Using VistA in a small office

[Mike Schrom]

Some points regarding VistA in a small office. I just joined a group
of 2 full time and 1 part time ENT docs. Having used VistA in the VA
hospital for most of its life, and having played with it outside for a
while, I set up a server running Ubuntu and wireless laptop running
Windows XP as a proof of concept for my new partners to see how a cost
effective, open source EHR can work. They were impressed and gave me
the go ahead. We are not using all of the features, by any means, but
I have set up a bare bones EMR system. Basically just chart notes.
Currently we are tied to a proprietary Billing system.
I used the astronaut installer and Kevin’s CPRS in order to make the
load on the front desk and transition from paper charts as simple as
possible. The front desk will just input basic name/DOB/SSN via the
“Add Patient” button. My demo system used Dragon Naturally Speaking
8.1 for my dictations, with a lot of macros to input boilerplate text
(“Insert Ear Exam”, “Insert Nasal Endoscopy”). However the @#$%^&*( at
Nuance have crippled Dragon in the current version 10 so that you
can’t dictate into EMRs unless you buy the $1800/person “Medical
Version”. However, the new Laptops we ordered have MS Vista (with an
upgrade to Windows 7 promised), which has an excellent speech engine
built in. With a free add-on from Microsoft for speech macros - - - IT
Works! I had it read some old medical records to import my most used
words, and I can say “tinnitus” without getting “tenet assists”. With
training, and the speech macros, I only have to correct a few words
per note.
After I set up the new servers (raid on each and a mirror located at
the satellite office), on the agenda are scanning outside
correspondence, input of medications (non VA) and encounter info, so
Medicare can have its “Quality” data.
With regard to scanning documents, our medical records clerk looked at
the VistA Scanning application and turned ashen. It was too
complicated, as I feared, so I plan to have her use Acrobat to scan
old charts and outside reports, which she was much more comfortable
with, and read them from within CPRS via a “tools” link.
Someday a link to a billing system would be great.

[David Whitten]

This is very encouraging Mike.
Please continue to give us status reports as things occur. this was very enlightening.

David

[kdt...@gmail.com]

Thanks for the experience.

I have Dragon 8 medical, and it cost $800. I can't believe they upped
the price to $1,800 for version 10. What jerks!

For what it is worth, this is how I use Dragon. I dictate into a
portable digital dictation device. I then run it through Dragon, into
the Dragon pad. I then have an employee check it for errors, and then
they cut and paste it into my templates. I like this best as I don't
have to dictate all the stuff that is the same from visit to visit.
When they are done, it shows up on my Alerts menu, so I know to review
the document and sign if OK.

Kevin

[Mike Schrom]

We do not have enough employees two cut and paste like that. I'd
dictate directly into CPR S. My speech macros allow me to dictate the
same information repeatedly. All I have to do is say "insert new
patient exam" and I get:

CHIEF COMPLAINT.

HPI.

REVIEW OF SYSTEMS
General: None. Eyes: None. ENT: None, except as noted
above.. Skin: None. Respiratory: None. Cardiovascular:
None. Gastrointestinal: None. Musculoskeletal: None.
Gynecologic/Male Genital: None. Neurological: None.
Psychiatric: None. Endocrine: None. Hematopoietic, Lymphatic:
None. Allergy: None.

PAST MEDICAL HISTORY
Operations: None. Major illnesses: None. Allergies: None.
Therapeutic/Drug Status: None.

Family History: None.

Social History
Tobacco: None. Alcohol: None. Recreational Drugs: None.

EXAMINATION

EARS

External Ears: No lesions or deformities Canals: Right: Normal,
Clear to TM Left: Normal, Clear to TM TMs: Right: Normal Left:
Normal. Mobility: Right: Normal. Left: Normal. Weber: Midline.
Rinne: Positive Bilaterally.

NOSE

External: No lesions or deformities Septum: Midline Mucosa:
Normal Turbinates: Normal Middle Meatus: Clear, no polyps, lesions
or drainage.

(and so on)

I just have to change the pertinent details, and my impression and
plan. I edit as I go and signed the notd when I am done. When I
walked out of the exam room, the note is completed and signed. For
the moment, I print the notes out, but I expect to set up a fax on one
computer to fax the notes directly two referring Physicians.

As you might have noticed I used windows speech recognition to create
this reply. This is as it recognized my speech, with no editing at
all.

Mike

> > Someday a link to a billing system would be great.- Hide quoted text -
>
> - Show quoted text -

[Joseph Dal Molin]

> (“Insert Ear Exam”, “Insert Nasal Endoscopy”). However the @#$%^&*( at
> Nuance have crippled Dragon in the current version 10 so that you
> can’t dictate into EMRs unless you buy the $1800/person “Medical
> Version”.

Mike are you saying that Dragon 10 does not integrate with CPRS like its
predecessors did? Or is it crippled in recognizing medical terms that
the previous version recognized before? In either case this is plain
stupid... many years ago I was offered the opportunity to run Philips
voice recognition software business in Canada.. I turned them down
because at $4,000 a pop I told them they would not succeed in the
primary care market... they didn't.... and so Nuance is pricing itself
out of this market niche real fast. It also says that their basic engine
has become too good and is competing with their "specialized" versions.

