Friday, November 10, 2006

Guidelines in the EMR

I have been thinking about how to put guidelines in the EMR so that I can use them in practice more effectively. This is a recent review in BMJ : they found that
  1. integration with charting
  2. computer-based generation of decision support
  3. automatic provision of decision support as part of workflow
  4. provision at time and location of decision making
  5. request documentation of reason for not following recommendation
were associated with more use of the recommendations in practice. Some of these things I can do now, some I can't.

The integration with charting is pretty easy for simple recommendations. For example, I made a template for the GAC recommendations for sinusitis. It has checkboxes for symptoms, and a text box for recommendations (copied and pasted from the website). I had a patient with sinusitis, loaded the template, and showed her the recommendations (no XRs, no antibiotics). These can just be saved to the clinical record, since the amount of writing on the record doesn't really matter anymore. I guess that takes care of point 3 and point 4 as well.

I copied and pasted below a slightly more complicated template I made to help me with the management of patients with chest pain. I used a "history builder", which is where you click on snippets of phrases to put them in the record, then a table, a textbox, and a drop-down list (the table didn't format properly when I copied it for here):

chest pain Updated By:(Michelle Greiver)

chest pain
chest pain Patient complains of retrosternal chest pain; The pain is worse with exercise or stress; Patient states pain is better with rest or NTG.
number of symptoms 3
Simple Table

Risk of heart disease

Age (yrs) Men, 0-1 sympt Women, 0-1 sympt Men, 2 sympt Women, 2 sympt Men, 3 sympt Women, 3 sympt
30-39 4 % 2 % 34 % 12 % 76 % 26 %
40-49 13 % 3 % 51 % 22 % 87 % 55 %
50-59 20 % 7 % 65 % 31 % 93 % 73 %
60-69 27 % 14 % 72 % 51 % 94 % 86 %

Risk of heart disease (%) 76
Test suggestions:
Risk <20%: observe, reduce risk factors
Risk 20%-80%: cardiac stress test, unless contraindications
Risk >80%: refer, stress test for prognosis, consider angiogram
Test chosen: Cardiac stress test;

I don't really see how the computer can generate automatic decision support in the current EMRs. The decision support tools are all "outside", on the web or on PDAs, and not integrated. Nor does the EMR request a reason for not following recommendations, even if I choose to bypass an alert that a patient is allergic to that medication. I am not sure how well accepted such a request would be.

I think more advanced functions, like context-specific suggestions, will be in EMR ver2. In the meantime, I can use what I already have. I programmed the new Rourke well baby record, using pieces that were in the EMR for the old record. I also pasted the Rourke patient education recommendations to a website. When parents are in, I ask if I can email it to them; they then have access to all the great links from the Rourke. I also printed a copy for a new mom who doesn't use email.

One of my front computers crashed on Tuesday; we had a blue screen with a note to get support. Dell sent a technician to replace the motherboard (didn't work), then the Intel chip and memory (didn't work), and now I think they are going to reload Windows. We are using the laptop as a back-up, so there are still two computers at the front. Some redundancy is good to have.



Anonymous said...

Like you, I have programmed the Rourke 2006 guidelines into my EMR. While it's great to have updated guidelines, I found the new format to be cumbersome to program in. It seems that the authors intended the education/safety issues (that span a few age groups) to be covered over the course of a few visits. Unfortunately, this doesn't work in our EMR, so I copied the contents of the entire Education/Safety box into each of the corresponding age visits. I guess this means that I'll be covering the same items 3 times with parents! How did you tackle this issue?

Michelle Greiver said...

I couldn't think of a good way to handle this either. I did the same thing you did, which is copied the whole thing for each visit. What I plan to do is address the whole thing at the initial visit, and ask mom if she has any questions at visits 2 and 3. I've been loading the template, and going down the list with both mom and me looking at the screen. This may not work if the baby is crying or very fussy, and then I'll put an alert to do this section at the next visit. I'll see if this approach works.

I can't figure out how the education/safety piece can be addressed in a timely manner in an office visit. I feel as if I'm just rushing through it. That's why I put it on the website so I can email it. That complements what I am saying at the office.

Anonymous said...

Thanks for sharing your thoughts on this. After reading about your link to the Rourke on your website, I put the back pages of the Rourke Handout into my EMR so that I can print them out (along with Nipissing Developmental Screen) and give them to patients.