Visionblogged

Flu Macro 2011

2011-10-04T14:12:00.002+01:00

I have an AutoHotkey macro for flu immunisations that manages batch numbers and can be set to add a prescription if needed.

http://bit.ly/p1eeKh

On Google Docs.

Journal views and SCI GW

2011-09-05T09:32:00.002+01:00

A thing that really annoyed me was the breaking of the management of tabs in journal - the wrong View Options would appear when selecting from a (R) click.

At the NVUG Scottish Conf in June someone in the audience reminded me that you need to put the SCI GW tab as the last tab, otherwise things break. And, true enough, having done this the View Options all work again.

SCI GW is painful to use though. Slow.... and clunky.

Remember always in the GW referral to check and edit medical history - try not to send details of a patient's erectile dysfunction to the eye specialist etc...

More macros

2011-05-21T09:24:00.002+01:00

Ah but of course it is never so simple...

If the patient has a Vision reminders (yellow box) open then this gets the focus when you do winactivate.

So, this is my solution though I am sure there must be a more elegant one...

;Send focus to Consultation Manager
Set_Focus_ConMan:
Process, Exist,conmgr.exe ; set the variable errorLevel to the PID of con man
if ErrorLevel ; If Errorlevel is not zero then it is the PID of conman so
IfWinActive, ahk_pid %ErrorLevel% ; if it already active do nothing!
{
ExitApp
}
else ;otherwise...
{
WinActivate, ahk_pid %ErrorLevel% ; activate conman
IfWinActive, Patient Reminders ; and if the reminders are there they get the focus! So, close them
{
WinClose, Patient Reminders
sendinput, !vr ; then reopen them and conman will now be properly activated and have the focus
}
}
IF NOT ErrorLevel ; if errorlevel is zero con man is not running.
MsgBox,,Macro Run Error!, Consultation Manager is not running!
ExitApp

Autohotkey Vision

2011-05-19T14:54:00.007+01:00

Hello. Been a bit busy :)

Have started playing with Authohotkey, which is super if a somewhat a steep learining curve. Far more powerful than MacroExpress. Pleased today as this script:

Set_Focus_ConMan:
^+C::
Process, Exist,conmgr.exe
WinActivate, ahk_pid %ErrorLevel%
return

activates Consultation Manager as the active window, either as a subroutine when called or via the hotkey CTRL+SHIFT+C. I will call it as a subroutine, the hotkey was just to show it works.

This is good because MacroExpress could never do this reliably for me.

:)

2010-12-01T10:04:00.003Z

NVUG Local User Group Meeting
Monday 6th December
12:00 for lunch, provided by pharmaceutical company
12:30 till 14:00 for meeting

Place:
Glenburn Health Centre
Health Education Room
Fairway Avenue
Paisley
PA2 8DX
tel: 0141-884-7788

Brief:
This is a small clinical user group meeting. We have places for about 15 people, and about 10 are coming already. Please e-mail me at paulagmiller at gmail.com to confirm your attendance.

Agenda:

Installing, configuring and using Macro Express with Vision
(with apologies to all Authohotkey fans!)
Electronic Palliative Care Summary in Vision - how to and options
Q&A / discussion

Hope to see you there!

Stop using the journal!

2010-10-25T10:55:00.001+01:00

Fix the views - stop using the Journal

Yes, hello again. This is a slow and very occasional series. If anyone else wishes to volunteer as an editor / contributor please let me know.
Right, what is this about? It is the next step in using Vision with a modicum of success for consulting and it is mostly about telling you to STOP USING THE JOURNAL!
When, when you had paper records, did you ever lay each item in the record out in the order in which it was entered and make any kind of useful decision? It just is not how we use medical records - we use filters and structure (even in paper) to view the information we require. The Vision Journal is the TAB OF LAST RESORT. But, for reasons best known to INPS themselves, the Journal remains the first thing newbies see and the first tab most people are introduced to.
Well, stop it. Please. It is too much.
Here are some alternatives:

Patient Record Views

The ‘Patient Record View’ is the name for all the sections and tabs you see when you look at the patient’s record. That is all it is. There are some default system views available for you to use and, better still, you can make your own or tweak your current one. Most people seem to end up on View 4, which is not awful. View 7 will give you a Consultation Pane as well, into which you can manage Consultation Topics (also useful for Problems) but not everyone likes the loss of space to the Consultation Pane. (get a 23’’ widescreen monitor, it makes life so much more pleasant!)
You can change these from, where else but, Consultation Manager, Options, Setup. Then the ‘Patient Record’ tab:

So, you can select ‘Standard system distributed options’ from the topmost dropdown and this will let you select from system views. Try some out, it is easy to change back, and see if you find one you prefer. If a tab is missing or there is one you do not need, these can be changed so don’t panic if the view you look at is not immediately providing everything you require.

Some of these Views still Default to Journal!