Thank you for sharing your experiences from the front lines...they are
very valuable!!!!

Joseph

[kdt...@gmail.com]

You may be new in practice, and what you can do is dictated by the
senior partners. But eventually you should be able to do what seems
best to you. I.e. you will be able to decide if it is worth paying
someone to do this for you. And then it becomes a question of doing
what you do best (medical) and let someone who is earning less than
you to do the less efficient stuff.

I have 4 employees. The one who does the dictation stuff normally
does my billing. I largely type my own notes (believe it or not, this
is more efficient), and only do the dictation stuff when I get
behind.

Using Dragon to insert templates is good, but it won't let you
automatically insert text objects into CPRS. I.e. I have an object
that pulls vitals. And another one the inserts data tables pulled
from prior notes.

I also want to echo Joseph's question. How does Dragon 10 know that
you are dictating into an EMR? The text window is just a standard
text window. Can you not dictate into other applications, i.e. text
pad? If so, you, you could dictate into text pad, then issue a
command to select all and copy, and then do a block paste into CPRS.

Kevin

[VistaVIS]

Mike -
This is really very informative.

Just a question - I always thought that we could use any normal Wintel
server for Vista application. So when you say "After I set up the new

servers (raid on each and a mirror located at

the satellite office)" - what was the basis for selecting RAID servers
+ mirror one?

[Mike Schrom]

Nuance's argument is that their specialized medical language model is
worth more. Agree or not, they specifically show on their web site
that the medical version is compatable with VistA, which means that
the preferred version isn't. The cut and paste method probably would
work, I used it a long time ago with ViaVoice, but it's an extra
step. I don't need to include things like vitals, but you can use
the patient data objects in VistA along with dictation. As an aside, I
typed my PhD thesis with the same three fingers I use now, but typing
is not efficient for me, however, I see our residents at the VA type
their notes along with templates in VistA.

> > > - Show quoted text -- Hide quoted text -

[Mike Schrom]

You need an ironclad backup strategy. I've seen enough posted here
about server crashes that I decided to put my data on a server with
RAID drives (software- Bhaskar!) with a second machine six miles away
at our satellite office using GT.M's mirroring capability so that if a
drive fails, we have the duplicate in the RAID array, and if the whole
computer fails we have the mirror which can be brought up quickly.

[RogerLee]

I'm sorry for being naive, but is VistA, "out of the box" effective in
the small doc/clinic environment? Is it recommeded to make any
changes? Other than scanning and dictation, what are the other major
roadblocks, specific to VistA? Thanks for the education!

[Mike Schrom]

Make no mistakes, VistA is designed to run hospitals, integrated
health systems and the like. The primary care providers order labs, x-
rays and drugs which are processed in-house by the lab, radiology and
pharmacy departments. Consults are sent to consultants and answered by
specialists in the same group. That's the way the VA works. In a small
office, I just ignore the functions I don't use. I don't write drug
orders because the local Rite Aid Pharmacy is not using VistA to
process prescriptions. Same with labs and radiology. But I find that
using VistA as a stand alone electronic chart program, while it may be
a little like shooting a canary with a cannon, does work with little
modification. The biggest improvement IMHO has been Kevin Toppenberg's
mods to CPRS which allow direct entry of patients, without an
administrative department "registering" patients. Same with the GUI
scheduling, which I don't use because our schedule is integrated with
our proprietary billing system. One of my cardinal rules is never make
the front office staff do double entry.

[VistaVIS]

Vista may not have e-prescription feature as of now, but we can still
write med order that can be probably printed as paper prescription,
right? I mean even in a small office VistA can do a lot other than
maintaining charts.

[Mike Schrom]

Yes, I think I've heard that some people are doing that now. I don't
know how to set that up, plus in New York State, where I practice, we
are required to use an official, state provided form for
prescriptions. The idea does sound attractive, though. Write an order,
as I do at the VA, and the patient picks up the printed RX at the desk
when they check out. Interestingly, we have had some recent problems
at the VA with patients not going to the pharmacy to pick up
prescriptions that have been ordered in our outpatient clinics.

[Nancy Anthracite]

WorldVistA EHR and I believe other versions of VistA outside of the VA have
something called Autofinishing. I suspect if you format the output correctly,
it could print on particular locations on a form that was fed out of a printer
so that you could use the required prescription form if it will feed through a
printer. Is it something with a carbon so that a dot matrix printer might be
needed?

--
Nancy Anthracite

[Mike Schrom]

There are two types of Rx form for printers, a 3.5 inch wide thermal
printer roll, and an 8.5 x 11 sheet which is perforated at 1/4 of the
sheet (you throw away 3/4 of each page).I don't think there are any
carbon or NCR papers with duplicates.

On Nov 12, 7:12 pm, Nancy Anthracite <nanthrac...@earthlink.net>
wrote: