Making EMR Work Better Tips and Hacks for the Busy Doctor Matt Anderson and Alisha Liggett

This is version dated: 2013-10-08 Most recent version is available at www.socialmedicine.org/quick Table of Contents Introduction...... 4 Warnings...... 4 We need your help...... 4 Existing, global quicktexts that you may find useful...... 5 How to load quick texts into the EMR...... 6 How to load information into the flowchart...... 7 What if you don’t see a field for the value you want to enter?...... 7 R commands: Retrieving Information...... 8 A warning to begin:...... 8 Suggested Retrieval Quick Texts...... 8 BMP (.rbmp)...... 8 Diabetes Quick Review (useful for when people want refills) (.rdm)...... 8 GYN tests (.rgyn)...... 9 Hepatitis Serologies...... 10 Hematology (.rhem)...... 10 HIV Results (.rhiv)...... 11 Lipids (.rlip)...... 11 Liver function tests (.rlft)...... 12 STD Screens (.rstd)...... 12 TB screening (.rppd)...... 13 Thyroid (.tsh)...... 13 Vaccines (.rvax)...... 13 Vital signs (.rvs) Adult Version (Flu Season)...... 14 Vital signs (.rvsp) Pediatric (Flu Season)...... 14 Write your own retrieve commands:...... 16 How do I find the name of a test or observation?...... 18 Jump Commands...... 19 Suggested Jump Commands...... 19 Jump to order Xrays (.jray)...... 19 WIC forms (.jwic)...... 19 Jump to M11Q (.jm11Q)...... 19 Jump to order a pap (.jpap)...... 19 Jump to School Forms ,jschool...... 19 Write your own Jump Commands...... 20 Other Useful commands...... 21 .trans (Translation Numbers)...... 21 Change log...... 22 Introduction

This guide is designed to help you make the most of EMR.

Using C-EMR has been challenging for most of us. We understand that the system may be replaced sometime next year, but in the meantime we still have to take care of patients. We developed these tricks and quick texts to facilitate our work as physicians – to get us the information we need when and where we need it. We hope that they will be helpful to others.

Warnings

Retrieval quicktexts only retrieve information from the C-EMR flow chart. This poses three problems:

1. Information on systems that is not sent to EMR (like lab values from hospitalized patients) is not available to you. The only solution to this is to look at CARECAST 2. Information that is not “dispersed to the chart” (that’s the stuff with the exclamation point beside it) is not available to you. We will explain later on how you can enter this manually. 3. Sometimes items in the flowchart have more than one name. We will explain later how to find some of these names, but we are not sure we have all.

The bottom line is that there may be additional information available that is not in the EMR flowchart but is not retrieved by our quicktexts.

We need your help

Please let us know if you identify any mistakes in our quicktexts. In addition please let us know of any texts you think should be included in this document. Write to Matt Anderson at [email protected] Existing, global quicktexts that you may find useful

.imm Jumps to the immunization ordering page .tsh Gives the most recent TSH .colonoscopy Retrieves last colonoscopy .prb Pulls up the patient’s problem list .med Pulls up the patient’s medications .flowud Takes you to the screen to update the flowchart .vpnl Pop-up with prenatal labs .updprob This takes you to the update problem list screen How to load quick texts into the EMR

Click on the Options tab (this is on the very top of the screen).

Quick Text shows up as the first option on the menu. Click on it.

Change the “View Quick Text for” option to “Personal Use” (instead of “Global Use”)

In the field for replace write the name of the quick text you want to insert (eg: .rhiv) Note: Most quick texts begin with a dot, but this is actually not necessary. (It’s just sensible)

In the field for “with” put in your new quick text. If there is text in this field now you may want to “Select all” and delete it before putting in the new quick text.

Click on the button for “Replace”

Enjoy your new quick text. How to load information into the flowchart

Sometimes information that shows up in lab reports is not put into the flow chart. One important example is HPV values. When this happens you see a little ! next to the result and the bottom of the report says: “An exclamation mark (!) indicates a result that was not dispersed into the flowchart.”

If you want to put this information into the flowchart here is what to do:

1. Start an update (we use the clinical lists update) 2. Click on the “Flowchart” icon (or use the quicktext .flowud) 3. A box will open. In the View field you will see one of a variety of different flow sheets in EMR. You can scroll through these different flowsheets.. 4. There is a button on the lower left corner of the box which says “New”. Click on this 5. Write in the date in the field that says: “Observation Date” 6. Once you have written in the date, click on the calendar icon to the right. 7. The date you want is highlighted on the drop down calendar. Click on that date. 8. You can now scroll down the list of tests and write in the value in the appropriate field 9. Click “OK” and your value is now in the flow chart.

