1. Advanced Basics Don Stewart PPUG 2009 DonS@SDALC.org

2. Advanced Basics Templates Labels Quick Text Letter Codes Clinical Elements Lab Data Conditional Logic

3. Templates Types and strategies

4. Types of Templates for Today Note Templates – Problem Templates – Super Templates Message Templates History templates – Past Medical History – Social History – Family History NOT EEF, Flow Chart, Lab, Clinical Element, Health Maintenance, Image, Letter, Page, Prescription, Order Entry

5. Overview Why use templates? – Speed of data entry – Structured data entry You know where to find things You don’t forget to document things You can save things for later use – The ability to “pull” data into your note

6. What is wrong with Templates? One size does not fit all Needs for chronic disease management quite different from needs for urgent care Easy to be fraudulent Excessive length of notes “Cook-Book Medicine” The patient’s story is the most important diagnostic tool, and templates tend to depersonalize it.

7. Urgent Care Templates Goal is to get paid and document what you did. Speed of entry a priority Chronic disease management NOT an issue.

8. Chronic Care Templates: Subjective These templates should provide a summary of the chronic issues you are addressing, including – Past history of the problem – Current status of symptoms, disease activity markers, quality of care markers – Past and current lab values that matter – Patient Self-Management Goals – Other related and important issues

9. Chronic Care Templates: Objective Past pertinent physical findings should be visible when the patient is being examined Vital signs that are not to goal should be flagged The template should remind the provider to do and document the necessary elements of the exam

10. Chronic Care Templates: Assessment The template should prompt the provider to consider all appropriate parameters It should show the important data so the provider does not have to scroll back through the note. It should be easy to understand

11. Chronic Care Templates: Plan Should document treatment changes Follow-up plans Counseling activities – What was said – How much time was spent Labs, consultations, and procedures ordered

12. Acute Care Templates in the Primary Care Setting Should be – Quick to fill out – Uncomplicated Should document the visit adequately for reimbursement Should remind the provider of other chronic conditions or health maintenance issues that might need to be addressed

13. Primary Care Templates Both Acute or Urgent Care and Chronic Care have to be served by the same template You have to be able to address multiple issues in a given visit, both acute and chronic. Essentially, you need a Super Template, as developed by Greg Omura, MD, or you need a flexible templating system as developed by Rita Hanson, MD. Both of these systems are available for sale by their authors.

14. Labels and Quick Text The elements that make up your templates.

15. Labels «*» <----- The label marker has several functions within a template or quick text: – It serves as a marker one can Tab to, to insert text – It can enclose characters that define quick text, which will expand when clicked  «*Quick Text» – It can enclose characters that provide information of various sorts, but which disappears when the note is saved  «** For Example: a Comment **» – It can enclose a Link  «LINK: CALC | C:\calc.exe»

16. Quick Text Tips Keyboard Shortcuts: – Add an "open label" character: <<  Alt+0171 – Add a "close label" character: >>  Alt+0187 Give your quick text a unique first character to avoid it being overwritten with updates – «*Don Stewart’s Quick Text» – «~Joe Blow’s Quick Text» – «$Mary Money’s Quick Text» – «^Charlie Carrot’s Quick Text»

17. Formatting Issues with Quick Text In the Template Editor, you can enter quick texts “back-to-back,” but when they are saved, a space is put between each quick text

18. The Same Template After Saving After the previous template is saved, the system inserts spaces between quick texts.

19. This Leads to Variation in Spacing

20. After the Quick Text has been Clicked

21. After the Note is Saved

22. Work-Around using Quick Text You can put quick texts within a quick text that do not have spaces between them. This worked in versions prior to 9.3.1.