Yes, they do. Lets deal with this. Depending on your role there will be different things you wish to look at when you first enter a patient record. As a GP I am more interested in the clinical narrative, i.e. the stories, rather than the test results or the prescriptions. Journal view fills up with results and scripts, and this is at least partly why it is not of value for everyday consulting. You can create an ‘Initial filter’ in Vision so that the first thing you see is filtered to only show specific data items. I use this to exclude scripts and results (and some other stuff). The feature for doing this is hidden away and not by any means immediately obvious, so listen carefully.
You will see on the top of this list are the words ‘Initial Filter’. As well as being words this is actually a control, i.e. a bit of functional interface that does stuff. Right click on it:
And you get this menu. You will see you can ‘Save selection’ - what selection, where? I will tell you. Also you can ‘Rename Initial Filter’. All this does is change the words ‘Initial filter’ in the navigation pane to say words of your own choosing. I will say no more of it!
When setting this up you need to first select ‘Show Items with no data’ as this will display in the Navigation Pane all possible data types that can be recorded and shown in the patient record. This will allow you to select them for the Initial Filter, even if that particular patient has no records of that type.
So, do that!
So now you can see all the possible items of data that can be recorded about a patient.

We need to select the ones we wish to use as our ‘Initial Filter’ - the data items that are displayed on our filtered tab. To do this, hold down CTRL and click on each data category you want to display. For example:

Happy with that? Now (R) click on the label at the top ‘Initial Filter’:

And select “Save selection as Initial Filter”. Then do the same again - (R) click, and deselect “Show items with no data”.

Next you need to set up the ‘Filtered List’ tab as your initial tab, assuming you want this to happen. As things stand whenever you first click on the ‘Filtered List’ tab it will now show you data items from the Initial Filter - i.e. the ones you just selected by CTRL+clicking.

To make it the initial tab, (R) click on the tab label:

to see this:

Select ‘View Options’, and this opens:

If you check on ‘Initial Tab’ here then whenever you start in Consultation Manager this tab will show first. And NOT the journal tab. So now you can begin to see the wood from the trees :)

Keyboards!

2010-09-16T18:06:00.000+01:00

Use the Keyboard

To use any clinical computer system with a modicum of success in General Practice you are going to have to learn to type. Worse than that, you are going to have to learn how to use a computer keyboard and then learn and use some Vision 3 specific shortcuts and keystrokes.
Do not despair!
Well, unless you have never really used a keyboard at all, in which case your ‘learning curve will be steep’. A euphemistic way of saying you have a lot of work to do...

I’ve never typed before!!!!

In this scenario you have two options, maybe three but the third is a little desperate.

Option 1

Learn to type.
OK, not to be facetious but really, unless option 2 below is possible for you, spending some time actually learning to type and use a keyboard is what you will have to do. You need to plan for this, get the time and, of course, in the brave new world of re-validation and appraisal, you can add all the hours into your PDP. Not that that necessarily cheers you up.
There are free online typing tutorials and lessons - use Google. Or you can buy commercial computer assisted learning packages, or you could go to night school. You do not need to know how to touch type, just enough to find your way around a keyboard and do more than one finger typing. Touch typing is a bonus, but not something I have ever learned or been taught.

Option 2

Can you retire? Seriously, the input device for your computer system is a keyboard and, in one form or another, this is likely to be the case for many years to come. If you cannot learn to use a keyboard, then you cannot use your computer.

Option 3

Wait for technology to do something better.
This is a bit of a stretch. Voice input needs you to be competent with a computer, able to navigate documents and, in fact, to be able to type. It also requires significant training to increase the accuracy, and this takes time. Further, talking to your computer is not always easy, especially with the patient in the room.
Perhaps new technologies and innovations will suddenly make the QWERTY keyboard obsolete. Perhaps, but not very likely. I would not pin your hopes on option 3, though it may make for an interesting debate as part of a procrastination strategy until, eventually, you can do (2) or face up to having to do (1).

Can’t I just use the mouse anyway??

Well, mousing is inevitable in pretty much any Windows application but using Vision with mouse and keyboard is slower than just using the keyboard, at least for the tasks that can be achieved with keyboard alone. Further, using your computer in front of patients is much more discreet if you can surreptitiously type ‘ALT, L, B’ to get the blood pressure listing up, whilst still paying them some attention. Mouse distracts the hand and the eye. Keyboard alone is better for rapport.

What can I do with Vision and the Keyboard?

Lots. Most of Consultation Manager can be navigated, and most of the functions accessed, via the keyboard. Although built as a Windows graphical interface program, Vision contains keyboard accelerators and shortcuts to let you do most of the work without ever touching the mouse.
It is definitely worth making the effort to learn. Force yourself to start using the keyboard today, and within a week you’ll never look back!