What if you don’t see a field for the value you want to enter?

This can be a problem. Each flow chart has its own set of values. There is one flowchart for “ALL” but it does not include all possible values in the flowchart. Do your best to look for a flowchart with a name that suggests your test is on it. It’s a bit of trial and error unfortunately. R commands: Retrieving Information

A warning to begin:

In the Introduction we noted some limitations to the retrieve commands namely – they only tell you what is in the EMR flowsheet. There may be additional information available in other databases or not dispersed into the flowsheet.

In addition the vital signs commands bring up the last recorded vital signs. You need to put in today’s vital signs before you run these commands.

We have provided suggested names for the quick texts, but feel free to use your own.

Suggested Retrieval Quick Texts

BMP (.rbmp) Most recent SMA7 ({LASTOBSDATE("na")}) in C-EMR reviewed: Most recent BMP (06/04/2013) in C-EMR reviewed: NA: {LASTOBSVALUE("na")} , K: {LASTOBSVALUE("k serum")} NA: 140 , K: 4.1 Cl: {LASTOBSVALUE("cl serum")}, C02: {LASTOBSVALUE("c02")} Cl: 103, C02: 30 Glucose: {LASTOBSVALUE("glucose ser")} Glucose: 124 BUN: {LASTOBSVALUE("bun")} / creat: {LASTOBSVALUE("creatini BUN: 14 / creat: 0.7 ne")} EGFR: > 60 ml/min, Calcium 9.6 EGFR: {LASTOBSVALUE("gfrc")}, Calcium {LASTOBSVALUE("calcium")}

Diabetes Quick Review (useful for when people want refills) (.rdm) Diabetic review: Diabetic review: Weight: {LASTOBSVALUE("weight")} Weight: 98.01 (12/27/2012), BMI: 19.21 (12/27/2012) ({LASTOBSDATE("weight")}), BP: 145/75 (12/27/2012) BMI: {LASTOBSVALUE("bmi")} ({LASTOBSDATE("bmi")}) HgA1c: 6.3 (12/27/2012) BP: {LASTOBSVALUE("BP systolic")}/ Microalb/crt ratio: 1301 MG/G (12/27/2012) EGFR: 27 {LASTOBSVALUE("BP diastolic")} ({LASTOBSDATE("bp (12/27/2012) systolic")}) LDL: 102 (12/27/2012) HgA1c: {LASTOBSVALUE("HgbA1c")} ({LASTOBSDATE("HgbA1c")}) Microalb/crt ratio: {LASTOBSVALUE("MCROALB/CR U")} ({LASTOBSDATE("MCROALB/CR U")}) EGFR: {LASTOBSVALUE("GFRC")} ({LASTOBSDATE("gfrc")}) LDL: {LASTOBSVALUE("LDL")} ({LASTOBSDATE("LDL")})

GYN tests (.rgyn) Most recent gyn results in C-EMR: Most recent gyn results in C-EMR: Mammo: {LASTOBSVALUE("Mammogram")} ({LASTOBS Mammo: Normal (done elsewhere) (09/01/2012) DATE("Mammogram")}) Pap: Negative (02/07/2013) Pap: {LASTOBSVALUE("Pap HPV: Negative (02/07/2013) smear")} ({LASTOBSDATE("Pap smear")}) GC/Chlamydia: Negative/Negative (02/07/2013) HPV: {LASTOBSVALUE("HPV CBE last done on: 02/07/2013 result")} ({LASTOBSDATE("HPV Result")}) GC/Chlamydia: {LASTOBSVALUE("gc pcr")}/ {LASTOBSVALUE("chlamydiapcr")} ({LASTOBSDATE("ch lamydiapcr")}) CBE last done on: {LASTOBSDATE("breast insp")}

Hepatitis Serologies Hepatitis Screening in CEMR Hepatitis Screening in CEMR SGOT/PT: {LASTOBSVALUE("SGOT (AST)")}/ SGOT/PT: 27/29 06/07/2013 {LASTOBSVALUE("SGPT (ALT)")} {LASTOBSDATE("SGPT HepA: Negative (06/07/2013 9:11:00 AM) (ALT)")} HepB sAb: Negative (06/07/2013 9:11:00 AM) HepA: {LASTOBSVALUEDATE("anti-hav igg")} HepB sAg: Negative (06/07/2013 9:11:00 AM) HepB sAb: {LASTOBSVALUEDATE("anti-hbs")} HepB cAb: Positive (06/07/2013 9:11:00 AM) HepB sAg: {LASTOBSVALUEDATE("hbsag")} HepC Ab: Negative (06/07/2013 9:11:00 AM) HepB cAb: {LASTOBSVALUEDATE("anti- HC Viral Load: hbc")} {LASTOBSVALUEDATE("anti-hbc/igg")} HepC Ab: {LASTOBSVALUEDATE("hep c ab")} {LASTOBSVALUEDATE("hcv virus ab")} HC Viral Load: {LASTOBSVALUEDATE("hcv rna qt")}