23. Or, Use a Pick List

24. The Work-Around Template

25. > Expanded Unfortunately, in 9.3.1, quick texts within quick texts expand with a space between them

26. The Pick List

27. Before Saving

28. After Saving the Work-Arounds As you can see, only the pick list saved without extra spaces

29. Letter Codes The data elements “built in” to Practice Partner

30. Letter Codes Letter Codes provide a way of inserting a wide variety of data types into a note: – Demographics – Lab Values – Clinical Elements – Calculated values – Health Maintenance – System Values

32. Calculated Letter Codes ||BODY_MASS_INDEX|| – Will only return a value if you have a weight recorded on the day it is used in a template/quick text ||BODY_SURFACE_AREA|| – BSA (m2) = square root of (height (cm) x weight (kg) / 3600) ||EST_CREATININE_CLEARANCE|| – Not documented in 9.3.1 – uses Age, Sex, Weight. Better than estimates by lab.

33. Clinical Elements “Do it yourself” Letter Codes

34. Reusable Data Elements: Clinical Data Elements (1) With version 9.x of Practice Partner, Clinical Data Elements were introduced. CDEs have many advantages over Lab Data Values for storing and reusing clinical data. You can enter CDEs in a note, or through a graphical interface You can “type” data as text, numeric, or date

35. Reusable Data Elements: Clinical Data Elements (2) Clinical Element names can be up to 29 characters in length Clinical elements can store up to 40 characters if entered through the GUI, but only 39 characters if entered with a dot code in a note. Note that leading spaces count in this. CEs can have attributes, which store up to 25 additional characters of information, though in 9.1 only accessable through the GUI

36. Graphical User Interface For Clinical Data Elements

38. Dot codes and Conditional Logic for Clinical Data Elements CEs can also be entered through notes using dot codes, and can be pulled into a note through Conditional Logic..CE: Dx Date Diabetes: «DEL» Or ||CLINICALELEMENT ||

39. Clinical Data Elements and “Natural Language” Using CEs simplifies creating templates that recall data in a “natural language” format: ||PAT_FNAME|| was diagnosed with diabetes around ||CLINICALELEMENT ||. becomes Mickey was diagnosed with diabetes around Summer 2006.

40. Lab Data It isn’t just for labs...

41. Reusable Data Elements: Lab Data Elements (1) In the past, we could store data as lab values. For example:.L: DiabetesDxDate: «DEL» would allow us to save something we could bring back later as: ||LAB ||

42. Reusable Data Elements: Lab Data Elements (2) So, if you enter this in a template:.L: DiabetesDxDate: «DEL» Summer 2006 It becomes this when recalled: DiabetesDxDate: Summer 2006

43. Reusable Data Elements: Lab Data Elements (3) Limitations of Lab Data Elements: – Lab Names are limited to 18 characters in length – Lab data is limited to 19 characters – You cannot suppress the display of the name without using conditional logic – It is hard to limit the choices for what data is saved

44. Reusable Data Elements: Lab Data Elements (4) Workarounds (to hide the Lab Name): || IF LAB = “True” {The patient has diabetes.} ELSE {IF LAB = “False” { The patient does not have diabetes.} ELSE {Diabetes status is not recorded.} } ||

45. Reusable Data Elements: Lab Data Elements (5) Workarounds (to force specific choices).L: HasDiabetes: «REQ» «*True» «*False» «*Unknown» However, users can always type in something else besides the choices– the key is to make the choices you want easier to click on than typing something else.

46. Conditional Logic How to control what your templates and quick text do

47. Conditional Logic Resources On my web site – http://www.sdalc.org/Physicians%20Only/Practice %20Partner%20Resources/PracticePartnerResourc es.htm http://www.sdalc.org/Physicians%20Only/Practice %20Partner%20Resources/PracticePartnerResourc es.htm – Conditional Logic Tutorial PDF – Conditional Logic Power Point Presentations at the UG Meeting On my flash drive

48. How Conditional Logic Works The most basic statement is in this form: || IF {this happens}|| For example || IF PAT_SEX = “male” {he} || In the above, everything between the two || delimiters will be replaced with the word “he” if the patient is a male, and the phrase will evaluate to nothing if the patient is not a male.

