Technically, this article is about installing virtual Windows machines for free on your Mac so you can use PACS rather than about how to use PACS on a Mac, because, as far as I know, you can't.

A colleague uses a Macbook Air at work except the hospitals imaging system uses PACS with some unfortunate software requirements:

1. Internet Explorer 6.0, 7.0, or 8.0
2. Windows XP (Service Pack 3) or Windows Vista Home Premium or Windows Vista Business 64 bit or Windows 7 32 and 64 bit
3. Windows 3.1 Installer
4. Microsoft .NET Framework 3.5 (Service Pack 1)
5. Windows Media Player 11.0

This made him sad because he also had to carry around a crappy Windows machine.

Thankfully, we were able to easily solve his problem today.¹

The technique we used came from a 2 year old article from OSXDaily. It uses VirtualBox from Oracle to create a virtual machine and then load a free version of Windows XP for the purposes of testing IE.

The technique is really pretty simple, although you need to not fear the terminal.

First, download and install Virtual Box.

Second, go to the terminal² and paste one of the following depending on the version of Internet Explorer you need:

• Internet Explorer 7

curl -s https://raw.github.com/xdissent/ievms/master/ievms.sh | IEVMS_VERSIONS="7" bash

• Internet Explorer 8

curl -s https://raw.github.com/xdissent/ievms/master/ievms.sh | IEVMS_VERSIONS="8" bash

• Internet Explorer 9

curl -s https://raw.github.com/xdissent/ievms/master/ievms.sh | IEVMS_VERSIONS="9" bash

In everything goes well, this will install the Windows operating system needed and the version of IE as well.

Finally, run the application VirtualBox and you'll be able to boot up the Windows virtual machine.

If you have trouble doing that there are several more resources that can help:

• Microsoft's virtualization website. You can pick from Windows XP, Vista, 7, and 8.

• Chris Warton's blog. Has some tips on installing one of the above Windowns virtual machines into Virtual Box.

• Greg Thornton's Github repository for automatic installation of Window's VMs. Has more detailed instructions.

Let me know if this works for your and allows you to use PACS on your Mac. I'd be interested to know how much this is effecting physicians.

The workflow is straight forward and assumes that you are reading a website in Safari and have already copied the quote you want to the clipboard:

1. You are prompted for an attribution (either the author or the website you're quoting), the title of your post which will also be used as the url of your post and part of the file name, tags (optional), and comments (optional).
2. The url of the frontmost tab in Safari is saved as a variable.
3. Text is written to a file.

Only three steps. The real power is in what text is written to a file and the name of the file.

The text is just the boilerplate of a Scriptogram blog post with variables to fill in the data.

Title: %Variable%Post Title%
Date: %ICUDateTime%yyyy-M-d HH:mm%
Link: %Variable%currentURL%
Tags: %Variable%Tags%

[%Variable%Attribution%](%Variable%currentURL%):

> %CurrentClipboard%

%Variable%Comments%

The text is written to a new file each time as long as the date and post title are unique. I like my file name to consist of the date and the post title as follows:

/Users/michael/Dropbox/Apps/scriptogram/posts/%ICUDateTime%yyyy-M-d% %Variable%Post Title%.md

Took me all of 5-10 minutes. I surprised myself getting the whole thing correct on the first try. Typically it takes me half an hour to get the format of the macro set up and another 2 hours debugging it.

Google is the company that built Android after the iPhone, Google Plus after Facebook, and now a subscription music service after Spotify. They entered the RSS reader market, wiped it out, and are now just walking away from it.

It is the "walking away" part I need to remember so I don't end up relying too heavily on their services or sink too much time and data into their silos.

Thankfully, it's not very difficult to restore this functionality.

