medicare-driven billing system.

Imagine a hypothetical situation:

A physician sees a new patient for worsening knee pain. After carefully reviewing her history, performing a detailed exam and reviewing prior labs and radiographs, he diagnoses her with osteoarthrosis of the knee. He then spend 25 minutes explaining what OA is, the risk factors, treatments and the importance of weight loss and exercise in the treatment plan, answering questions about diet and exercise. He starts her on an anti-inflammatory and prescribes physical therapy. He fills out a form she brought allowing her to start an exercise program at the local YMCA and writes a work excuse for her missing work for the appointment.

If the doctor spends a total of 60 minutes for this visit, he has to bill by the complexity of the medical decision making (MDM), which for the current problem, workup and treatment would be billed as a new patient, level 3, for a total work RVU of 1.42.

On the other hand, if he says he only saw the patient for 45 minutes, he can bill by time, which would be as a new patient, level 4, for a total work RVU of 2.43.

A sampling of local doctors gives me a range per RVU of 30-45 dollars.

So, by saying he spent 15 minutes less with the patient than he actually did, he can actually bill $30-45's more. Or he could actually spend 15 minutes less, see a follow up patient for the extra 15 minutes that he also bills by time, for an established level three for 0.97 wRVUs. He makes a total of $60-90/hour more by spending less time with the patients.

How the hell does this make any sense?

Aug 16, 2012

The day Twitter died

Brent Simmons:

Twitter may grow and grow and make fantastic amounts of money for a bunch of people. It may be around for decades.

But the nerd consensus that Twitter is deeply cool, that it’s the only game in town worth playing, is shot.