Epic SmartPhrases

If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.

I previously wrote that I have done a lot of customizations to Epic. In this post I’ll explain how I use SmartPhrases. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period.

My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. I also don’t like to pull in information into my note, such as past history, labs, etc. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is .soap which looks like this:

Subjective:
@AGE@ @SEX@ with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself.

The patient’s relevant past medical, surgical and social history was reviewed in Epic.

Objective:
***

Assessment:
***

Plan:
***

@MEF@

Bolding the SOAP elements visually makes it easier to find things. To use a SmartPhrase within a SmartPhrase you just precede and end it with “@”. The final SmartPhrase MEF is just one I created to add the FACP title, which the built in .ME doesn’t.

I usually enter this in my office, reviewing the chart before I go in to see the patient. I then look at my last note (often using a Dragon script to get it quickly) and copy and paste my assessment. Now my note my look something like:

Subjective:
72 year old male with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself.

The patient’s relevant past medical, surgical and social history was reviewed in Epic.

Objective:
***

Assessment:
1)Hypertension – Suboptimal control.
2)Hyperlipidemia – At NCEP ATP III guidelines.
3)Type 2 Diabetes Mellitus – Uncertain control.

Plan:
***

Daniel C Ginsberg, MD, FACP

Before pasting and still looking at the last note, I also check the plan and often add what I did then to my current note. At the end of first sentence I type the SmartPhrase .ALV (At @HIS@ last visit I) and then add what I did. I use the following SmartLinks all the time in SmartPhrases: @his@, @caphis@, @him@, @he@, @caphe@.

So after typing or using Dragon, the sentence now looks something like, “At his last visit I started him on lisinopril.”

I then check to see what tests the patient has had, and what specialists the patients has seen, and add those at the bottom of the Objective section. I just add the date and make reference such as:

6/12/14 Lab – See report. (the latter created with the SmartPhrase .LSR).
7/2/14 Colonoscopy – See report. (the latter created with the SmartPhrase .CSR).

I try to be consistent with how I name SmartPhrases to make them easier to remember. I also use the Synonyms tab to add other names, especially for ones I have problems remembering.

When recording the history, if you’re not using Dragon, use SmartPhrases for common things to save time, such as .w = with, .co = complains of, .ha = headache.

For the physical exam in Objective, each system as a Smart Phrase, for example:

.GEN
General – Patient appears well in no apparent distress, alert & oriented.

.HEENT
HEENT – PERRLA, EOM with FROM, normal conjunctiva & lids, throat clear, normal lips, gums and teeth, neck symmetric without cervical or supraclavicular adenopathy or mass, thyroid normal

.LUNGS
Lungs – clear to auscultation, no accessory muscle use

.COR
COR – RRR without S3/S4/M, no carotid bruits (Incidentally for the most part I try not to abbreviate creating SmartPhrases since it doesn’t save any time and I don’t want other readers to have guess what it means, but I keep some that are pretty ingrained in clinicians and are unlikely to be confused).

.ABD
Abd – soft, nontender without mass or hepatosplenomegaly

I have variations for each part. For example:

.ABDLUQ
Abd – soft, tender LUQ without guarding, mass or hepatosplenomegaly

.ABDLLQ
Abd – soft, tender LLQ without guarding, mass or hepatosplenomegaly

.EXT2
Extremities – 2+ pedal edema, normal pulses

.GYNE
Gyn – normal external genitalia, urethral meatus, vaginal mucosa and cervix, PAP smear obtained, no adnexal or bladder mass palpated, uterus not palpable

.GYNEH
Gyn – normal external genitalia, urethral meatus, vaginal mucosa, cervix absent, no adnexal or bladder mass palpated, no palpable uterus

I have SmartPhrases for the most common exams I do that combine multiple SmartPhrases.