1. On your iPhone, create a bookmark of this page.
2. Copy the following text to your clipboard:

javascript:(function(){

function allowTextSelection(){
  var styles='*,p,div{user-select:text !important;-moz-user-select:text !important;-webkit-user-select:text !important;}';
  jQuery('head').append(jQuery('<style />').html(styles));
  
  window.console&&console.log('allowTextSelection');
  var allowNormal = function(){
    return true;
  };
  window.console&&console.log('Elements unbound: '+
    jQuery('*[onselectstart], *[ondragstart], *[oncontextmenu], #songLyricsDiv'
    ).unbind('contextmenu').unbind('selectstart').unbind('dragstart'
    ).unbind('mousedown').unbind('mouseup').unbind('click'
    ).attr('onselectstart',allowNormal).attr('oncontextmenu',allowNormal
    ).attr('ondragstart',allowNormal).size());
}

function allowTextSelectionWhenPossible() {
  window.console&&console.log('allowTextSelectionWhenPossible');
  if(window.jQuery){
    window.console&&console.log('jQuery has now loaded');
    allowTextSelection();
  } else {
    window.console&&console.log('jQuery still not loaded.');
    window.setTimeout(allowTextSelectionWhenPossible, 100);
  }
}

if(window.jQuery) {
    window.console&&console.log('jQuery exists; will use');
  allowTextSelection();
}else{
  window.console&&console.log('jQuery not loaded; will include.');
  var s=document.createElement('script');
  s.setAttribute('src','http://code.jquery.com/jquery-1.9.1.min.js');
  document.getElementsByTagName('body')[0].appendChild(s);
  allowTextSelectionWhenPossible();
}


})();  

1. Go to the bookmark menu in Safari, find the bookmark you just created, and hit edit.
2. Replace the URL with the clipboard contents.
3. Go to Uptodate or any website that blocks copying.
4. While on that page, hit the bookmark, and functionality should return.

Credit: I got the JavaScript above from Alan Hogan.

Yea, though I walk through the valley of crappy medical forms,
I will fear no .docx: For PDFpen Pro art with me;
Thy "create form fields" command, it comforts me.
Thou preparest a Dropbox folder before me in the presence of all my devices;
Thou annointest my terminal with bash; My stack doesn't overflow.

Surely TextExpander and Keyboard Maestro shall power all the shortcuts of my workflow,
and I will compute in the House of the Mac forever.

As an open, universally used EMR data standard does not exist, created my own system that I'd like to share with you. It is based on a set of principles that I've adopted from other modern, technological principles.

Principles

1. Data must be easily entered at the point of care.
2. Data must remain in the possession of the physician.
3. Data must be protected from becoming unreadable due to expired proprietary formatting.
4. Data must be encrypted.
5. Data must be rapidly accessible both locally and remotely.
6. Data must be easily searchable from outside the files proper.
7. Data must be easily displayed in a aesthetically pleasing format that can be changed in time.¹

Hardware

Buy an 11 inch Macbook Air and turn on File Vault (full disk encryption) in the system preferences.

Solution - Software

Write your notes into a plain text editor, using a text macro application, and save them as plain text files into one folder.

The Painful Part - Putting Your note in Their chart

Your note saved in your records needs to be placed in the clinic or hospital records that the patient is at. If they have an EMR, just copy and paste the note into their application. If it is a paper chart, print it out.

Security

Maintain physical security over your laptop. It must always be in your possession or locked up in a safe or office that no one else (including janitors) have access to. The easiest system it to just keep your computer on you always, or locked in a safe at home.

Make a strong password. At least 8 characters, capital and lowercase letters, numbers, and symptoms. Make it some kind of phrase that it easy to remember and type. E.g. Caesar?:ettu,Brute²

Backups

Make clone back ups of your machine. Make multiple copies of your back ups. Encrypt them. Keep them locked up. You can even make a USB necklace with all the notes on them.³

Search

Use Spotlight or the powerful search feature of TextWrangler to rapidly search through all your notes when you need to find something like "all your patients with psoriatic arthritis on azathioprine" or "all the consults sent to me by Dr. so-and-so".

Formatting

Formatting is really not necessary but if you want to print out pretty notes or add letterhead to your faxed PDFs, you can use the Markdown format when writing your notes and the Marked application for creating pretty PDFs with custom CSS formatting.

Conclusion

In the end, you have an accurate, fast, reliable, secure, and searchable record system. It's relatively cheap with the only significant cost being the hardware. You can use it across multiple clinics and hospitals using different medical record systems while maintaining a single unified records system on all your patients.

