The English language is a code. But computers are lousy at recognizing it, at least when it comes to medical terminology. You think hieroglyphics seem complicated? Seen SNOMED?
You have your EMR. Unlike most MDs, you’ve actually populated your problem list with diagnoses. You thought you were done.
There are different levels of computer usage. Early on, perhaps at the very first stages, there is computer billing. OHIP has stopped accepting any kind of written entry. Remember those paper cards we had to fill out?
So, we start billing on computer, and then get our secretaries to do appointments on the thing. My secretary kept a double system going for a couple of weeks, logging appointments in a paper book system, as well as the computer, until she could trust what she was doing.
BIG LEAP, is record keeping. Physicians (at least in the past) were not taught how to use the EMR. I couldn’t type, at all. I was the dinosaur, dragging my feet. I couldn’t get it. I had a flow sheet of diagnoses, that I kept up to date, and a flow sheet for meds. Labs were kept separately in a duotang, right in the chart, as were consults. My hand-written notes were for me anyway, right? Hey, they were my work notes! Mine!
Well, partially. Anyway, eventually, objections are drowned out, and progress…happens. What a horror show. Work days never ended. I worked countless evenings trying to get those flow -sheets transcribed. Mavis Beacon helped.
And I did see the advantages. People could read my work notes. Prescriptions were legible, and the computer drug interaction warning system helpful. In a few months, we decided to go for a direct download of lab data: now, I could graph results.
But sit back and think. Really, what have you got? A highly legible, be it searchable, and graphable, expensive paper charting system. A lot of us have the EMR now. Have outcomes improved? Maybe a little. Less errors…
The next big step is to use the computer to help us do action research, those annoying QIPs the government wants us to do.
I know you don’t have the time. Computerization and the EMR has added easily 1-2 hours on to my day. Now they’re asking me to think of what I’m doing! Of how to improve care, and outcomes! I mean, where do they get off?
The computer can help us do this analysis, but the stupid thing doesn’t recognize English, at least well enough. How do you list diabetes in your problem list? We all do it differently. DM, DM1, DM11, MODM, diabetes mellitus, glucose intolerance, impaired fasting glucose, syndrome X, ^ Hba1c, ^ FBS, hyperglycemia, glucosuria, is there more? Probably.
You want to have the computer pick up ALL the diabetics. You need to formally tell the computer what the diagnosis is, in a language it understands. Software vendors give you some options.
SNOMED CT (or SNOMED clinical terms) is the best. You can google the acronym, and see its historical basis. Simply put, this system is international, and the most precise. You can pick not only DM, but DM11 with nephropathy.
There are other systems. Simpler systems may be … simpler. Two or three options. You can still simply use “diabetes mellitus” without including the nephropathy, but you have the option. SNOMED is becoming standard. If you use another system, sooner or later you’ll have to switch over anyway.
I use PS Suite, or whatever they call it now after Telus bought it out.
Click on your diagnosis in the problem list, and the computer will take you through the steps to pick a SNOMED diagnosis. The problem turns from blue to black.
It’s another daunting task. I’ve heard some MDs employ bright high school students to do this. Good Luck. I’ve tried it…
We are the transition generation here, folks.
We’ve got to grind it through.
(SNOMED does sound friendly, though, doesn’t it? Like we could stick a carrot in its face or something…