49. IF The is a letter code. PP Help has a list of letter codes, but it is easier to see more examples by going to the Maintenance Menu  Tables  QuickText, then press the letter code radio button You can use values like ||PAT_SEX||, ||PAT_AGE||, and ||LAB ||, as well as ||BODY_MASS_INDEX|| and ||VITAL_HGT||, as well as the other vital signs.

50. is a Logical Operator – =means “equal to” – <>means “not equal to” – <means “less than” – <=means “less than or equal to” – >means “greater than” – >= means “greater than or equal to” Comparisons are done as Strings, not Numbers

51. is a string. It can also be a letter code. (unless it is a letter code) has to be quoted, e.g. – ||IF PATIENT_SEX = "male" { } || – ||IF LAB > "160" { } || The Quote Marks can’t be curly (“”), must be straight ("") “Nothing” or “No Value Found” = ""

52. {this happens} {this happens} means that whatever is between the curly braces { } is printed or evaluated if the CL statement preceding it evaluates to “TRUE” If the CL statement preceding the { } does not evaluate to “TRUE,” then nothing is done with whatever is between the braces.

53. ELSE You can add an ELSE { } behind the first pair of { } to print an alternative statement or do a new comparison For example: || IF PAT_SEX = "" {he or she} ELSE { IF PAT_SEX = "male" {he} ELSE {she}} ||

54. CL and HM You can use Conditional Logic with Health Maintenance, but you can only test whether a value is present. You cannot test what the value is You cannot do this: – || IF HM = "X" { } else { } || You can do this: – || IF HM = "" {needs to be done} ELSE { HM } ||

55. Formatting You can use carriage returns and “white space” to make your statements more readable: || IF PAT_SEX = “” {he or she} ELSE { IF PAT_SEX = “male” {he} ELSE {she}} || As opposed to : || IF PAT_SEX = “” {he or she} ELSE { IF PAT_SEX = “male” {he} ELSE {she} } ||

56. AND and OR To get more complex, you can use AND or OR after your first comparison and before your first “{“. || IF PAT_SEX = “male” AND PAT_AGE > “50” {he might just need a prostate exam} || IF, ELSE, AND and OR used in conditional logic must be capitalized

57. Logical Statements within Logical Statements You can put a complete logical statement within a pair of { } || IF LAB [-Date] < "40" AND PAT_SEX ="male" { The HDL is too low.} ELSE {IF LAB [-Date] < "50" AND PAT_SEX = "female" {The HDL is too low} ELSE {The HDL is OK} } ||

58. Conditional Logic with Letter Codes ||IF BODY_MASS_INDEX <> "" { IF BODY_MASS_INDEX < "18.5" {.MP: Underweight: 783.22 } ELSE {IF BODY_MASS_INDEX >= "50.0" {.MP: Super Obese : 278.01 } ELSE {IF BODY_MASS_INDEX >= "40.0" {.MP: Morbid Obesity: 278.01} ELSE {IF BODY_MASS_INDEX >= "35.0" {.MP:Obesity Class II: 278.00} ELSE {IF BODY_MASS_INDEX >= "30.0" {.MP: Obesity Class I: 278.00} ELSE {IF BODY_MASS_INDEX >= "25.0" {.MP: Overweight: 287.02} } } } ||

59. EST_CREATININE_CLEARANCE || IF EST_CREATININE_CLEARANCE <> "" {IF EST_CREATININE_CLEARANCE > = "90 mL/min" {«** Normal Renal Function **» «*_MP_CKD1»} ELSE {IF EST_CREATININE_CLEARANCE < "15 mL/min" {.MP: CKD Stage V: 585.5 «*_MP-ESRD» } ELSE {IF EST_CREATININE_CLEARANCE < "30 mL/min" {.MP: CKD Stage IV : 585.4 } ELSE {IF EST_CREATININE_CLEARANCE < "60 mL/min" {.MP: CKD Stage III: 585.3} ELSE { IF EST_CREATININE_CLEARANCE < "90 mL/min" {.MP:CKD Stage II: 585.2} } ||