Friday, 11 June 2010

How to Consult with Vision: Part 2

Using Vision: Part 2

Hello again. Optimistically starting Part 2 the next day, though on call all day which may somewhat limit my time to write this.

Where are we? Now you have your head around Read Terms and Vision SDAs, which is great. Next you need to start to learn how to use Read Terms in the consultation.

Read Formulary

There are somewhere in the region of 120,00 Read Terms in the Read Dictionary (if we include synonyms). This is a LOT. In day to day general practice, for consulting, you probably need about 200 to 500 terms. Here are some of the terms you are not going to need:

Ok, so the chances of you ever needing these are pretty remote, though I agree in General Practice you can never say a thing will never happen. What you do not want though is, by default, when you are doing normal, everyday consulting terms such as these being searched on or presented to you. 'Jet' is the classic illustration of this. You may wish to record 'E274500 Jet lag syndrome', but if you type 'jet' as a keyword into an un-configured Vision system you get the one shown above. I practice in Paisley, which adjoins Glasgow airport. Even here I would hope my need of T546 above would be never or once in a career!
Vision provides a tool for dealing with this problem and this is called the 'Read Formulary'. Using the Read Formulary limits your initial search to a small set of practice selected Read Terms, so that you can avoid seeing a whole lot of inappropriate or crazy terms when you go looking. The functionality for turning on the Read Formulary is hidden away in Security, Edit User. As most clinicians never go near that bit of Vision, it is up to your system administrator, often the practice manager, to access this function and turn it on for each user that wants to use it (which should be everyone, in most circumstances). Unless your trainer or IT Facilitator has turned this on for you, you will find that you are currently using Vision with the entire Read Dictionary - all 120,000+ terms, and this will not be making your life easy, simple or pleasant. Now is the moment where you need to have this fixed, but - be warned - if you have been using Vision for a while you will be in the habit of finding a term to use despite the formulary not being on. When you switch it on, things will be different. So, do this for one or two people at a time to try it out, get a feel for the changes and then roll it out to everyone else.
The other thing you will need to do is to populate your Read Formulary with something, otherwise there will be nothing there.

Switch it on

You need to have access rights to Vision Security to do this. Check now - from the main Vision screen select 'Modules' then 'Security'. If you cannot access this (it is greyed out or absent) then you will need to seek out the person with admin rights to your Vision system and have them access it. If no one in your practice has rights to it, I would call helpline or complain to someone.

When you open this you get a listing of users like this:

Names have been blurred to protect the innocent.

Find your name (or the person you want to turn on Read formulary for), and Right Click on it, then select 'Edit User'.

This opens this form:

And that section in the red rectangle above is where you need to make changes. You must make sure that there is a tick in the checkbox labelled 'Select Read term from Read formulary', and that the radio button 'Keyword' is selected in the frame 'Read term selected by'.

Do that, click OK, save any changes and exit the security module.

Now that user is selecting from the Read formulary by default. Better get some stuff into it!

Populate Read Formulary

There are three ways to get things into your Read formulary:
  1. Add them yourself
  2. Import someone else's formulary
  3. Use the 'Create List' functions in the 'Populate Read Formulary' tool.

Of these, I would go for (2), with a bit of customisation over time with (1). Using (3) in a practice where a limited set of consulting codes has been employed is more likely to find for you ill advised terms ('Had a chat to patient'), and disease / condition terms. What you need is a formulary full of History and Examination terms, and this is often best obtained by importing someone else's.

To obtain a Read formulary for importing you can:

  • Download one from the User Group You need to be a member, and if you are not then JOIN!!!
  • Get one from a neighbouring practice, assuming they have one that is effective!
  • Ask on the NVUG forum for one to import. Again accessed via the NVUG web site.

They come as files with the suffix '.fmy'. These are essentially text files and can be viewed in Excel, if you are feeling competent and curious.

Open up the 'Populate Read Formulary' tool from the main Vision menu:

Opens this:

Is there anything there?