Hematology (.rhem) Most recent Heme tests in C-EMR reviewed: Most recent Heme tests in C-EMR reviewed: WBC: {LASTOBSVALUEDATE("wbc ct blood")} WBC: 3.2 (04/22/2013 1:37:00 PM) HCT: {LASTOBSVALUEDate("HCT")} HCT: 33.7 (04/22/2013 1:37:00 PM) HGB: {LASTOBSVALUEDate("hgb")} HGB: 10.1 (04/22/2013 1:37:00 PM) MCV: {LASTOBSVALUEDate("mcv")} MCV: 88.7 (04/22/2013 1:37:00 PM) Platelets: {LASTOBSVALUEDate("Plateletk/ul")} Platelets: 183.0 (04/22/2013 1:37:00 PM) INR POC: {LASTOBSVALUEDate("INR POC")} INR POC: 2.2 (06/04/2013 8:46:17 AM) Ferritin: {LASTOBSVALUEDate("ferritin")} Ferritin: 30.0 (04/22/2013 1:37:00 PM) RDW: {LASTOBSVALUEDate("rbc wdth ur")} RDW: 15.1 (04/22/2013 1:37:00 PM) Lead: Lead: {LASTOBSVALUEDate("lead")} Retic Count: Retic Count: {LASTOBSVALUEDate("retic count")} HIV Results (.rhiv) Code Results Last CEMR HIV results: Last CEMR HIV results: CD4={LASTOBSVALUE("ABSOLUTECD4")}, CD4%= CD4=661 /UL, CD4%= 29 (06/07/2013), {LASTOBSVALUE("CD4 %")} ({LASTOBSDATE("CD4 %")}), HIV VL= 64 (06/07/2013) HIV VL= {LASTOBSVALUE("HIV-VL")} ({LASTOBSDATE("HIV-VL")}) Syphilis: Negative (06/07/2013 9:11:00 AM) Syphilis: {LASTOBSVALUEDATE("syphserlgy")} RPR RPR {LASTOBSVALUEDATE("rpr titer")} GC/Chlamydia: Negative/Negative (06/07/2013) GC/Chlamydia: {LASTOBSVALUE("gc pcr")}/ Pap: HPV: {LASTOBSVALUE("chlamydiapcr")} Toxo: ({LASTOBSDATE("chlamydiapcr")}) {LASTOBSVALUEDATE("rpr")}Pap: {LASTOBSVALUEDATE("Pap smear")} HPV: {LASTOBSVALUEDATE("HPV result")} Toxo: {LASTOBSVALUEDATE("toxo titer")}

Lipids (.rlip) Last Lipid Profile Last Lipid Profile Cholesterol: {LASTOBSVALUEDATE("cholesterol")} Cholesterol: 196 (06/07/2013 9:11:00 AM) HDL: {LASTOBSVALUEDATE("HDL")} HDL: 42 (06/07/2013 9:11:00 AM) LDL: {LASTOBSVALUEDATE("LDL")} LDL: 130 (06/07/2013 9:11:00 AM) Triglycerides: {LASTOBSVALUEDATE("triglyceride")} Triglycerides: 118 (06/07/2013 9:11:00 AM) Ratio: {LASTOBSVALUEDATE("chol/hdl %")} Ratio: 4.7 (06/07/2013 9:11:00 AM) CPK: {LASTOBSVALUEDATE("cpk")} CPK:

Last Liver profile Last Liver profile SGOT: 27 (06/07/2013 9:11:00 AM) SGOT: {LASTOBSVALUEDATE("SGOT (AST)")} SPGT: 29 (06/07/2013 9:11:00 AM) SPGT: {LASTOBSVALUEDATE("SGPT (ALT)")} T. Bili: 0.6 (06/07/2013 9:11:00 AM) T. Bili: {LASTOBSVALUEDATE("BILI TOTAL")} Alk Phos: 79 (06/07/2013 9:11:00 AM) Alk Phos: {LASTOBSVALUEDATE("alk phos")}

We have included LFT’s in this quick text but you don’t necessarily need these.

