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| From: | dguest |
| Subject: | Re: [Gnumed-devel] Changes to GuiMain - Suggestions (ctd) |
| Date: | Tue, 07 May 2002 21:18:48 +1000 |
| User-agent: | Mozilla/5.0 (X11; U; Linux i686; en-US; rv:1.0rc1) Gecko/20020417 |
RichardI like the automatic generation of the notes with the word wheel as you describe below ... except for history taking. My problem with it is that it forces you down a previously determined track even if it is your own individual track. My approach is to let the patient spill out their history in their own unstructured way and then go back and expand on certain points. I touch type and try to eyeball the patient as they give the initial history. It is prefererable to keep symptoms at one per line to aid adding new items, annotating existing items and moving the data around. I have added the history component from one of my typical consultations as an addendum. The dashed lines are the annotation of the initial symptom and are added on the second and subsequent runs through the history.
My patients almost always have two problems and often up to four or five. I have played around with the best way of recording the data in these multi-problem consultations and do not have a perfect answer. I think encapsulating each problem in its own section of the page is the best approach. I prefer [S1O1A1P1; S2O2AOP2] to [S1S2O1O2A1A2P1P2]) but use a line of tildes as a demarcator on the first run through the history.My preference is still for a three window approach, 40% width is sufficient for my note taking as mentioned but I agree that the 60% width is necessary for displaying other data for the reasons you state below. My difficulty is placing the third box so that I can see the summary items of the information that I am seeking, whether they be correspondence, pathology or previous notes. I _do not_ want to obscure my current consultation screen or reduce width of the "Detail info" display window. As a first draft my preferences are:-
|---------------------------| |----------------------------------------------------|| Short patient id line | | Scratch Pad | |---------------------------| | |
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|---------------------------| | Warnings / Reminders
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| | Ico|Ico|Ico|Ico|Ico|Ico|Ico|Ico
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| Current | | Summary screen
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I am not a great believer in the value of voice dictation or video taping the consultation. My notes are a summary of the consultation not a re-enactment. (It was only barely sufficiently interesting the first time through.)
I agree that one day computers will record all this information, lay it out neatly, make the diagnosis and prescribe the correct medication. At that point the doctor will be superfluous. Unfortunately that will also be the day that the patient is superfluous.
"Open the door, Hal!"
"Sorry Dave. I'm afraid I can't do that." Dave richard terry wrote:
To further re-iterate on the reason for the two column approach to the screen design. The reason one needs about 60% of the screen real estate on the left hand side, apart from the previously given reasons below, is that it is an ideal size to reproduce a 'page' of information to display. Eg one can display most of an A4 letter in this area, an Xray image, a drug monograph, a graph with decision support attatched, drug interactions etc. These visually fit well there. If you go for a three column approach as suggested by david it simply doesn't work.The remainder 40% on the right hand side is also ideally sized so one can fit most lists of things, reminders, the scratch pad.On Tuesday 07 May 2002 8:59 am, you wrote:Can I make a suggestion. Obviously everyone is going to have slightly different Ideas. Could those who have eg David's comments send me a sketch of the relative sizes of the screen you wish to be apportioned to whatever, and I will do some mucking around in VB to see how your ideas link to functionality and the incorporation of decision support. I think it is vital that this prototyping be done so as to incorporate any new ideas with merit, or to show others how their idea can either already exist in the paradigm or be traded off against some other functionality. a Simple box sketch would suffice, I've time this week and over the weekend to muck around with it. David, I think we have the opportunity here to do more than just 'record data items' in a vertical column. The whole idea of the 'word wheel' as used in my program is to minimise typing and to provide contextural information when needed in an intelligent way. I would assume that in the distant future consultations will be automatically videoed, translated on the fly, the computer will sort out what the doctor said, what the patient said, what was presenting symptoms, what was doctor assessment, and put them logically into notes. However this is a long way off. In the meantime we can get much more out of progress notes than just list them in a column. Consider that during a consultation I might write the following. S: URTI symptoms 0 :ENT NAD, febrile, cough, chest - left basal crepitations, A: left basal pneumonia P: Amoxycillin 500 tds, paracetamol etc FBC for wcc CXR review 10/7 (incidental items might have occurred as well:) Scripts