.BRIEF0
@GEN@
@NECK@
@LUNGS@
@COR@
@EXT@

.BRIEF2
@GEN@
@NECK@
@LUNGS@
@COR@
@EXT2@

I also have multiple SmartPhrases I use to put in the patient instructions section, covering such things as diet, exercise, and instructions on getting lab work. I have one lab instruction that says to fast, with an explanation of what that entails, and one that says it doesn’t matter whether one fasts. Both include some of the labs they can go to and the hours they are open. In between each section I place a line with a SmartPhrase.

.LINE
*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-

For a comprehensive book on SmartPhrases, check out Advanced Charting Techniques for EpicCare Physicians: Super Efficiency with SuperPhrases by Peter G Churgin, MD, CCFP. I don’t really use his system as I had developed my own before I read his book, but they are kind of similar.

Posted in Informatics | Tagged , | Leave a comment

How to Get Rich – A Guide for Pharmaceutical Companies

The Changling Ming Dynasty Tomb of the Yongle Emperor

The Changling Ming Dynasty Tomb of the Yongle Emperor – copyright 2012 Daniel Ginsberg Photography

Thanks to Congress, Medicare is not allowed to negotiate for the cost of medications. The bill was shepherded through by congressman Tauzin, the chairman of the House Energy and Commerce Committee that regulates the industry, who subsequently stepped down then took a job as the President and CEO of the Pharmaceutical Research and Manufacturers of America. This is a lobbyist group for pharmaceutical companies.

Here’s a suggestion to pharmaceutical companies; the next time you come out with a new first in class medication, for which there are no other medications that can be substituted, price it at 10 billion dollars a month. After the first prescription gets filled, it may move Congress to act, but by then you will be set and it won’t matter if you don’t sell another pill.

Posted in Business of Medicine, Medical Politics, Pharmaceuticals | Tagged , , , | 2 Comments

Quitting Smoking and Happiness

The FDA is proposing a new rule in regards to tobacco regulation. As detailed recently in the New York Times, the benefits of stopping smoking, such as less heart and lung disease, would need to be discounted 70%, making it that much harder to justify spending money on smoking cessation. It sounds like something inserted at the bequest of tobacco lobbyists. Tomorrow is the deadline to make a public comment. Here is what I submitted:

I think it’s a dire mistake to discount the economic and health benefits of stopping smoking because of the loss of enjoyment. Although smokers may get temporary enjoyment from smoking, they also get enjoyment from being healthy. Surely one gets more pleasure taking a walk in a park and living at home, than pushing an oxygen tank down a hall in a nursing home because of severe emphysema. Smokers die at a younger age than they otherwise would. What about the enjoyment their partners, children, and grandchildren lose when the smoker dies prematurely? Loss of enjoyment should not be part of the equation, unless it’s a negative number which would serve to magnify the cost smoking places on individuals and society.

Posted in Government, Legal, Medical Politics | Tagged , , , | 1 Comment

If Doctors Ran Their Practice Like The Airlines

Copyright: <a href='http://www.123rf.com/profile_itrace'>itrace / 123RF Stock Photo</a>Physicians could make so much more money if we could charge like the airline industry does.

Starting with appointments, there would be a surcharge for the most popular times. Last minute appointments are extra, on the theory that the patient would be willing to pay more if they are acutely ill. If we have a particularly light day, we might run a special and see patients at a discount. It goes without saying that when booking an appointment in advance, you’d would have to use your credit care to make a non-refundable deposit.

When you check in for your visit, it would cost $5 if you want to sit down while you wait. Magazines can be rented for $1 and there would be water bottles for sale if you’re thirsty. You can pay $7 for two hours of wi-fi to access the internet, or if you are sick or a hypochondriac and visit often, pay $10 per month for unlimited use.

If you’re one of those couples that book your appointments together, there will be a surcharge if you want to share the same room.

Just like it costs more for each piece of luggage you take on the plane, we would charge for each prescription we write. Medications that were more complicated to prescribe would have a surcharge. Want a form for work, to get out of jury duty or a parking permit? That will be extra.