Liver function tests (.rlft) Last Liver profile Last Liver profile SGOT: 27 (06/07/2013 9:11:00 AM) SGOT: {LASTOBSVALUEDATE("SGOT (AST)")} SPGT: 29 (06/07/2013 9:11:00 AM) SPGT: {LASTOBSVALUEDATE("SGPT (ALT)")} T. Bili: 0.6 (06/07/2013 9:11:00 AM) T. Bili: {LASTOBSVALUEDATE("BILI TOTAL")} Alk Phos: 79 (06/07/2013 9:11:00 AM) Alk Phos: {LASTOBSVALUEDATE("alk phos")}

STD Screens (.rstd) STD screens in C-EMR: STD screens in C-EMR: HepB sAb: {LASTOBSVALUEDATE("anti-hbs")} HepB sAb: NEGATIVE (07/21/2005 7:07:39 PM) HepB cAb: {LASTOBSVALUEDATE("anti-hbc")} HepB cAb: Positive (06/25/2004 7:07:39 PM) HepC Ab: {LASTOBSVALUEDATE("hep c ab")} HepC Ab: Positive (12/18/2001 7:07:39 PM) Last HIV test: {LASTOBSDATE("Hivtestdate")} Last HIV test: HPV: {LASTOBSVALUEDATE("HPV result")} HPV: GC/Chlamydia: {LASTOBSVALUE("gc pcr")}/ GC/Chlamydia: Negative/Negative (05/14/2013) {LASTOBSVALUE("chlamydiapcr")} Syphilis: POSITIVE (05/14/2013 10:43:00 AM) ({LASTOBSDATE("chlamydiapcr")}) Syphilis: {LASTOBSVALUEDATE("syphserlgy")} RPR: {LASTOBSVALUEDATE("rpr")}

TB screening (.rppd) Most recent TB screening in C-EMR reviewed: Most recent TB screening in C-EMR reviewed: PPD: () PPD: {LASTOBSVALUE("PPD result")} ({LASTOBSDATE("PPD CXR: No TB (11/23/2012) Result")}) Quantiferon: Positive (06/07/2013) CXR: {LASTOBSVALUE("CXR")} ({LASTOBSDATE("CXR")}) Quantiferon: {LASTOBSVALUE("tb quant")} ({LASTOBSDATE("tb quant")})

Thyroid (.tsh)

This exists already in EMR

Vaccines (.rvax) Code Results Recent CEMR vaccines: Recent CEMR vaccines: {LASTOBSVALUEDATE("flu vax")} {LASTOBSVALUEDATE("flu vax #2")} Fluzone =>3 (10/03/2011 2:38:20 PM) {LASTOBSVALUEDATE("tdap")}{LASTOBSVALUEDATE("td")}{LASTOBSVALUEDATE("td Tdap (04/06/2007 9:05:59 AM) booster")}{LASTOBSVALUEDATE("adacel")} Pneumovax (06/07/2013 8:21:06 AM) {LASTOBSVALUEDATE("pneumovax")} HEP1: HEP1:{LASTOBSVALUEDATE("hepbvax#1")} HEP2: HEP2:{LASTOBSVALUEDATE("hepbvax#2")} HEP3: HEP3:{LASTOBSVALUEDATE("hepbvax#3")} VAR: VAR:{LASTOBSVALUEDATE("varivax inj")}{LASTOBSVALUEDATE("varivax #2")} Menactra: {LASTOBSVALUEDATE("varicella #3")} Menactra: {LASTOBSVALUEDATE("menactra")} Vital signs (.rvs) Adult Version (Flu Season) Code Results Vital Signs: Vital Signs: Weight: {LASTOBSVALUE("weight")} / BMI: {LASTOBSVALUE("bmi")} Weight: 243 / BMI: 33.08 Pulse: {LASTOBSVALUE("Pulse Rate")} Pulse: 95 Blood Pressure {LASTOBSVALUE("BP systolic")}/ Blood Pressure 126/69 {LASTOBSVALUE("BP diastolic")} BP done on: 11/19/2012 BP done on: {LASTOBSDATE("BP systolic")} Temp:98.20 (F) / 36.78 (C) Temp:{LASTOBSVALUE("Temperature")} (F) / Glucose (FS): on {LASTOBSVALUE("Temp(Deg C)")} (C) Glucose (FS): {LASTOBSVALUE("bg finger")} on {LASTOBSDATE("bg Have they had their flu shot this season? finger")} ------

Have they had their flu shot this season?