Future

I hope we don't have to wait long until we do have cross platform, open EMR records. Until then, I think this is the best solution for physicians who have a modicum of nerd power.

Read the full 6000 work original post from which this abbreviated version was created.

Over my time as a fellow and a private practice physician, I've created what I consider a relatively elegant and easy system for moderately skilled tech-nerd physicians to create, store, retrieve and disseminate their documentation and I'd like to share a small part of it with you.

I didn't mean this post to become as long as it had. I tried to keep it short by leaving out most of the specifics, potential pitfalls, and alternatives. I failed. So I've created a "too long: didn't/don't read" (TL;DR) version that is both interspersed throughout the text below or available as a separate post.

Introduction

Data is important.

Data fails when it is inaccurate or inaccessible.

Paper charts and modern EMRs excel at failing in both of these areas.

Physicians need a better way to manage their clinical notes than is afforded by the software tools they are issued and most clinics and hospitals.

Inaccurate

TL: DR: Boilerplate templates and copy-and-paste (CAP) have resulted in voluminous, inaccurate notes. Poorly designed software that inhibits data entry encourages the use of these templates and copy-and-pasted inaccuracies. This also inhibits entering all the pertinent data so that data is lost due to lack of documentation.

The perils of modern EMR documentation are well described in the literature. Most of the inaccuracies are created because of a combination of pressure to document unnecessary data in conjunction with the power to easily create this unnecessary documentation by templates or copy-and-paste.

Daily, I see patients in consultation for very specific joint symptoms in which the prior notes have a well documented, template-created, ENT exam but no joint exam.¹

I saw one patient whose initial visit to his PCP was for a sore throat and the exam dutifully noted pharyngeal erythema and tonsilar exudate, as did every subsequent exam for the next 2 years. Either it was the longest lasting case of strep throat in the history of medicine or the data was inaccurate.

All physicians know that a detailed, page long list of negative symptoms is most likely to mean the ROS was never done rather than that it was done completely.

And yet, sadly, this data stands as canon in the indelible, idealized EMR.

When you can't even look at your own notes from a year ago and trust in their accuracy, you're lost.

Another part of the reason that the data is inaccurate is because of numerous barriers to data entry. In a finite amount of time, I will have to document less if I use a feather quill than if I use a ballpoint pen. The same is true with computers. If the software is poorly designed requiring multiple screens, menus, pop ups, check boxes, and radial dialogue boxes, then the data will be incomplete or less accurate because it could not be entered frictionlessly.

It seems clear to me that no one who has ever created the UI of an EMR has actually had to use it to document multiple encounters in a busy clinical practice. This may explain why those physicians who frequently praise their EMR are either academics whose residents are writing their notes, or have paid underlings entering most of the data.²

Inaccessibility

TL:DR: Modern EMRs, paper charts, changing jobs, network outages, server crashes, and outdated/unsupported data formats all conspire to keep you from accessing the data you created and need to take care of your patients.

Physicians spend a large amount of their time documenting the clinical history and exam; the interpretation of the combined history, exam, labs, imaging, and pathology; and treatments (and most importantly) the response to treatments over time. This historical knowledge is priceless and yet too often is neglected.

As physicians spend so much time creating this record and since it is so important to providing the best possible care, you would think we would guard this record religiously and yet I would assume that most physicians have no ownership over their work product. It is a common theme in the internet nerd community that one should own their data so that if you decide to stop using a company or the company shuts down, you have not lost your data. How much more important are our clinic notes than some Instagram photos or blog posts about your latests cooking experiment?

Notes can be inaccessible to the physician who created them for many reasons but primarily due to no longer working at the facility where they created the not or just not having remote³ access.

Notes are written in one practice but when the physician leaves he doesn't take the notes with him. In the days of paper charts, this might have been an unfortunate necessity but in the digital age the entire record could fit on a thumb drive.

Notes are written in the hospital on rounds. The notes stay in the hospital chart, completely inaccessible to the individual physicians's clinic EMR.

Not long ago a colleague left the state. I inherited many of his patients. I was completely unable to get records. He no longer had them as having left them with the clinic when he moved. The hospital owned clinic was shut down. The hospital medical records department had no idea where they might be and seemed insulted that I would even ask them the question as their mandate ended at the hospital doors. All that knowledge and work was lost.