Windows Shortcuts

I got stuck on this section for several weeks for no more reason other than I think you could find these out yourself! However, the things that help are knowing how to manage text in documents, and how to navigate round forms and documents using the keyboard. So, FWIW, my to ten important ones would be:
CTRL+C: Copy
CTRL+V: Paste
CTRL+X: Cut
TAB: That’s the key on the left of the keyboard with two arrows going in opposite directions. You can use this key to move forwards through fields on a form. If you press SHIFT and the TAB you will move the ‘focus’ on the form back one step.
Arrow keys: Up, Down, Left and Right. Up and down often let you select new options in a list, e.g. in Vision Read term select. Left and Right will move back and forwards one letter in text, whilst up / down will move one line up / down in text. If you use CTRL+ an arrow key it will move one word right / left or one paragraph with up / down.
CTRL / SHIFT +CLICK to select: If you hold down CTRL and click on lines in Vision it will select them as you click. If you hold down SHIFT+ click it will select everything between two lines.
HOME: Moves to the start of a line.
END: Moves to the end of a line
Page Up: Moves a whole page upwards, and I am guessing you can work out what Page Down will do :)
Windows Key: if you have a Windows keyboard then the key between ALT and CTRL bottom left is the ‘Windows key’ and this can assist with a few shortcuts. Is use this key + L to Lock my PC when moving away from my desk.
ALT: The ALT key generally opens menus in applications, and is one of the mainstays of navigating round Vision with the keyboard.
More: Have a look at http://support.microsoft.com/kb/126449 for more information...

Vision Shortcuts

Function Keys

Traditionally new Vision practices are given a little keyboard overlay for the function (F) keys. This has some value :) The function keys generally do these things in Vision:
F1: Help. Should be ‘context sensitive’, in other words open at an appropriate place for the tast you are doing
F2: List Medical History. Just not so useful now we have the Vision 3 views, this was the default access to medical history list in early Vision versions and possible VAMP Medical.
F3: Find!!. It finds stuff, or opens the Find / Search form again depending on what you are doing. So, it should open the Find Patient form, or Find Read Term, or Find Therapy.
F4: Opens the ‘Scripts’ list
F5: Opens the ‘Repeats’ list
F6: (with CTRL) cycles through open Vision windows
F7: Starts a consultation and with SHIFT closes a consultation
F8: Opens the Add New Therapy form
F9: Once to create an issue of selected repeats, a second time to send them to the printer or ETP
F10: Expands the tabbed data display pane, hiding the others. F10 again to bring them back.
F11: Opens the Medical History Add form. Useful when you do want a specific SDA.
F12: Display the practice Guidelines Index.

ALT+A+?, ALT+L+?

Open Vision Consultation Manager and a patient record. Press ALT once (don’t keep it pressed down!). If you look at the menu across the top, that is the words ‘Consultation Summary Guidelines...’ you wills ee that some of the letters have been underlined.
Pressing the underlined letter will open that menu.
So, to ADD stuff, we can do:
ALT, A, the letter in the menu e.g. ALT, A, B will open the Add Blood Pressure form; ALT+A+W will open the Add Weight form.
ALT, L, the letter in the menu e.g. ALT, L, B will list the blood pressures.
So, the magic keys are (and I have only listed the most useful ones):
P: Problem
L: Medical history
G twice: Gets you to Allergy add.
I: Immunisations
B: Blood Pressure
H: Height
W:Weight
A: Alcohol
K: Smoking

CTRL+K

Does the same as OK or ‘Save’ on many, many Vision forms.

ALT+A for ‘Another’

On Medical History Add use ALT+A to add another. This lets you speed through Read data entry using keywords and keyboard. e.g:

srt, ALT+A, okthr, ALT+A, advrx, CTRL+K

Would record:

1C92. Has a sore throat
2DC4. o/e Pharynx NAD
677B. Advice about treatment given

CTRL+letter on tab

This lets you move to the tab in consultation manager that corresponds to the underlined letter in the tab title.
It works reasonably reliably, but not if you have a form open or if the focus has moved to another pane.

ESC for cancel

Don’t press ‘Cancel’, hit the Esc key instead! In the above (CTRL+letter for tab) if a form is open press Esc to dismiss the form, then the CTR+ combination to get to the tab you want.

Ok, I am done with keyboard shortcuts. Let’s move on!

How to Consult with Vision: Part 2

2010-06-11T11:54:00.002+01:00

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:

Add them yourself
Import someone else's formulary
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 http://www.nvug.org. 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.

How to record consultations with Vision

2010-06-10T17:49:00.002+01:00

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!

'How do you just look at the record w...

2010-05-26T16:44:00.002+01:00

'How do you just look at the record without opening a consultation'

First way:

If you see this form when you select a patient:

Click on 'Cancel' or, better yet, just hit the 'Esc' key top left on your keyboard. This will dismiss this form without starting a consultation.

If you don't see that form before you start a consultation, i.e. Vision just immediately opens a consultation without asking, then use the second way...

Second way:

Change the settings for Consultation Manager. Click on Consultation, select Options, then Setup, like this:

Opens this form:

Uncheck the box 'Start a new consultation automatically when patient is selected'. (note it is checked in the picture, you would uncheck it!).

OK that.

Now, when you select a patient you will not start a consultation.

As shown, you can control whether you ever see the 'Consultation Form' shown in 'first way' above using the options under 'Display Consultation Form'.