given for dichotride for stone Reminded faecal occult bloods due 0 given form. Now, your progress notes already have a fair bit of 'auto-generated' text, namely the script data, the request forms for CXR, pathology forms for FBC, scripts for the medications including what they were for the doses, repeats etc, and info re the reminder. All this was generated just by your activity. As for the SOAP notes, much of that can be auto-generated as well because the information is contextual eg the minute you start typting UR, up pops the word wheel options around symptomatology (cause the program knows that in the editing area you are typing on the symptoms prompt line), so often a minimal one key press allows you to select the symptoms. Once you hit the enter or tab key and end up on the Objective line, again, contextual information is presented in the word wheel using YOUR LANGUAGE, ie the computer has learnt from previous consultations how you describe patients symptoms with URTI's, so again a short pick list is easy to choose from, or you can add new terms if needed. In reality we use the same language over and over again. Hitting enter brings us the Assessment line, which operates similarly etc. The Plan line can be further refined so that typing Amo brings up the word wheel with amoxycillin (which the system recognises as an antibiotic hence includes the doses etc, so just the act of selecting amoxycillin 500 will autogenerate a script for the caps (as this is an adult, or syrup if it were a child at the approprate dose for age), so you may not even have to switch to the script module. At the same time the system is monitoring what you are doing because once the symptom line got the URTI symptom the decision support guidlines start to swing into action using Ken's information set and underneath the editing area start to appear guidlines for managing and treating URTI's etc. All this is acheivable using current technology and databases. Malcolm Ireland and I (malcolm is an academic GP/practicing GP/head of HUDPG IT department in NEwcastle/has IT degree f rom uni) sat and played with this stuff back in 1996/7 and even using vb3 it was easy to implement. Note that you need about 60% of the width of the screen to acheive this. the remainder on the right being used for your lists of meds/path etc, the scratch pad, and reminders about overdues. The reason you need this space is as follows: -_________----------------------------------------------------------------- --------------------------- | Subjective | URTI;cough;runnynose;fever; |Objective | T38;unwell;left basal chest crepitations;increased RR; |Assessment | basal pneumonia;left;urti; |Plan | CXR;FBC;Amoxycillin 500tds;Paracetamol;Review 10/7 --------------------------------------------------------------------------- ----------------------------------- decisions support txt: current recommendations for the management of urti's are.. bla bla bla : where seco ndary infeciton is present : firstline agents are amoxycillin (covers xyz bacteria...bla bla bla (click here for more detail). (note the font size/colour is different so it doesn't distract you) --------------------------------------------------------------------------- ------------------------------------- (and underneath this there is still room for a list containing info you need to pay attention to but havn't yet eg) - there are 3 outstanding pathology reports for this patient - letter from cardiologist Dr All Heart not yet read - missing immunisations: fluvax, pneumovax --------------------------------------------------------------------------- -------------------------------------- Inputting data in this format is incredibly quick, and if saved in an appropriate fashion lets you pull back alot of detail for research. The computer can also monitor wether you take the time to access the decision support info, the same area under the editing ar ea automatically can pop up disease/drug interactions at the same time (eg having noted you put the patient on drug X, it may recommend that because the patient is on drug Y that it's dosage is reduced, or that because the patient has renal failure, a drug dosage is reduced. Note that ALL OF THIS IS VISIBLE IMMEDIATELY TO YOU. Once you confine yourself to either small vertical columns, or screen wide text boxes you really restrict your screen real estate. Putting some notes in in this manner can allow you to input a whole lot of info automatically eg if the Objective line contains BP=120/70, this is automatically parsed and stored as systolic/diastolic if W=79.4 etc the weight is automatically stored. Anyway, Have to see some patients as is nearly 9am. Hope this helps PLease send me you ideas re shapes/functionality so I can muck round with them.
*History* continuing abdo pain headaches - frontal, mild, constant, paracetamol helps poor sleeping - dozes for an hour - wakes repeatedly through the night - will stay awake for 1-3 hours each time -- now sleeping in separate room to wife - tired in morning - slight improvement in late afternoon edgy, cannot relax - only feels good when out doing heavy manual work in garden generally unwell last six months seen by Dr W. gastroscopy - mild distal oesophagitis last Monday colonoscopy 3 weeks ago - haemorrhoids, few pelvic diverticulae ~~~~~~~~~~~~~~~~~~~~~~~~ initial nausea on Lipitor now settled
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