Next, records can be inaccessible because they are locally stored but you are remote, or because they are remotely stored, "in the cloud" in today's parlance, but the internet/server/power is down. Local data is fast, while remote data is slow. Remote data can be ubiquitous, while local data isn't.

Finally, data can become inaccessible due to proprietary data formats. Again, it is well documented that many EMRs create lock-in with their proprietary data format. Even if you can someone get that data out, it is unlikely that the data will survive future advances in technology. Simply put, I cannot read documents I created with word processors from the early 1990s, where as I can still read hand written notes from the same time. Data needs to be in some kind of common, non-proprietary, future-proof format.

Solution preamble

This is not a best practices solution.

This is not an ideal solution.

This is a practical, this-is-the-world-I'm-living-in solution.

It is based on principles that are unchanging but is created with tools that are constantly changing and therefore it adopts to the tools.

It is not a complete EMR. It is a note taking system that I use that is powerful, practical, and functional within the confines of the modern medical system. I certainly wish there was a feature complete, powerful, EMR that allowed me to own my data and accurately input my notes with the benefits of remote and local storage combined. There is not.

It is not likely to be useful as-is for most physicians, but those with a modicum of technical knowledge should be able to easily adapt it or it's principles to their own system.

Principles

1. Data must be easily entered at the point of care.
2. Data must remain in the possession of the physician.
3. Data must be protected from becoming unreadable due to expired proprietary formatting.
4. Data must be encrypted.
5. Data must be rapidly accessible both locally and remotely.
6. Data must be easily searchable from outside the files proper.
7. Data must be easily displayed in a aesthetically pleasing format that can be changed in time.⁴

Solution - Hardware

TL:DR: Buy an 11 inch Macbook Air and turn on File Vault in the system preferences.

Although the software is probably the most important part of my system, everything starts with the hardware. Hospitals and large medical clinics typically buy cheap Dell computers running Windows. This inevitably leads to slow, uncustomizable, one-size-fits-no-one machines running outdated software, bogged down by bloatware and viruses.

My weapon of choice is a Macbook Air. Apple computers are considered more expensive, but comparing equivalent models, are equal or cheaper than a similarly powered machine from another company. SSD drives are ridiculously faster than the traditional HDD. The Macbook Air⁵ is light enough to be easily carried around a clinic or hospital and small enough to type with on your lap or throw on any counter, exam table, or chair. The size also means that I can easily take it with me anywhere resulting in physical security of my files, part of the HIPAA requirement. While $1000 may be expensive compared to cheap Windows laptops, it's cheaper than any board test I ever took and for something I use 8-12 hours a day, seems like a bargain to me.

The operating system for a new Macbook Air is OS X 10.8 or "Mountain Lion". This operating system has built-in full disk encryption. While benchmark tests will show that this slows down the speed of the machine (as the CPU has to decrypt and re-encrypt your data on the fly as you open and change files) in clinical practice you will never notice. Having all my files encrypted provides security to my patient's data and has frequently shut down any complaints from CMIOs that I'm using my personal hardware in the clinic. This disk encryption is part of keeping your patient records safe and HIPAA compliant and most clinics and hospitals have yet to comply with this kind of security. When my last clinic decided to implement disk encryption on numerous Windows machines from Dell and HP running various OS's and with standard HDDs it was a nightmare. Nurses were locked out of computers for days and a drastic decrease in speed was noted immediately. In OS X you just need to flip a switch.⁶

If you want, you can get an external monitor, keyboard, and mouse to use when not mobile. My colleague does this. My wife and I do not.

Solution - Software

TL:DR: Write your notes into a plain text editor, using a text macro application, and save them as plain text files into one folder.

Now that I have the hardware, the next question is what to use to create the note.

Short answer: Anything but the EMR.

Longer answer: EMRs seem almost deliberately designed to be impossible to create notes with easily. They also typically store the data in proprietary formats and the data is usually locked into the EMR. So don't use it. Yes, in a sense this creates more work, but I argue you'll save time in other ways and with the benefit of owning your data.