When it comes time to undress for an exam, prepare to bring your own gown, or fork over $2.50 for the paper version. Don’t skimp paying 50 cents for the lubricant!

Do all these charges sound bad? Don’t worry. Hand washing is still complementary!

Posted in Business of Medicine, Medical Humor | Tagged , | 1 Comment

Up in Arms, Up in Smoke

20090715_japan_0671If you apply for health insurance, you may find you have to pay higher rates if you’re a smoker. Now federal regulators are trying to decide if insurers who participate in the Affordable Care Act (aka ObamaCare) exchanges can add a surcharge for those using e-cigarettes or vaporizers.  They already can for cigarettes in most states.

Some argue against this, in the name of harm reduction, the idea that if people are going to smoke, it’s better to smoke something safer. For example, Reynolds American Inc spokesman David Howard, said, “We don’t believe policies should be implemented that might deter current smokers from considering switching to smoke-free alternative products like e-cigarettes.”

Numerous studies have, shown, however,that the best way to get people to cut back on smoking, is to make it more expensive. E-cigarettes and vaporizers are cheaper than cigarettes, so paying more for insurance for all forms will encourage more people to stop smoking. No one is suggesting that those smoking alternative forms of tobacco be charged more than those who smoke cigarettes, so even if insurers charge extra for those who use e-cigarettes or vaporizers, they will not pay more than if they stuck with cigarettes, so really it won’t deter smokers from switching. People switch because it costs less, it’s more socially acceptable, or they perceive it to be safer.

In that last regard, vapor may be safer than cigarettes, but we really don’t know. Recent studies show they can definitely have known carcinogens, such as formaldehyde. Would you really want to inhale a chemical used to embalm corpses? I tell my patients that if they use e-cigarettes to help them quit smoking, which may or may not help, then I’m alright with that, but the goal should be to stop using tobacco products, and not just switch from one habit to another.

 

Posted in Government, Legal | Tagged , , , | Leave a comment

Humor Down Under

Bathroom door at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.

Bathroom door at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.
Bathroom doors at Kawarau Bridge, the first commercial bungee jump in Queenstown, New Zealand.

Continue reading

Posted in Medical Humor | Tagged , , | 2 Comments

Who Are You Calling Old?

Moth on bricksA local family medicine residency program sends second year residents to rotate through my internal medicine clinic. Reviewing the note that one of them wrote, I saw that he described my 66-year-old patient as, “Elderly, ” though did note that she appeared younger than her age. I let that young whippersnapper know that age is relative, and that I doubted he would consider 66 as elderly once he reached his 50’s!

Posted in Medical Humor | Tagged , , | 2 Comments

Pierce County Medical Society Website Launch

Pierce County Medical Society LogoI’m proud to announce that today the Pierce County Medical Society (PCMS) went live with a newly redone website. I’ve been working on it for over a year.

There is a lot to see on the site. I’ve created a video that gives a tour of the site. It’s aimed at members, who see a link after logging on, but most of the content is useful for the general public, including how to use the Physician Search section to find a doctor in Pierce County.

Posted in Community, Informatics | Tagged , , , , , , , , , , , , , , , | 2 Comments

Tort Reform and Forced Sterilization in North Carolina

Torte - Image credit: <a href='http://www.123rf.com/photo_13722428_delicious-slice-of-home-made-sachertorte-cake.html'>digitalsun / 123RF Stock Photo</a>

In 2011 the North Carolina legislature made major changes to the law governing medical malpractice claims. This tort reform, among other things, capped non-economic damages at $500,000.

Such caps on damages do not restrict payments for financial losses, such as future income not earned due to no longer being able to work as a result of injury or death because of something a doctor did, or neglected to do. Rather it limits awards to compensate for such things as pain and suffering.