To start a consultation:

When you want to, press F7 (or press the 'chair') icon to start a consultation.

Consultation Types

2010-05-24T11:55:00.002+01:00

Below is advice for our reception staff on selecting the correct consultation type

Consultation Types

Please use the correct consultation type for the encounter.

The consultation type is selected here:

And can be quicly selected by pressing the first letter of the type of consultation you are recording. For example, press 'A' twice to select 'Administration', or 'T' once for 'Telephone call from a patient'.

Alternatively, click on the drop down list with the mouse and select the correct one.

You can change it by double clicking on the bottom right part of the screen, here:

Which will open back up the Conusltation details form as above.

Which Type?

Use some common sense to select the best type. Do not, for example, use 'Home Visit' unless you are actually seeing the patient on a home visit!

Please use:

ADMINISTRATION:

Use for any mail processing, recall management, records review and coding.

TELEPHONE CALL FROM A PATIENT

Use for any phone calls received from patients or their carers or representatives. Commonly use for Home Visit requests.

TELEPHONE CALL TO A PATIENT

Use whenever you call a patient or their carer or representative.

THIRD PARTY ENCOUNTER

When contacted by a patient's relative, carer or other person about a patient at the reception area.

MEDICINES MANAGEMENT

For all updates to prescriptions and prescription requests.

REPEAT ISSUE

For repeat prescriptions issues.

SURGERY CONSULTATION

When seeing a patient for HCA activities, i.e. in a consutling room for BP checks etc.

RESULTS RECORDING

When transcribing any results from paper to computer record

OTHER

For anything else, including e.g. encounters at the reception desk with the patient which require some entry in the record, but are not prescription requests.

Vision 3 therapy and Emergency Care Summary

2010-05-17T10:07:00.003+01:00

To include a medication in ECS

Vision 3 sends Acute prescriptions and Issues of Repeat Prescriptions to ECS. Acute prescriptions are included regardless of whether they have been printed or sent to eAMS provided their Date Prescribed value is within the last 30 days. Issues of Repeat Prescriptions are sent regardless of whether they have been printed or sent to eAMS provided their Date of Issue is within the last 12 months.
Note that Repeat Prescription Masters are never sent to ECS – only issues.

To include a medication in ECS but not generate a prescription

In Vision 3 this can be achieved by creating an Acute medication or a Repeat Prescription Master and un-checking the ‘Print Script’ check box.
For an acute medication this will be available to ECS on the next upload, with the time constraints as above. For Repeat Prescription Masters the user must select the prescription and Issue from it (F9 once) as the issue will appear in ECS.
Items with the check box ‘Print Script’ un-checked will not be printed or sent to eAMS.

To include medication prescribed outside the practice in ECS

Vision 3 offers a drop down selection box on new medication forms for ‘Source of Drug’. This is to allow practices to record items supplied outside the practice on the local system and thus inform decision support as well as providing a more complete record.
All Acute medications, regardless of the value for ‘Source of Drug’, will be sent to ECS if within the 30 day time limit. If a medication remains current for a patient after 30 days a new Acute will need to be added if still required for ECS. It is good practice to append the Dosage field with text indicating the source of the drug, as ECS does not import or display this value.
Repeat Master Medications with a Source of Drug value of anything other than ‘In Practice’ cannot be issued from, and thus will not be displayed in ECS. As a workaround for this users can create a new Repeat Prescription Master and leave the Source of Drug field as ‘In Practice’, un-check the ‘Print Script’ check box and append the Dosage value with text to indicate the source of the drug. This master should then be issued, and the issue will remain valid for ECS for up to 1 year.

DLM 300

2010-05-17T09:51:00.002+01:00

Got this last week, enable eCMS which, for those not in Scotland, is the new electronic prescribing service known as the 'Chronic Medication Service'. Be interesting to try when it arrives - I think we need to be switched on by the Health Board, and have some local pharmacies also capable.

Annoyingly discovered recently that eCMS is only available to patients receiving free prescriptions by virtue of age or specific chronic diseases. Humph.

295

2010-02-09T11:41:00.003Z

On DLM 295. This:

http://www.inps4.co.uk/my_vision/downloads/dlm/index.html

is currently the place to go for DLM Help files. Every time you get un update, which happens automatically, it is sensible to check the user guide to see what's new.

As it happens, in 295 there is not a lot for Scotland! Installment prescribing we already have - it is a little button adjacent to the Advice for Patients one on therapy-add forms and simply lets you free text the installment dispensing arrangment. AFAIK in CMS (which is the Scottish e-pharmacy model of repeat dispensing (and so much more, of course!)) the installment info goes along with the message when sent electronically, although I do not think this applies as easily to the AMS model.

Not sure, frankly. Whatever, it is just a button that lets you type in some free text instructions.