I advocate you write your notes in plain text. Plain text is praised by programmers and nerds of every walk of life from lawyers to physicians because it is "open", non-proprietary, future-proof, easily encryptable, easily compressible, and results in small file sizes.

Plain text can be written in any text editor. You can even write in word processors like Word or Pages, but I strongly recommend against it. All computers come with a text editor like TextEdit on the Mac and there are many different free and cheap text editors available. Byword, IA Writer, Multimarkdown Composer⁷, TextWrangler, and Textmate are just a few that I own and use based on my whim and mood. The great thing about plain text is that it does not have any formatting that locks it into one application.⁸ So if you create a months worth of notes in Byword and then decide to start using IA Writer because of its cute blue cursor, you don't have to change anything about your data.

Your text editor will present you with one big text field that you can type or dictate into. No modal boxes. No pull down menus. No changing from screen to screen just to document different parts of the HPI.

I save each clinic, phone, and hospital note as a separate text document in one large folder called "patient notes"⁹.

Of course, a large empty sheet can be intimidating and also somewhat slow. You don't want to have to type out your headers and other boilerplate every time. For example, you don't want to type out the name and date yourself each time you create a note, do you? So you need a text macro program. I've written about these before and there are plenty of others who have as well. Anything you are going to type over and over should be automated¹⁰.

I use TextExpander and you can read my many posts on it or search the web for other's articles. Basically, get a text macro program and learn how to use it. Don't create all your macros at once. Build them up slowly and organically over time as you need them. It will take awhile, but your speed and accuracy in documentation will be impressive. In time, you will go from macros that turn .hum into adalimumab (Humira) to macros that turn .mtx1 into Rx: start methotrexate 2.5mg, take 15mg (6 pills) every 7 days, #30, refill 1 and eventually into macros that turn .ddxcie into

Differential diagnosis of chronic inflammatory effusion/monoarthritis

1. Mycobacterial infection  
2. Fungal infection
3. Lyme arthritis  
4. Monoarticular presentation of rheumatoid arthritis  
5. Seronegative spondyloarthropathies  
6. Sarcoid arthritis   
7. Foreign-body synovitis  

Consider ordering: CCP, RF, TB (quantiferon), ACE level, fungal cultures and smear, mycobacterial cultures and smear, Lyme serum, Lyme PCR joint, MRI, HLA-B27, ophthalmology consult, and/or CXR if not already complete.

Some EMRs¹¹ have macro functionality built in but that is limited to the program and the confines/rules of the program. By using a separate application that functions on top of the underlying applications you can use the same macros anywhere. So, if I get an curbside consult email from a family physician asking about what they should be considering in a patient with a chronic inflammatory effusion of the right knee, I can actually type 7 characters and hit send.¹²

I have a friend who has created amazing macros for things like the NIH stroke scale and a complete neurological physical exam that not only allows him to quickly document those items, but also serves as a kind of checklist to remind him not to skip anything.

I use it for everything from commonly misspelled works, to entire paragraphs of patient education, to plans of care, to templated procedure notes, to macros that calculate and type the patient's age when I type the patients date of birth into the note.

Other Examples:

• .dxra = Rheumatoid arthritis (714.0)
• HepB/C = hepatitis B surface antigen, hepatitis C antibody
• .posana = A positive ANA does not diagnose an autoimmune disease nor does a negative result exclude it; however, ANA is positive in 99% of patients with Systemic Lupus Erythematosus therefore a negative result strongly argues against such a diagnosis.  ANA can be positive by definition in 5% of the healthy population, typically in titers less than 1:320.  Up to 20% of healthy relatives of patients with rheumatic disease and up to 75% of healthy individuals older than 70 will have a positive ANA (typically less than 1:80 with a speckled or homogenous pattern).  Other conditions associated with a positive ANA are thyroid disease, chronic infections including TB/viral hepatitis, subacute bacterial endocarditis, malignancies, any of the auto-immune or connective tissue disease, multiple sclerosis and patients with silicone breast implants.  In the absence of physical or biochemical evidence of pathology, a positive ANA is not clinically useful.