------

Vital signs (.rvsp) Pediatric (Flu Season) Code Results Vital Signs: Vital Signs: Height: {LASTOBSVALUE("height")} in. ({LASTOBSVALUE("height Height: 60 in. (95%) %tile")}%) Weight: 172.00 lbs. (99%) Weight: {LASTOBSVALUE("weight")} lbs. ({LASTOBSVALUE("weight BMI: 33.71 %tile")}%) BMI: {LASTOBSVALUE("bmi")} SBP: 101 (29%) DBP: 67 (62%) SBP: {LASTOBSVALUE("BP systolic")} ({LASTOBSVALUE("SYS BP BP done on: 10/08/2013 %ILE")}%) DBP: {LASTOBSVALUE("BP diastolic")} ({LASTOBSVALUE("DIA BP Temp: 99 (F) / 37.22 (C) %ILE")}%) Pulse: 96 BP done on: {LASTOBSDATE("BP systolic")} Flu Shot Indicated? Temp:{LASTOBSVALUE("Temperature")} (F) / {LASTOBSVALUE("Temp(Deg C)")} (C) Pulse: {LASTOBSVALUE("Pulse Rate")}

Flu Shot Indicated? Write your own retrieve commands: The syntax of these commands is straightforward and can be illustrated by the tests for SG0T which is called (SGOT (AST)) and SGPT (SGPT (ALT)) in EMR

Here are the variations of how you could combine these two values:

Code What you see {LASTOBSVALUEDATE("SGOT (AST)")} 36 (05/14/2013 10:43:00 AM) {LASTOBSVALUEDATE("SGPT (ALT)")} 32 (05/14/2013 10:43:00 AM)

{LASTOBSVALUE("SGOT (AST)")} 36 {LASTOBSVALUE("SGPT (ALT)")} 32

{LASTOBSDATE("SGOT (AST)")} 05/14/2013 {LASTOBSDATE("SGPT (ALT)")} 05/14/2013

Adding your own text LFT Values: LFT Values: SGOT: {LASTOBSVALUEDATE("SGOT (AST)")} SGOT: 36 (05/14/2013 10:43:00 AM) SGPT: {LASTOBSVALUEDATE("SGPT (ALT)")} SGPT: 32 (05/14/2013 10:43:00 AM)

LFT values on: {LASTOBSDATE("SGOT (AST)")} LFT values on: 05/14/2013 SGOT: {LASTOBSVALUE("SGOT (AST)")} SGOT: 36 SGPT: {LASTOBSVALUE("SGPT (ALT)")} SGPT: 32 LFT Values: LFT Values: SGOT: {LASTOBSVALUE("SGOT (AST)")} on SGOT: 36 on 05/14/2013 {LASTOBSDATE("SGOT (AST)")} SGPT: 32 on 05/14/2013 SGPT: {LASTOBSVALUE ("SGPT (ALT)")} on {LASTOBSDATE("SGPT (ALT)")} How do I find the name of a test or observation?

Usually the test names are the same as the one in the flow chart. You may, however, need to look through multiple flowcharts to find your test.

When the test name is not the name on the flow chart, you need to do some hunting: 1. Go to one of the test patients in EMR (e.g. TEST, AETNA). 2. Start a flowchart update (.flowud) 3. Find the test or observation whose name you need. 4. Update some value in that field. (e.g. write “Positive” in the Quantiferon field) 5. Click OK 6. At the bottom of the box you will see written: ‘ADDED NEW OBSERVATION OF” and there you will see the name of your test or observation. 7. This technique allowed us to figure out that the name for Quantiferon is “tb quant”. Who would have thought of that? Jump Commands

Suggested Jump Commands

Jump to order Xrays (.jray)

{ADD_FORM_COMP("Enterprise","Radiology Order Form","AT_END","OPEN")} .

WIC forms (.jwic)

{ADD_FORM_COMP("Enterprise","WIC Forms","AT_END","OPEN")

Jump to M11Q (.jm11Q)

{ADD_FORM_COMP("Enterprise","M11Q","AT_END","OPEN")}

Jump to order a pap (.jpap)

{ADD_FORM_COMP("Enterprise","Pap Order Form","OPEN")}

[This opens the form in the side-bar but does not take you to the form.

Jump to School Forms ,jschool {ADD_FORM_COMP("Enterprise","Peds School Form","OPEN")}

Write your own Jump Commands

The syntax of these commands is straightforward

{ADD_FORM_COMP("Enterprise","NAME OF FORM","OPEN")}

The difficulty comes in finding the “NAME OF FORM”. Sometimes it is the name of the form, sometimes it is not.

Other Useful commands

.trans (Translation Numbers) Translation by Pacific Interpreters 800 264-1552 Access 830358 Translator Name: Translator Number: Change log

6/16/2013: Original File created

7/15/2013: .rvs added

10/8/2013: .rvs (adult vital signs updated) .rvsp (pediatric vital signs created .jpap (clarification note added) .trans (added)