In theory in a new Vision system the Read formulary will be empty. If you have had Vision for a while, there may be stuff in there already. Also, in some practices, INPS may have provided the NVUG formulary for you, but not necessarily have turned on access to it for users. So, let's have a look and see what is there.
For this we use the menu option 'Formulary, Maintain':

which opens this (click on 'Display from Formulary' checkbox to see what is there):

Have a quick scroll down the list. If the codes in there are ones you like and want to keep, then great - you can add the imported formulary's terms to these. If not, start afresh - close that window and use the 'Remove all formulary entries' option above to clean it out, or just wait till you import one and choose to 'replace' at that time.

Import Read Formulary

Select the menu options 'File, Import Read Formulary':

[Note the other option above it that will let you export your current formulary. You may want to consider doing this as a backup before making any changes to the existing one.]

You then need to navigate to the folder and file where your borrowed or gifted formulary file is (the one suffixed '.fmy), select it and Vision will pause for a few moments whilst it analyses it. It might present you with some advice or warnings, follow what it says. Eventually you will get to this:

Now you can decide whether to Add or Replace. Add is usually safest, but it is your call. Decide, click OK and wait a few minutes.

Job done. You have now changed it so that you are selecting Read Terms form the practice's Read formulary by default, and are able to do so using Vision keywords.

The next part is hopefully going to be about getting stuff into Vision using keywords and menus. Better go do some visits.


Thursday, 10 June 2010

How to record consultations with Vision

Using Vision: A beginners guide for clinicians

Part 1 of an occasional series

If you are new(ish) to Vision, or not so new but still feeling frustrated, then this occasional series is meant to help. It's occasional because it's written in my own time and there are no guarantees I can finish it, at this stage at any rate.

Comment if you find it useful - this may even encourage me to do more!

Why Vision is Different

Vision is different from paper records, and from many other clinical information systems, because it uses a very structured approach to data recording. What this means in practice is that nearly everything you record in Vision hangs off of a Read Term. This scares people at first, because all they want to do is type in text. But, generally speaking, computers are not very good at understanding text so, if you want a high quality (and thus usable) medical record you need to record the stuff you need to record in a way the computer can use it.
The consequence of all this is that unless you understand Read Terms at least a tiny bit you will find Vision a mystery. Most clinicians (but not all) do not understand Read Terms. Some think they do, which can be a good start, but actually they misunderstand them through limited exposure and use. Some understand their structure very well, but not how to use them in clinical practice.
The other big difference with Vision is that it lets you the user, and your practice, configure it and set it up to work as you want it to. This is both a blessing and a curse. It's great to be able to choose, but unless you (or someone in your practice) bothers to learn how and why to use the configuration tools and then implements these changes, it can remain a frustrating mess. OTOH, once you have learned the basics, and set it up, it will work like magic :)
Don't panic, it is actually dead easy to use and to use well, but you will have to learn what you are doing - it won't just magically happen.

Why bother with Read Terms?

Because without them your computer system will just be a jumped up word processor. Unless you tell the computer that the patient has Hypertension using a code, then the computer will not know the patient has Hypertension. We have learned some of this through QOF, I think. But Read terms also contain many, many other codes and descriptions for many, many other pieces of clinical information. Not all of these bits of clinical information are hugely useful on their own. For example, the term 'O/E Blood Pressure Reading' is of limited value if all you do is type in some free text for the systolic and diastolic values. Remember - the computer cannot use text alone; it needs structured data. So Vision associates Read Terms with special forms or 'Data Areas' for capturing all this other data in a useful (i.e. 'structured') way. So, the Read term 'O/E Blood Pressure Reading' is associated with a Blood Pressure form, where you can add lots of other things about a blood pressure if you so wish. Storing Systolic and Diastolic in this way means that they can be searched on, reported on and analysed both for individual patient care, and for other uses such as QOF.
Vision does this for lots of Read terms - associates them with forms that let you capture the other bits of data relevant to that Read term in a structured way. They call them, rather annoyingly, 'Structured Data Areas', which when Vision first came out sounded cool, but in the iPhone age starts to sound a bit geeky. Whatever you call them, this method of associating clinical terms to clinical data is pretty much how things are done (or should be done) in clinical computer systems. It means that a blood pressure in Vision is always understood by the system as a blood pressure. There is only one place to store it (though lots of ways to get there), and that place captures all the bits of data about a blood pressure you may ever wish to record. For those who are interested, all this is the basis of an Information Model.