One type of macro I use constantly is one that changes any medicine abbreviations like LEF into the full generic and brand name: leflunomide (Arava). This creates an extra level of education and safety for other physicians who may not be as familiar with our specialities medicines and also for the patient, who may know their drug by it's generic name "Avara" while I type LEF or leflunomide. I frequently give my patient's their notes or at least the assessment and plan at the end of each visit so having this clarity built in without any extra work on my part is important.

The Painful Part - Putting Your note in Their chart

TL:DR: Your note saved in your records needs to be placed in the clinic or hospital records that the patient is at. If they have an EMR, just copy and paste the note into their application. If it is a paper chart, print it out.

So, you have your note. Now what? This depends on the medical record system for your hospital or clinic, but with one commonality: it will be ugly, slow, inelegant, and painful. You have to put your note into the medical records of the clinic or hospital in which you're seeing the patient. EMRs are not open and do not use common data formats even between the same EMR at different hospitals. Paper charts are still used widely in most hospitals in the country. There's just no getting around this no matter what you do. If you want to keep your data and want to benefit from the legibility and speed of typed text on your own machine, you just have to put up with it.

At my last job the clinic had an EMR and the hospital used paper charts. It is likely that you have a similar situation.

EMR Charts

In my EMR and in whatever EMR you are likely to be using, you will need to copy and paste the text into the EMR. In EMR's that have a large open text field like CPRS this is relatively easy. In complicated EMRs like NextGen, you'll have to find a free text dialogue box and paste it in there before "generating" the note. There may be issues with poor line formatting but there are ways around this.¹³

Frankly, I have to force myself not to care about the formatting of my notes in the EMR because those who make them and those who buy them just don't care and I would waste hours of my time trying to make them look good. I just copy-and-paste, close my eyes, and hit submit. I have to console myself that the note in my system and the note I send out to the physicians consulting me looks like I actually care.¹⁴

Paper Charts

When at a clinic or hospital with a paper chart, I carry a small, retractable universal printer cord with me that I can plug it into the back of the networked printers at the nursing stations and just printing my note to place in the chart.

Solution - Backup and Security

These are your notes. These are your patient's notes. They are gold and they are poison. You absolutely cannot afford to lose them to theft or to data lose both because of the loss of such valuable information and also due to potentially severe financial penalties from violating patient privacy laws. Your back ups and your security must be strong and usable (read: easy).

Security

First, you must maintain physical security. This means the computer you use and any back ups you have must be physically protected. You don't leave your computer unattended in your office. You don't leave your back ups in your unlocked office on your desk.

My computer is on me 90% of the time during normal life, and when it is not, it is locked up. My backups are also either on my person or locked away in a hidden location. Use both physical security and security by obscurity.

Second, you must have a strong password to lock your machine. It should be easy to remember and easy to type but it also needs to be long ¹⁵ and not simple words. iloveyou, password, 1234567, qwerty, asdfjkl; and temporary are not secure passwords. Use 3-4 words you can easily remember but aren't easily associated with you (kids and pets names are bad), substitute a few characters here and there, and that should be good enough in most cases. A good one might be something like Caesar?:ettu,Brute¹⁶.

Third, your data should be encrypted. This can be really complicated and painful to do. But you bought a Macbook Air and turned on File Vault, right? Ok, moving on.

Finally, your remote data must also be transmitted and physically stored securely. If you're using a public company then I would say to be safe you need to have a HIPAA (I think the fancy acronym for this is BAA.) agreement in place with them and they need to promise that they are following HIPAA compliant practices. Most services such as Dropbox, do not. ;-(

Thankfully, there is a new product (and more on the way) that provides remote, encrypted data in a Dropbox-style fashion for a reasonable price: Transporter. You can plug their device into your own networks (that should be physically and electronically secured) and it creates a Dropbox-style folder on your machine giving you the power of Dropbox (both remote and local data synchronization) without the messy business agreements and monthly cost. I have not implemented this into my workflow yet, but will in the next two months. I plan on having one at my clinic and one at home providing cloud storage and back up while maintaining a local copy as well.

Backup

There are many articles out there on the importance of backing up your data. Google them. Read them. Do them.

I make multiple clone back ups of my computer which includes my patient notes. I keep one copy on me and I keep two other copies locked in fire proof safes. It's really not that hard and it is your responsibility.