Physicians in Washington State, and elsewhere, have lobbied for tort reform. Although some physicians have been guilty of gross negligence, in many cases doctors are sued, and juries award large amounts of money, because a patient has suffered, but not necessarily because of something the physician did wrong. Because physicians worry about getting sued, they tend to practice defensive medicine, and order more tests and procedures than necessary as a result. Besides wasting money, it can cause harm. I’ve had patients who have had dozen of CT scans, because every time they go to the emergency room for abdominal pain, they get one to make sure they don’t have such things as appendicitis. The radiation from the CT scan increases the risk of developing cancer in the future. Although such scans are certainly warranted at times, I believe they are excessively ordered because of fear of getting sued.

Between 1929 and 1974, North Carolina forcibly sterilized 7600 people it deemed socially or mentally unfit. Recently the state agreed to set up a $10 million dollar fund to compensate living victims. So far they’ve identified 177, though as of 2010 the State Center for Health Statistics estimated that 2,944 victims may have still been alive. If they end up with 200 such people filing claims, they would each get $50,000. That’s only one tenth of the amount allowed in that state for non-economic damages, and one hundredth if 2000 filed claims, and infinitesimally less in a state that has no such cap. Physicians may be well off, but their pockets are not nearly as deep as a state.

If a physician inadvertently sterilized a patient while treating them for something else, they could be sued for large sums of money for depriving them the chance of procreating. If states can cap non-economic damages for doing the same, isn’t it only fair that limits be placed on non-economic damage for malpractice for physicians who were trying to do the right thing? Although that’s true in about 30 states, the Washington State Supreme Court ruled such caps unconstitutional in Sofie v. Fiberboard Corp., 112 Wn.2d 636 (1989). Although that was not a medical malpractice case, the reasoning goes against the decisions made by a majority of other states, and ignores the fact that resources are limited. No caps in theory means a jury could bankrupt an individual or company, no matter how large, and no matter how many hurt if that happened, all in the name of “justice” to benefit one person, and their legal team of course.

Posted in Government, Legal | Tagged , | Leave a comment

Prostate Cancer – A Fish Tale

20090709_japan_0057

Have you heard that fish oil supplements cause prostate cancer? The news items come from an article published online July 11, 2013 by Brasky et al. in the Journal of the the National Cancer Institute, “Plasma Phospholipid Fatty Acids and Prostate Cancer Risk in the SELECT Trial.

This study looked at 834 men diagnosed with prostate cancer, and compared them with 1393 men, matched for age and race, that did not have prostate cancer. They then looked at the amount of omega-3 in their blood and compared the groups.

They found that those with the highest omega-3 levels had the highest risk of prostate cancer, 44% higher over all. This study followed up on one published earlier by the same group that suggested increased risk from fish consumption. The levels of omega-3 in the highest group were fairly modest, equivalent to eating an oily fish, such as salmon, twice a week.

Before jumping to the conclusion that men should not take fish oil or consume much fish, there are a number of things to consider. First of all, association does not imply causation. What does that mean? Just because two things occur together, it does not mean that one caused the other. If you look outside on a rainy day, you will see many people carrying umbrellas. But you would be wrong to conclude that carrying umbrellas caused it to rain.

It could be that it wasn’t the omega-3 in fish, or fish oil supplements, that caused prostate cancer, but rather something else in the products, such as mercury or other toxins in the fish. If you ate fish raised in places low in pollution, or consumed ultra-filtered fish oil, then perhaps it would not be a problem. This study does not answer that question.

Even if eating fish or taking supplements increases the risk of prostate cancer, studies have shown it decreases the risk of cardiovascular (heart) disease, which is far more common.

This study was not the preferred double-blind, placebo controlled study, and the conclusion may just be wrong. After all, other studies have shown that fish consumption decreases prostate cancer. For example, one in the Lancet showed decreased risk of prostate cancer in those who ate moderate or high amounts of fish. Also consider that Japanese men consume much more fish then American men, yet have far less prostate cancer.

So until I see more convincing evidence, I’ll continue to take my fish oil capsules, and enjoy eating salmon.

Posted in Clinical | Tagged , , | 2 Comments