CVS risk has been updated too, though still no ASSIGN. I use a guideline linking off to the ASSIGN web site, and in this guideline I display all the relevant bits of data such as LDL, HDL etc. ASSIGN is here:

http://assign-score.com/

We have just signed up to PTI which is an NHS Scotland service run by Information Services Division (ISD). Sounds a tad Orwellian, but we will let that slide for now... They hoover up data (anonymised, or as much as it can be) and analyse activity then provide reports on data quality and workload back to practices. Not a bad thing, we hope. Slightly concerned that they do not gather data from Telephone Encounters, of course now about 25% to 30% of our workload. Perhaps a need for more GP involvement at the receiving end?

Awaiting the new Problems functionality impatiently, as I like working with Problems but become frustrated by clutter, and footerieness of the current implementation albeit it is usable, but just not wonderful. Using a Problem orientated approach with Vision does start to make more sense of your patients' conditions and, indeed, problems than the simple journalised narrative plus priority approach (although this is very powerful method of working with V3).

Meanwhile GP appraisal beckons yet again, and yet again I have failed to make use of DXS tools for helping with this. Perhaps one to add to my PDP for next year: learn how to record learning with DXS. A tad recursive, but I understand educationalists don't mind this sort of thing.

Problems with Read Code Add in Guidelines

2009-11-24T19:56:00.003Z

It is probably just me but why am I losing the start of text when I do Read Code add to a guideline? In design mode looks like this:

And when run like this:

Grrrr. A bug? Or me being overtired?

Seasonal Flu Macro

2009-11-06T12:32:00.001Z

For Macro Express:

Using 'Patient Advice' in guidelines

2009-09-30T15:53:00.006+01:00

Doing a Cervical Cytology refusnik disclaimer guideline. Not very exciting. More dealing with bureacracy than treating patients, I fear. However, needs must. I used 'Patient Advice' section in guidelines for this.

Hassle with this is, as I re-discovered whilst using it, that the text all prints on on one line, even though it appears correct on the screen.

The answer to this is to use simple HTML tags in the text display, as below.

Then it all prints out nicely.

A tad annoying though, if you are unsure of using HTML.

Chronic Disease Register Guideline

2009-09-29T18:38:00.008+01:00

It has annoyed me for some time that we have no 'flag' for all the chronic disease registers nowadays, with QOF making the 'on the register' decision via formulae based on Read codes and Therapy. So the old Vision 'Registers' are not really relevant today, although the functionality is still there for thems that want it.

So, when I open a patient's record it would be nice to quickly be able to tell if they are on any of the QOF registers, and not just from yellow reminder texts. Of course, you could drive this from Recalls but this implies an overhead of maintenance as people's conditions change and they come off of or move onto registers. Better, I thought, just to have a guideline that lifted all the codes from the INPS V14 QOF guidelines for disease registers, and put them all in one place.

Now done this, but it has taken me most of the day between patients...and will probably still need tweaking.

First off, I can find no easy way of copying between guidelines. I know you can copy a whole guideline, but not between them. So amalgamating all the filter lines for each disease area means re-typing them. Bummer. I used Snagit to capture all the lines from the QOF guidance, like this:

Then I created a new guideline called 'Chronic Disease Registers' and, for each QOF disease area re-entered the Register line as from these screenshots. Except - not exactly. I used the 'All other Clinical Data' entity only, rather than individually using the 'Problems', 'Registers' and 'Medical History' entities.

I think this will be OK - we are not using problems (roll on 295 or whatever with problem enhancements), and this entity should capture any other entity with the shosen Read code and other attributes such as Date and Episode Type. We shall see.

From the QOF 14 lines, if the Read Code is fully defined, e.g. 'H33z200' then I think this means it is not doing a child search also, i..e it means 'equals this code exactly'. OTOH if it is not, as in 'H332' it will also include all children.

So, finally it looks like this:

Which when run looks a little easier to understand!

One thing I did learn was that you can copy lines on the same guideline, by holding down CTRL and dragging the line you wihs to duplicate.

Now put this guideline into the practice index and tell my colleagues it is there. This latter the trickiest part of any guideline - getting others to actually use the thing.

Medication decision support options

2009-08-20T16:37:00.004+01:00

"Never" is back on drug-disease checks, and 'suppress all' on duplicate therapy. I have changed my settings as follows:

I have left on duplicate therapy (doubling), as I like it but it would be good if we could use a shorter date offset for this.

at 10

2009-08-20T16:13:00.000+01:00

Top tip:

"In Event Date on a data entry form, you can enter the phrase "at [patient's age]", eg at 7, and Vision will enter the year when the patient was this age. This is useful for entering historical records."

280

2009-08-20T15:44:00.002+01:00

Yay, we got this last week. Finally. Staff had training on this a few weeks back, but I missed out on that. I have downloaded the User Guides, which are helpfully located on the INPS Web Site:

http://www.inps4.co.uk/my_vision/downloads/dlm/index_map.html

And I see now require you to click your country, as the development of services in the various parts of the UK continues to diverge.

