I am considering adding some optional fields for the diagnoses. Optional as for a busy practise, you may not have time to fill in this type of data. So, one possibility is that if you double click on a diagnosis, it brings up another screen that has Who made the diagnosis Exact dates, approximate date, age of onset, date became inactive What criteria used to make the diagnosis Level of confidence A little spiel backgrounding the history of this diagnosis The idea is to hide most of this information until you need to see it. But the other problem is, that if you delete the diagnosis, all this data will be lost ...
OOOOohhhh. Love this topic (as you know). I'd love to hear more about what you thinking might work here. I could envision the treeview working well here .. not sure if SynapseGUI does treeview.
I have been thinking about this for a while. I'm not sure any "Box Model" method will work here. Flexibility I think is ultra important. Two patients with the same diagnoses may require vastly different disease "summaries". Keeping a list like this up to date, will prove a challenge. My actual suggestion was .... a tab called PMHx (Past Medical History). Where the <u>diagnoses</u> Tab is more of a diagnostic tag for the patient's chart ... the PMHx can go into detail, when the clinician feels it important (every doctor has their own things they feel are important). I was going to make it easy on you and suggest that the PMHx could be identical to the SHx tab ... (maybe with versioning). Free Form reigns supreme. One use for consultants would be that opening "Summary Paragraph" that many consultants start their notes with. The best example is Cardiologists. To me, it's like they are reminding themselves, but to new doctors involved in their patient's care ... it's a quickie helpful summary. One cardiologist ... does this.. ie. He is a 76 year old man with bypass surgery in 1990, circumflex graft stenting in 2001, and hypertension. (that is a short one, some patients have longer ones). For me, I'd use the PMHx mostly for free form notes on MAJOR diagnoses. It would be a place where Two to three sentence summaries on major patient issues would be discussed. This section would slowly grow over years. If the truth be known, I've been using the Social Tab for this for selected patients. [] I often find myself copying and pasting summaries from consultants into this section. Our local Cancer facilities often have a 2-5 line summary of the cancer care for patients when sending referral notes. I just cut and paste this info into the SHx section so I can access it later. Many other doctors might have other uses for the PMHx tab. It is really handy to have a "Free Form" Medical Notes section. EMRs often have too rigid structure and the details of the patient's care get lost in codified mumble jumble. Viewing a patient as a set of ICD9 codes was pushed on doctors via silly billing requirements.
The problem with free form is that it is very hard to get the data out again .. eg. CCR export. I agree that maintaining such a list will be very hard ... If you have a separate tab for this, then you start to violate rules on database normalization. I will have to think on this some more.
Not all data needs to be "extractable". Medicalcharts would be useless ifall youkept was extractable data. No EMRout there can extract such asummary, so let's notburden ourself with that goal - yet. Why does the Social Tab not violate this then ? Because it doesn't do versioning ?
Database normalization refers to keeping only one copy of the information in your database. So, social history is just one copy .. unless you put the social history into an encounter which does then violate this principle. Thinking more about this, it's not just past medical history we are talking about, but more about disease management. The encounters document day to day management, but there needs to be a place for documenting strategic management of chronic diseases as well. The diagnostic lists are really aide-memoire, and for generating ICD-9s for billing. Perhaps it will be a subtab for Diagnoses.
I see this sort of "free-form key medical summary" as distinct from the topic of strategic CDM. But I'd love to chat about how an EMR might do CDM. Osteoarthritis is a good one. I go through somewhat of a "protocol" before I refer a patient on for possible surgery. If there was a way to document this method easily, when I referred a patient, I could just send over the general OA management summary to the surgeon. I suppose most medical situations rely on the patient to remember what was done for them ... which is of course inherently flawed (sorta like my accountant asking me questions, or a mechanic asking my wife about her car). I'd say some documentation strategy for CDM would be challenging, but a good goal for the future. I think that easily documenting CDM care would help multi-provider clinics the most (ie. where a doctor,nurse practitioner, nurse, social worker, whomever all see the patient). Collaborative care is the future.
So, we now have at least 3 requirements for diseases. More detailed history ( onset, criteria etc ) A summary paragraph Chronic disease management plan Other consultants involved. If the illness is just a single episode, you may only use points 1, and perhaps 2.
I guess the big question is why have this tab at all ? For myself, (1) when sending a referral letter on a complicated patient (say a referral to a geriatrician), I'd like there to be significant snapshots of the patient's "major" illnesses in there. (2) to remind me what has happened to the patient. (3) to have somewhat of a summary for a doctor covering my patient (ie. locum tenens) (4) a free form location to put important information, that doesn't have a place elsewhere. (I should compile a list of information that kinda meets this criteria). (5) I have been putting names of physicians that see this patient in this location (SHx, for me)as well. I think I decided to put this info there because I couldn't easily send who was seeing the patient to a consultant from the list of "Correspondents". while on the topic, It would be useful from a Management perspective to also say which consultant is managing the disease (ie. Bre_ast Cancer, etc.). more later. dinner time.