You can also set up a remote backup/storage using something like the Transporter mentioned above.

Finally, text files are so small, you can even easily keep a copy of them on an encrypted USB drive you wear around your neck on a chain.¹⁷ Now that's dedication.

Backup up my data is just a part of my day. I'd sooner leave my door unlocked then not backing up my files.

So that covers principles 1-5 that I [enumerated above][Principles], leaving only search and formatting.

Solution - Search

Use Spotlight or the powerful search functions in applications like TextWrangler to search quickly and easily in all your notes at once.

Google redefined the power of search in our minds, first with ability to easily search the entire internet and then the ability to search your mail, your desktop, and all your files. Rather than having to store files/emails in complicated, sub-nested folders, you just type a few words that you expect to find in the file/email and instantly see all the matching results.

Mac's¹⁸ have full, in-file text search built into the operating system. It's called Spotlight and you can bring it up easily by hitting ⌘-spacebar or clicking on the magnifying class icon in the upper right of your screen. This is the fastest way to search your files. If you need a bit more power and fine-tuning use Spotlight the Finder (option-command-spacebar).

Just today a colleague asked me how many patients with psoriatic arthritis I have that are on azathioprine (Imuran). I didn't think I had any, but I checked and by typing the following characters and nothing else, I brought up the 4 notes on one patient in which I did: ⌘-spacebar .psa .aza.

Although I'm told that this is possible in some EMRs such as ***, it was not possible on the EMRs I've used in the past including NextGen, Epic, CPRS, and IPR.

Another example of this power is when another specialist approached me recently to ask about a patient he sent me. He couldn't remember their name and actually thought I probably hadn't seen the patient yet. By searching for consults ordered by this physician, I was able to pull up the consult note before he'd even finished speaking, and tell him my findings.

And I use this search functionally all the time. Whenever my nurse mentions a patient to me, my reflexes kick in and I quickly have their last clinic note open, and a new note created and ready for me to document whatever we're about to talk about.

It is about uniquitous access to information and easy, rapid creating of new data. I've never read GTD, but I wouldn't be afraid to show my system to David Allen.

Formatting

TL:DR: Adding formatting takes some more work and nerdery that you may want. If so, just write in plain text—it's fine. If you do want to be fancy then learn Markdown and CSS.

By it's very nature and what makes it useful for this kind of system, plain text does not have any formatting but there there are times when you may want some formatting. This is why many people when they write papers will use something like Word so they can add strange fonts, weird colors, or pictures. I was tempted to the dark side at one point because I wanted to have my letterhead in the header of the document. This is easiest with a word processor program but can still be accomplished with some nerdery.

I write my notes in a style called Markdown. Markdown allows you to write in plain text but add some extra characters that allow the plain text to be converted to a formatted style like HTML, while still maintaining readability in the plain text.

Confused? Me too at first, so here's an example.

If I want to bold something, I just put two asterisks on either side of the words **like this**. When you read it in plain text it "looks" bold or emphasized, right? Markdown also includes formatting for _italics_, headers, numbered lists, bullet lists, and links.

I then use an application called Marked which will take my text notes and display/save/print them with the Markdown formatting as well as with any other formatting I've created as a template using CSS. When I'm going to print a copy of my note for the patient or the referring physician, or when I'm going to archive it as a PDF¹⁹ I run it through Marked to get the final document.

This allows me to take a note that looks like what is on the left and print a note that looks like what you see on the right.

When I change clinics (new letterhead) or change moods (different font) or get older (bigger font), I can just change one CSS file rather than having to change every old note.

This last step is a bit more complicated and requires more educational investment that most will want to do. It's ok. You can still make great looking notes just using plain text formatting either with or without Markdown. Other possibilities are to use ALL CAPS for your headers, or to just print your notes out on a printer that is loaded with your office's letterhead.

