Advanced Basics

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Advanced Basics

• Don Stewart
• PPUG 2009
• DonS_at_SDALC.org

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Advanced Basics

• Templates
• Labels
• Quick Text
• Letter Codes
• Clinical Elements
• Lab Data
• Conditional Logic

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Templates

• Types and strategies

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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

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Overview

• Why use templates?
• Speed of data entry
• Structured data entry
• You know where to find things
• You dont forget to document things
• You can save things for later use
• The ability to pull data into your note

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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 patients story is the most important
  diagnostic tool, and templates tend to
  depersonalize it.

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Urgent Care Templates

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

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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

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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

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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

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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

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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

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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.

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Labels and Quick Text

• The elements that make up your templates.

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Labels

• lt----- 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

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Quick Text Tips

• Keyboard Shortcuts
• Add an "open label" character ltlt ?Alt0171
• Add a "close label" character gtgt ? Alt0187
• Give your quick text a unique first character to
  avoid it being overwritten with updates
• Don Stewarts Quick Text
• Joe Blows Quick Text
• Mary Moneys Quick Text
• Charlie Carrots Quick Text

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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
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The Same Template After Saving
After the previous template is saved, the system
inserts spaces between quick texts.
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This Leads to Variation in Spacing
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After the Quick Text has been Clicked
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After the Note is Saved
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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.
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Or, Use a Pick List
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The Work-Around Template
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ltltEarExamgtgt Expanded
Unfortunately, in 9.3.1, quick texts within quick
texts expand with a space between them
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The Pick List
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Before Saving
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After Saving the Work-Arounds
As you can see, only the pick list saved without
extra spaces
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Letter Codes

• The data elements built in to Practice Partner

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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

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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.

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Clinical Elements

• Do it yourself Letter Codes

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Reusable Data ElementsClinical 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

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Reusable Data ElementsClinical 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

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Graphical User Interface

• For Clinical Data Elements

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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
• CLINICALELEMENTltDx Date Diabetesgt

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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
  CLINICALELEMENTltDx Date Diabetesgt.
  becomes
• Mickey was diagnosed with diabetes around Summer
  2006.

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Lab Data

• It isnt just for labs . . .

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Reusable Data ElementsLab 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
• LABltDiabetesDxDategt

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Reusable Data ElementsLab Data Elements (2)

• So, if you enter this in a template
• .L DiabetesDxDate DEL Summer 2006
• It becomes this when recalled
• DiabetesDxDate Summer 2006

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Reusable Data ElementsLab 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

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Reusable Data ElementsLab Data Elements (4)

• Workarounds (to hide the Lab Name)
• IF LABltHasDiabetesgt True The patient has
  diabetes.
• ELSE
• IF LABltHasDiabetesgt False The patient does
  not have diabetes.
• ELSE
• Diabetes status is not recorded.

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Reusable Data ElementsLab 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.

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Conditional Logic

• How to control what your templates and quick text
  do

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Conditional Logic Resources

• On my web site
• http//www.sdalc.org/Physicians20Only/Practice20
  Partner20Resources/PracticePartnerResources.htm
• Conditional Logic Tutorial PDF
• Conditional Logic Power Point
• Presentations at the UG Meeting
• On my flash drive

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How Conditional Logic Works

• The most basic statement is in this form
• IF ltsomethinggt ltis related togt ltsomething
  elsegt 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.

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IF ltsomethinggt

• The ltsomethinggt 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 LABltAnyLabgt, as well as
  BODY_MASS_INDEX and VITAL_HGT, as well as
  the other vital signs.

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ltis related togt

• ltis related togt is a Logical Operator
• means equal to
• ltgt means not equal to
• lt means less than
• lt means less than or equal to
• gt means greater than
• gt means greater than or equal to
• Comparisons are done as Strings, not Numbers

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ltsomething elsegt

• ltsomething elsegt is a string. It can also be a
  letter code.
• ltsomething elsegt (unless it is a letter code) has
  to be quoted, e.g.
• IF PATIENT_SEX "male"
• IF LABltCHOLESTEROLgt gt "160"
• The Quote Marks cant be curly (), must be
  straight ("")
• Nothing or No Value Found ""

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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.

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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

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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 HMltsomethinggt "X" else
• You can do this
• IF HMltsomethinggt "" needs to be done ELSE
  HMltsomethinggt

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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

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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 gt 50 he
  might just need a prostate exam
• IF, ELSE, AND and OR used in conditional logic
  must be capitalized

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Logical Statements within Logical Statements

• You can put a complete logical statement within a
  pair of
• IF LABltHDL CHOLESTEROLgt-Date lt "40" AND
  PAT_SEX "male" The HDL is too low.
• ELSE
• IF LABltHDL CHOLESTEROLgt-Date lt "50" AND
  PAT_SEX "female" The HDL is too low
• ELSE
• The HDL is OK

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Conditional Logic with Letter Codes

• IF BODY_MASS_INDEX ltgt ""
• IF BODY_MASS_INDEX lt "18.5" .MP Underweight
  783.22 ELSE
•      IF BODY_MASS_INDEX gt "50.0" .MP Super
  Obese 278.01 ELSE
•          IF BODY_MASS_INDEX gt "40.0" .MP
  Morbid Obesity 278.01 ELSE
•              IF BODY_MASS_INDEX gt "35.0"
  .MPObesity Class II 278.00 ELSE
•                  IF BODY_MASS_INDEX gt "30.0"
  .MP Obesity Class I 278.00 ELSE
•                  IF BODY_MASS_INDEX gt
  "25.0" .MP Overweight 287.02 
•             
•                  
•              
•        
•                                                 
  

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EST_CREATININE_CLEARANCE

• IF EST_CREATININE_CLEARANCE ltgt ""
• IF EST_CREATININE_CLEARANCE gt "90 mL/min"
  Normal Renal Function _MP_CKD1
•  ELSE 
•      IF EST_CREATININE_CLEARANCE lt "15 mL/min"
  .MP CKD Stage V 585.5 _MP-ESRD 
•         ELSE
•            IF EST_CREATININE_CLEARANCE lt "30
  mL/min" .MP CKD Stage IV 585.4  
•               ELSE
•                  IF EST_CREATININE_CLEARANCE lt
  "60 mL/min" .MP CKD Stage III 585.3     
•                      ELSE
•                          IF EST_CREATININE_CLEARA
  NCE lt "90 mL/min" .MPCKD Stage II 585.2     
•                        
•                  
•           
•      

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