Audacious Align Avarice

Align is a probiotic manufactured by Proctor & Gamble. It’s a little pricy, but I often recommend it to patients with diarrhea or abdominal cramps. They’ve supplied me with $5.00 coupons to give to my patients.

Imagine my surprise to find the 2012 coupons are $4.50. Give me a break!

According to their web site, boxes of Align now have over $50 worth of coupons for their other products, as shown below. I guess that’s why they had to knock 50 cents off the price.

$10.00 off ONE
42 ct. Prilosec OTC®

$4.00 off ONE
Metamucil® Product

$5.00 off ONE
Olay® Professional Pro-X Product

$1.00 off ONE
Head & Shoulders Product

$7.00 off ONE
Crest® 3D Whitestrips Professional Effects

$10.00 off ONE
Braun Electric Shaver or Epilator (excluding MobileShave)

$1.00 off ONE
Bounty® 6-roll ct. Towels or Larger OR Two — Towels or Napkins ANY SIZE

$5.00 off ONE
PUR® Pitcher or Faucet Mount System

$1.00 off ONE
Charmin® Freshmates® Product

$1.00 off ONE
Oral-B® Pulsar, CrossAction, Advantage, or TWO Indicator or Cavity Defense

$1.00 off ONE
Charmin® Product

Buy ONE
Gillette® Deodorant, Get ONE Gillette Body Wash (Up to $4.29)

Surprising HIPAA Violation

The Health Information Portability Act (HIPAA) has criteria about not violating patient privacy, and potential harsh penalties for doing so. One needs to not only avoid saying a patient’s name to the public (meaning people not involved in the patient’s care), but not even to provide enough identifying information to allow someone to identify a patient. If you say you saw a 45-year-old male architect for diabetes, and there aren’t that many architects in town, you’ve probably supplied enough information for someone to figure out who you’re talking about.

I’m usually pretty conscious of it, and some of my colleagues are used to me ‘coughing’ “HIPAA” when they say a patient’s name aloud. One day, however, while eating lunch with my colleagues, I told the story of an 80+ man who came in complaining of a large bruise on his leg that he sustained after a fall when he tripped while running backwards. One of my colleagues said, “Was that Bob Smith*?”

“How did you know?” I asked.

“We go on the ski bus together and after he gets off he always runs backwards around the bus!”

*Not his real name, and yes, I got his permission to post this story.

Practicing Medicine Without a License

Not infrequently, patients question me about a medication because they’ve heard it’s unsafe. Often it’s from lawyers advertising the dangers of a particular medication or medical product. Although on occasion this may be a good service, most of the time it’s not.

All medications have both benefits and risks, and just because there is a potential problem, doesn’t mean it’s not worth the risk, and it doesn’t mean that alternatives are any safer.

Lately I’ve had patient’s refuse to take Actos for fear of bladder cancer. I don’t see lawyers advertizing about sulfonylureas, probably because they are generic, but they are more likely to cause hypoglycemia, which is much more common than bladder cancer, and may be more serious.

Maybe we need lawyers to go after the lawyers. “Did you suffer any problems after stopping a medicine because you read that it’s dangerous?” Sure, they’ll claim first amendment rights, but maybe they could charge them with practicing medicine without a license.

Epic Customizations

Epic is the electronic medical record (EMR) I use at work (actually my company calls it MultiCare Connect). There are a number of customizations one can do to increase efficiency, and I’ve done a lot. Keep reading to learn just how much.

There are SmartPhrases. These are shortcuts to write out text. Instead of writing “past medical history” one can write “.pmh” and it will automatically enter the three words. A SmartPhrase can contain other SmartPhrases enabling one to generate the shell of a note with a few key strokes, then just fill in the portions that cannot be automatically added.

There are SmartLists. This allows one to basically use a drop down box to select one or more options. Although I have 55 of them, each one consists of multiple entries. For example, if I want to enter the specialists a patient sees, I may select the cardiology and gastroenterology SmartLists, then select the physician the patient sees from each list.

There are a number of different Preference Lists. This is typically used to order various things and save them in the way you want, to save time later. In my Medication Preference List, for example, for an antibiotic it may say to take the medication twice a day until finished and include the proper amount of pills. In the description I write that it’s an antibiotic so my patients know what the medicine is for, and to lessen the chances the pharmacist may misread it. I also include an end date so the medication won’t show up on the patient’s medication list after they have finished taking them. It’s a bit of work, but once saved, it’s very quick to use in the future.

SmartText is kind of a SmartPhrase tied to certain situations. I’ve probably written more than one, but there is no easy way for me to look up which ones I’ve created.

SmartSets allows one to set up templates to do such things as place multiple orders and associate them with diagnoses and notes, and basically speed up various paperwork we have to do. Unfortunately a few years ago Epic made it much more difficult to write or edit SmartSets, so I’ve pretty much stopped working on them.

Letter Templates are just like they sound. I have one to tell women their PAP smear was normal, one to ask their employer to excuse them from work, one asking for a patient to be excused from jury duty due to their medical condition, etc. Unfortunately, as with the SmartSets, it’s no longer easy to write new ones or modify my existing ones.

For the medication dictionary, not only can I add words, but I can set it to auto correct words. If I type “referal”, for example, it will automatically change it to “referral”.

I use Dragon NaturallySpeaking to dictate parts of my notes, but I go beyond with custom scripts. For example, if I say, “order anemia panel” it will enter the proper codes for a CBC, iron/TIBC, ferritin and vitamin B12.

I’m constantly updating, but as of last week, these are the customizations I’ve done in each category.

Tool Number
SmartPhrase 1203
SmartText 1
SmartSet 28
Letter Template 16
Dictionary 5861
Preference Lists
Charges 4
EKG 3
Office Visits 1
Education 3
Immunizations/Injections 13
Labs 335
Imaging 170
Medications 3594
Orders 3
Procedures 41
Referrals 278
Supplies 2
Dragon Scripts 302
Total 11914

Each of the 11,914 items is a customization. It may be as simple as a word added to the dictionary, or represents paragraphs of text, a list of hundreds of items, or dozens of lines of computer code. Having been on Epic since 1998, that means I’ve averaged about a 1000 customizations a year.

All these customizations makes Epic very powerful, but unfortunately it was not designed well to share. Many of the items, such as Preference Lists, can be shared, but only by individuals importing someone’s list. If someone imports my Medication Preference List, it goes out of date as soon as I make a change. My list is so long it may take 5 minutes or so to import the list, and even if faster, most people are not going to remember to import the list regularly. It’s like backing up one’s computer. If not set to do so automatically, most people won’t do it. In addition when one imports someone’s list, it doesn’t show where it came from. I think it would be far better if people could subscribe to preference lists similarly to how one follows people on Facebook or Twitter. My medication preference list was designed for internists seeing adult patients. A family practitioner should be able to subscribe my list, to use on their adult patients, and another list to cover their pediatric patients. It is difficult to share customizations within my own company, and far harder still to share with people in other medical groups. Consequently thousands of people have to reinvent the Epic wheel.