McMaster EMRs for pediatric residents

V 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 submit

Choose pediatric monograph

Click to open

Meditech

• Main platform• Allows access to:

• Notes• Lab results

• Biochemistry• Hematology: CBC, Coagulation, Blood Bank• Microbiology (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 by learners on the phone via transcription service and transcribed for physician’s signatures

• Decentralized – dictated by physicians and transcribed by departmental assistants

• Ambulatory – available through Patient Link Viewer (next slide)

Using Meditech to access patient’s record

• Advantage• Contains all MUMC notes and results over

the last 15 years

• Only place to see microbiology results

• Disadvantage• Need to start Epic (Patient Link) viewer

to 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 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 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 treatment with 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 biopsy to guide management. In addition it was discussed that up to 70% of children will relapse and so monitoring urine for protein at home is important to detect a relapse quickly. Common side effects of prednisone were reviewed. The family also received teaching on how to check the urine at home for protein daily. The family was instructed to bring *** to the hospital should he develop fever or have chest pain, shortness of breath or signs of a blood clot such as warmth/swelling/pain in a limb. It was discussed with family that children with nephrotic syndrome are at slight increase risk for infection and clotting. The family was in agreement with plan of care and verbalized understanding of teaching. *** is to fluid restrict to 800mls per day and follow a low salt diet (no more than 2 grams per day)

Smartphrases

• Creation is taught at mandatory Epic access course

• Tip sheets for SPHs and many other useful tips are available on Dashboard

Scheduling page Content of Sticky Note can only be seen by the provider

Provider specificschedule

Division specificschedule

Use when patient is booked under ‘service’

Encounter page

Chart review page

Rooming page

Please enter past medical, surgical and family history here. Otherwise it is not possible to import it into notes

Note in Epic - 3 parts • Background information

• Entered by resident/nurse/physician at the first 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

Note

Click here to selecta pre-made template or start a blank note

Click here if you want to copy previous note and use it as a draft

Note made using a template

• Anything blue was pulled from somewhere else (usually Rooming)

• Anything yellow means a drop down menu to choose from

• The rest is free text to type in

Edit prepopulated text

Highlight 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 but doesn’t put highlights of this information in the Problem List then…

• The notes for the next and subsequent clinics will not have the original information and it will have to be manually duplicated from the first note or the whole original note has to be copied and then edited

• If physician puts information in the ‘Overview’ of a Problem then it will stay there and can go from the first to subsequent notes automatically

Creating problem list

1. Choose ‘Plan’

2. Type problem and press ‘Add’ then choose from the list

Overview of the problem

1. Click on problem

2. Click on overview to write comments

Problem and Overview comments will be recorded in Epic and can be automatically transferred to subsequent notes.

Overview of the problem – completed

If the problem list is programmed into the clinic template, then the overview of the problem automatically goes from the current note to the next note.

Standard questions can be converted into smartphrase

Smart phrase for Hypertension history

Choosing the smartphrase for Problem Overview

1. Click ‘Hypertension’2. Click ‘Overview’3. Type smartphrase name4. Press ‘Accept’

Overview of the problem – not completed

Overview of the problem – completed

If the problem list is programmed into the clinic template, then the overview of the problem automatically goes from the current note to the next note.

If it is not programmed then one can use .proboverviewsmartphrase to add problems with overviews to the clinic note

Clinic note with problem list

How can learners get physician’s smartphrases on their own

Click ‘Personalize’ and choose ‘My smart phrases’

Click on ‘Open’

In opened window type the name of the physician and press go

Acquiring smartphrase1. Choose smartphrase 2. Click ‘Share’

3. Click ‘Accept’

Choosing visit diagnosis from problem list

Click this icon to make particular problem your visit diagnosis.Green tick mark will appear.

Moving resolved problems to PMH

1. 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 particular problem

• 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 past medical history

• If the problem list is programmed into the clinic template, then the overview of the problem automatically goes from current note to the next 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 or other users in the same organisation can import one’s smart phrases without notification

• We are in the process of implementing the system when residents rotating through our service import specific smart phrases before their start day.

Flowsheets

Capture discreet data Can be programmed in a user friendly way

Should be considered as a building tool if parameter is important for future data capturing or research

Note vs letter

• Epic interpretation of both terms is probably different to one’s current practice

• 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) but usually contains a lot of information not important to the recipient and 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 and specialty 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 but addendums 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 places where this word is found: problem lists, 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 activity

• Some are similar to MS-Word: CTRL+C (copy text), CTRL+V (insert text) etc

• CTRL+SHIFT+I – opens Patient instructions section

• CTRL+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 there

• Arrange 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 article

• Attach patient information label from clinic to the first page and send it to Sovera

• After 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