Recalls is what I want to get my teeth into - a simple change but one that I have been wanting since first getting Vision in 1997 and watching the number of recalls for patients steadilly expand. Now with three statuses - Outstanding, Cancelled, Complete (and ) these become much more useful, but only with a little thought as to where to apply them. PHQ9 second assessment would seem likely, as we have missed a few of these already.

Not sure if 2nd PHQ9s actually do anything at all for patient care, but that would almost be a political statement and surely no the kind of thing I would want to be associated with.

Anyway, new recall functionality should be good. And hopefully put an end to the convoluted recall searches we had to do in the past.

ASSIGN

2009-07-21T10:43:00.004+01:00

In Scotland we can (and probably should) use the ASSIGN score to meet the hypertension QOF requirement. I have a small guideline for this, though it needs some changes to get the various advice codes in correctly. Meantime you use:

#38D6 to code it, and on the INPS QOF guideline this goes into a 'Scoring Test Result' SDA. Mine just drops into Medical History, I should probably change it :(

ASSIGN is on line in Scotland:

http://assign-score.com

and can be completed manually. I am sure (and hopeful!) that INPS will incorporate more directly the algorthm to Vision 3.

Perhaps sometime after we get DLM 280..... ahem.

Flu

2009-06-09T10:55:00.004+01:00

We are being somewhat pressurised by being in one of the influenza hotspots. I have a guideline for flu, looks like this:

No Read Code for 'No contact with Infectious Disease' or whatever, a little annoying.

Anyway, e-mail me for a copy. I'll see if the UG wish it for the website.

NHS Mail

2009-05-05T14:53:00.002+01:00

Stimied again. NHS Mail just causes me so much hassle.

Broken Con Man view

2009-05-05T10:22:00.003+01:00

Somehow I managed through carelessness to screw up my consultation manager view. This happened during the local UG meeting we ran a couple of weeks ago.

grrr....

Then I added the 'Current Consutlation' tab in rebuilding the view, and this cannot be removed AFAICT and simply replicates the Consutlation Pane. Not everyone likes the Consultation Pane, so presumably the Current Consultation tab is good for those folk. But, with a wide monitor, the Consultation Pane works fine.

So, more tweaking to do. I probably just need to re-do the thing from scratch.

QOf ooops

2009-04-02T14:37:00.001+01:00

So figures a little wrong on account fo the 'patients registered in last 3m' QMAS / INPS reporting problem. Like everyone. This statement if you have not seen it before:

"Following the QMAS transmission on 31st March 2009 INPS were made aware by practices that there seemed to be an error in figures reported to QMAS. The error is apparent in any audit line where registration dates and dates of birth are calculated to Reference Date, where the program mistakenly calculates these figures to next year’s Reference Date of 1st April 2010. This issue was not apparent during the extensive testing both before and after conformance of the audits and has been difficult to isolate even now.

We spent most of the day yesterday investigating the extent of the problem and trying to assess the implications for each practice, but INPS deeply regret that it is likely that ALL INPS sites will be affected by this and the data on any practice’s monthly submission could be incorrect. The level of inaccuracy in the figures will have dependencies on practice size, population turnover and demographics.

We are talking to the QMAS/PCAS/CMWeb teams in England / Scotland / Wales / Northern Ireland and will be negotiating with your PCT/LHB/HB as to how this situation is best managed. In the meantime we would advise all practices that their QOF submission is NOT signed off until a fix and resolution is available."

The senior management have kept the User Group informed of this situation and how they are dealing with it.

We hope that it will be resolved over the next few days. Information will be made available on the INPS website as soon as possible.

A special team has been formed on the help desk to deal with it.

We would emphasize the advice from INPS that no practice should sign off on their QOF submission until this issue has been resolved. If you have already signed off then contact your PCT/LHB/HB and advise them that you have just found out that your figures may be wrong and that this matter is being investigated by INPS.

QOFfffffff

2009-03-31T17:48:00.002+01:00

Ah, end of yr QOF time. Happy days. Surely the reason why we all came into General Practice in the first place. :(

Anyway, a combination of Contract Plus, Clinical Audit and almost working systems of recall seems to have been as good as we can do this year, with epilepsy and diabetes slipping away from us by one or two patients. Of course with a big chunk of the QOF dependent on a citizen survey (evidence based health care, this is what we like...) it is out of our hands.

Contract Plus has been very good and Clinical Audit is superb just now, with the direct access to audit groups in searches and Patient Groups making life just so much easier.

Then...it all kicks off again tomorrow.

yay!

:-(

Paisley / SW Glasgow UG

2009-03-17T11:15:00.003Z

As per below, practices in Paisley and SW Glasgow are invited to attend a local Vision User Group meeting at our practice on the evening of Thursday 23rd April at 6:30 for 7:00pm. No later than a 9 pm finish. Dinner provided by a pharmacuetical company.

Our address is:

Glenburn Health Centre
Fairway Avenue
Paisley
PA2 8DX
http://tinyurl.com/cfe55n

Please mail me or phone Marina on 0141-884-7788 to advise if you are planning to attend. Thanks!

Topics:

Consulting with Vision - hints, tips, and how tos.