Conclusion

What I have is an accurate, fast, reliable, secure, and searchable record system for every patient I've ever seen. The cost of the hardware is significant, but relatively not that expensive²⁰ and something I would buy anyway even if I wasn't a physician. The cost of the software can range from free to less than 100 USD. The skills necessary to use this system seem minimal to me, but being a tech nerd, I recognized that my opinion may be heavily biased. You will likely need to be able to type fast or have good dictation software. You will need to be comfortable around computers, which for our eminent members is likely not a given, but will certainly be standard for our new initiates. The more "advanced" features like Markdown and CSS, really aren't that difficult compared to memorizing the Kreb cycle or knowing when to appropriately order an ANA.

Future

I didn't create this system because I think I'm the smartest guy out there. I created it because I needed something that worked and everything I've used since I started my medical education²¹ has been truly atrocious to the point that even John Gruber took notice.

I truly hope that someday a system is created that works wonderfully and follows the principles I've listed above. At a minimum, I hope that a system is created that is so wonderful and powerful that I am willing to compromise on those principles in order to use it as it will mean a vast improvement in the care of patients and in the work burden of all physicians.

When I was in medical school, they issued the student's Sony Cliés¹. It was an awesome little device for the time and I took a lot of notes on it while on rounds. Sadly, a few years later, I was unable to read the files when the Clié finally died and I was unable to read the files with any of the software on my computers.

Since then, I've been an advocate for plain text file. Plain text does not use any strange or proprietary formatting so the files can be read on any platform and in any app. The data is about as future-proof as you can get.

There are many other benefits to plain text as well.

Although I use many apps on many devices to read my plain text files, my favorite by far is nvALT. It is fast, responsive, intuitive, and created by a programmer I highly respect. Unfortunately, it is free, but you can donate money like I did to support its continued development.

Today I found another useful way to use nvALT.

Creating a plain text wiki

As I was reading an article on auto-inflammatory syndromes, I was struck with the idea of creating a list of all the rheumatology diseases. I hit my hotkey trigger to bring up nvALT and typed "rheumatology diseases" to see if I might have started such a list before. No results appeared, so I hit enter and the document with the title "rheumatology diseases" was created.

I copy and pasted the list of auto-inflammatory diseases into the note and went back to reading the article. As is typical, the article started with the first disease and moved down the list. Now I wanted another text document about that disease in which I could write some notes. While it wouldn't be hard to do, wouldn't it be nice if the original list of diseases could link to this other document so I could easily browse them in the future?

It happens that nvALT has an in-app feature² that allows you to create links to other documents by wrapping the words in [[double brackets]]. Whatever words are in double brackets link to a note with the same words as the title. Example: "I love to eat [[chocolate]]." would link to a document with the name chocolate.txt. In my case, "FMF - [[familial Mediterranean fever]]" linked to a new document "familial Mediterranean fever.txt".

As I read my way through the journal article, I created a new text document for each disease that is linked to from the disease list document. I imagine in this way, I could accidentally end up writing a book someday, or maybe just a good wiki for my website. Since I'm writing it all in Markdown anyway, the conversion would be relatively simple.

Conclusion

It's simple. It's elegant. It's a total nerd-gasm.

At least that's how I remember the story.

From this I learned several lessons:

1. The legal system is not about justice.
2. The people closest to the medical system are the ones who abuse it the most.
3. Sometimes you have to take great risks to do the right thing.
4. The good guy doesn't always win.

Looks like the drug is coming back:

U.S. doctors have had no officially approved treatment for morning sickness since lawsuits forced Bendectin off the market in 1983. But the drug's main ingredients are vitamin B6 and an over-the-counter antihistamine, and obstetricians often advised pregnant women how to mix up the right dose themselves.

From Businessweek.

U.S. health regulators have approved a drug to treat morning sickness that was withdrawn from the market 30 years ago amid claims, since debunked, that it caused birth defects.

From Reuters.

With a click of a button I can easily do all these things, even when I know I shouldn't. And I'll get paid more. And I'll avoid lawsuits. And my patient interactions will be far more pleasant. I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.

There is no way around the fact that there will always be some amount of paternalism in medicine because there will always be a significant knowledge gap between the physician and the patient.

When "satisfaction" is taken to the extreme as a marker of quality and when "making the customer happy" becomes the primary rule in a clinic, good physicians will suffer great psychological pressure and patients will be at risk.

I think the ER is the place where we will see the worst consequences of this mandate.