So if they are so important, how TF do I use them?

And this is what gets folk confused and annoyed, because a) Clinicians like to write free text narrative (except very few of them really do that!); b) Read Terms are 'an abstraction of reality' so, inevitably, there are gaps, errors and ambiguities and c) Finding Read Terms can be tricky, especially if you don't understand how they are organised.
Regarding (a): in fact clinicians use convention and shorthand to record consultation narrative. Clinical notes are full of examples of this (e.g. 'o/e' for On Examination; the use of '0' (zero) prior to text to indicate the absence of something e.g. '0fc' for No finger clubbing), and most clinicians have spent large chunks of their careers learning how to do this. We do not just write long hand text. Vision can be used in a way that supports a lot of this clinical shorthand, making recording a consultation quick and intuitive whilst also gathering lots of useful data. How much of this you use or do is, of course, up to you - you can just enter a string of free text in the comments box, ideally underneath an appropriate Read Term, and this is often a good way to start.
(b) we cannot do much about, but understanding how Read is put together can help you in choosing a suitable term, even if it is not quite what you were trying to say. Qualifying or explaining the Read Term in the free text is entirely sensible, and what the free text is for!
(c) is overcome by this blog posting, which explains the basics of Read, and by the tools in Vision that make it easy to manage the Read Terms dictionary.

What are Read Terms then?

Read Terms are a 'clinical terminology', but you do not need to know this. Better to think of them as a 'Thesaurus' of clinical terms. They are a way of attaching a number to the stuff you do, so computers can make use of it and there are about 120,000 terms. These are organised in broad chapters, which are numbered (coded) beginning with the number '0' (Occupations) then '1' (History / Symptoms) and then continuing up to 9, then through A to Z. The chapters are hierarchical - that is, as you expand them the amount of detail, or how specific the term is, increases. For example:
Chapter 2 contains 'Examination / Signs' terms. It looks like this:

The number (and any dots that follow it) is the Read Code, thus '212A.' is the Read Code. Every Read Code has an associated description or term, in this case it is 'O/E Patient well'. There is other stuff that I am going to ignore for now, such as Preferred Terms and Synonyms, as you can get by without it. Read does, however, also have abbreviations for terms built in, which are typically short forms of the term. These can be up to 10 characters long. For example, 'MI' is an acronym for the Read Code 'G30.. Acute Myocardial Infarction'. This is important because Vision makes use of these as 'keywords' that lets users quickly find the term they want. More later.

The Read Hierarchy

Read is split into broad chapters, as mentioned above. If you examine the picture below, even briefly, you will see that chapters 0,1 and 2 are about history and examinations; chapters 3 to 9 are about stuff that clinicians and others do to, for or about patients; and chapters A onwards is all the disease stuff.
Now, clinicians often get hung up on trying to find a diagnosis for a patient every time they see them. If you are one of these people, please stop! In general practice we manage a lot of chronic disease and a lot of uncertainty. Much of the time there is no diagnosis, or the diagnosis is not new. What you want to record is what the history was, what the findings of your examination were and what you are going to do about it. IOW, terms from chapters 1 and 2, and sometimes 3 to 8.
If you do have a diagnosis, by all means add it and, usefully, abbreviations (or 'keywords') exist for many common ones, such as 'uti' or 'urti'.

Bad things to do with Read

Use 'Chat' and 'Patient Reviewed'

Because people get lost in Read, they latch onto an inappropriate and often useless Read term to give them a comment box to free text in. It is better, when learning, to at least use high level chapter headings about the stuff you have done and capture it there, e.g. '1....History / Symptoms' for free texting the history and '2....Examinations / Signs' for free texting the examination.

Say 'not' in free text

Classically, 'G20.. Myocardial Infarction' as the code, with the free text 'Negative'. Read does not say 'not a thing' very well, but it has some terms for 'negation' and they should be used where possible. Where not possible, record symptoms. For example '1822. Central Chest Pain', free text 'MI Screen negative'.

Free text values and data that should be captured!

For example, adding a blood pressure as free text is not much help:

If there is a 'Structured Data Area' for the thing you are trying to record, use it!