General discussion, queries and suggestions for future meetings.

I will chair / lead this but do not intend it to be a lecture! Open discussion encouraged.

Vision 3 first GPSoC level 4 system

2009-03-13T09:07:00.002Z

Good oh.

http://www.ehiprimarycare.com/news/4637/vision_3_first_gpsoc_level_4_system

Local UG Meeting

2009-03-10T12:25:00.002Z

Hi all

I am arranging a local NVUG meeting at Glenburn Health Centre in Paisley on the evening of Thursday 23rd April, from 18:30 for some food then going on till 9pm (or earlier) - subject matter yet to be decided. We can accommodate no more than 20 people though, so e-mail me sooner rather than later if you would like to attend.

paul at doctormiller.co.uk

Using 'Medical History'

2009-01-23T15:01:00.002Z

Thanks for comment re DLM260 post.

To force an item to the medical history rather than the SDA you can:

Use F11, which opens the 'add medical history' form.
Do ALT, A, L which normally will open the 'add medical history' form
Use a clinical data hotspot on a guideline, and force the Med3 code into the 'Add medical history' form.

Hope this helps!

Non Drug Allergies

2008-12-13T11:18:00.003Z

Non-Drug Allergy Checking

This from Laurie Slater on the forum (and gp-uk) regarding Nut Allergy and Abidec:

"...although nut allergy was read coded in the history, there were no
flags raised on prescribing this medication.."

But AFAICT it should work and have tested this morning as below.

Add code SN582:

then Vision opens the Non Drug SDA:

So 'OK' that then try and prescribe 'Abidec oral drops':

The Peanut Allergy does not appear in the red warnings but, nevertheless, when you click OK:

So, it does work if recorded in the SDA. I wonder if it was recorded as a Medical History item?

desktop background

2008-11-24T17:34:00.002Z

Ah well, this can be changed but you need to go digging in the registry, which I would clearly never do.

Also, if you then set the wallpaper through Firefox or MSIE then it will work as the control panel interface remains disabled via the group policy. Again, a registry key controls whether you see the wallpaper tab in display properties.

It is useful to have different wallpapers for different users as this then is a quick way of seeing if you are the logged in user as your desktop is immediately identifiable.

Not sure if changes I make locally will persist on reboot and relogin though. Find out tomorrow.

new server

2008-11-24T09:55:00.002Z

Hey ho, a new server at the weekend. DXS is broken. Foxmarks vanished (but I have fixed this - you need to tell it to use encryption and it works!). Can't change the wallpaper. This may simply be access to control panel that has been disabled..I feel challenged to work around it, even though am normally content not to have fancy backgrounds etc. I get the feeling that Clear Type is off by default. That is annoying.

This is because the server, and thus our logins, have been moved to the Glasgow domain, which is all locked down. Don't know yet *how* locked down it is, but will post any gripes as I discover them.

Annoying DXS being broken though...

post conference

2008-11-20T15:22:00.002Z

Well, that was a good conference. Well attended (despite the economic climate) and useful talks. Thanks to anyone who attended mine and patiently put up with me talking through a cold which still refuses to go away...Thanks also to the organising team!

Reviewing the prescribing safety settings for NVUG it is pretty clear that in all parts of the UK bar Scotland at present you are able to tweak these pretty much back to where they were prior to DLM 260. We north of the border will have to be patient till we see some relaxation of the rules.

Nice stuff coming up in Vision in the next few DLMs and I am looking forward to both the Free Text search facility and the changes to the problem management. I have largely given up on problems for the time being, but will revisit them when the changes are delivered.

SNOMED talk was also fun, but apologies to anyone who thought it might make some sense! Is SNOMED really fit for purpose? I guess the answer depends on what the purpose will be. One of the biggest difficulties with SNOMED is the lack of people in healthcare and developer communities who understand it. It is complex, perhaps necessarily so, but does the inherent complexity of it make it essentially unusable in the real world? I think we need to get end users educated in SNOMED as far as we can, as the end users can really only drive the functionality if they can understand (to an extent) the advantages and limitations of the terminology.

Anyway, feeling fairly crap with this cold and have work to do...

Conference

2008-11-10T12:09:00.002Z

Well, the new NVUG web site is up and running so well done to Simon Child for this. And welcome to the blog if you have navigated from NVUG.org to find it.

Conference this week so I am busy (overwhelmed, perhaps!) writing talks for the 2 days. Interesting breaking down the decision support for the 'Prescribing Safely' talk, and hope is that in Scotland DLM270 will return us to something more usable and safe. The SCIMP conference talk on Prescribing Safety was also enlightening, particularly the input from FDB on the difficulties that computers have working out if a patient has a condition.

Always reassuring, this, as it means GPs cannot (yet) be replaced by machines. Ahem. :-D

Also talking on SNOMED at the NVUG conference, which will be a) a challenge and b)slightly scary. I am expecting two people to turn up, right enough, one of whom will be lost and the other probably a clinical terminologist for a living. Joking aside, the challenge of moving the NHS people to using SNOMED is huge. Read has suceeded in part because people can understand it with only a little help. Thus they are able to explain it, and use it with success, in normal work. SNOMED is not easy to explain, nor immediately easy to use. I guess we are relying on the systems implementers to make SNOMED work under the bonnet, whilst all we need to do is steer in the right direction. Can that work? Let's hope...

DLM 260

2008-10-21T10:38:00.002+01:00

Ah...we got this. Med 3s in an SDA, need to make a decision as a practice if we use these or just use medical history. Mucks up our 'certificates' guideline also.

Immediately wrote a macro to do 'yes' and 'proceed' for drug warnings. I was used to working with the warnings previously, and now find I cannot easily filter out the stuff I want to see. Humph. Soon to be fixed in Scotland though, I believe.

Problems

2008-10-21T10:34:00.002+01:00

Worked with problems for about a month now and variable experience with them. Perhaps I need some training, not so much in the how to use the software, but perhpas more in how to run and operate a problem orientated record.

There is an overhead in maintaining the problem list, and making sure stuff you enter goes under the correct problem heading. Some of the V3 tools make this relatively easy, but overall it is a footer to maintain. If I get the chance I will try and attend the problems talk at NVUG this year, which may help.

Certainly it is useful to see a list of active problems for the patient when they come in the door, and makes it much easier to sort and recall what the current issues are.

I'll keep going with it for now. Getting the rest of the practice team to use them effectively would seem quite a difficult task though.

Problems

2008-09-22T11:28:00.002+01:00

Panel meeting at the week end mostly sorting out the conference.

I am going to experiment with moving to Problems, given that a couple of other panel members have been using these with a degree of success. I have always been put off previously by the data hygiene overhead, but we are a small practice relatively IT capable so maybe we could make it work?

Download the problems section of the training manual from here.

How to search

2008-09-19T09:37:00.013+01:00

OK, so not been so productive on the blog of late. Sorry. Anyone is welcome to join as an editor though, so let me know and I will sign you up (Karen!).

Here is how to do basic searches. If you have not explored searching, or were well turned off it by GPASS functions in this area, then it is a worthwhile exercise. Honest. It is easy to create a simple yet useful search and, if you wish to explore further, Vision 3 searching is flexible and powerful for more complex work. It can become confusing when you combine a search with complex reporting logic, but I am only touching briefly on that today.

OK, open Searches and Reports from the Vision 3 main Screen. It's under 'Reporting':

And this opens (in Glenburn) this:

which is immediately confusing! Essentially, though, it is quite feature rich and if you have not looked at searching previously it can seem a little daunting. Do not panic (at least, not over this). I am only going to demonstrate how to create a simple search, so click on the button as below titled 'New ad hoc search'.

OK, this opens the main 'New Search' screen, where you create new searches. This is where most of the work in searches is done.

You will see the form is divided into useful sections.

Group Input / Group Output
Input allows you to choose a group of patients that has previously been saved and use them as the input into the search. You get get such a group by running a search and saving the found patients as a group (Group output) or but saving the group from clinical audit.

Search details
This is where the meat of the search is configured, and is discussed in detail later.

Report Output
Allows you to configure how the search results are presented. The default is 'View' on screen, but other options will present you various amounts of printable detail.

Add Entity
Click the 'Add Entity' button next to 'Search Details' and you see this:

which may or may not be familiar to you. This form allows you to select from any of the Vision 3 'entities' for searching on and, once selected, you are able to search on the attributes of the entity....

Yes...?

Ok, well an entity is a thing that you might have recorded in the patient record, like a 'Blood Pressure' or a 'Weight'. And 'entities' have 'attributes', i.e. stuff around them that you record so 'Blood Pressure' has attributes of 'Date', 'Diastolic', 'Systolic' etc. So really, you add things to search on and then tell the system what values of that thing you are looking for.

Here we navigate to 'Blood Pressure' and OK that:

And 'OK' brings you back to this:

For our 'Search Details' we want to just search on our current active patients. Vision 3 keeps all your transferred out patients on the system (as do other clinical systems AFAIK) and, by default, searches are run on every patient in your database. To tell it to only search on our current patients we need to click on 'Patient Details' and then 'Selections' and tell V3 to look only at our 'Registered' and 'Applied' patients:

This opens the 'Criteria Select' form:

Navigate to 'Registration Status' and select 'Equals', then 'Permanent' also 'Applied':

OK that:

so we are making some progress.

We will set this up now to search on patients who have ever had a diastolic BP of > 85.

Select Blood Pressure in the Details screen and click on 'Selections':

Similar from to the one for Patient Details, but different criteria of course!

Navigate to 'Diastolic Pressure' and select 'Greater' and check on 'Inclusive' and add the value '85', so really we are doing a 'greater than or equal to 85' search.:

Ok that, and here is how it looks:

I only want a count of them, so change the 'Report Output' from 'View' to 'Count' as below:

Our search now looks like this:

Click on 'Run' and wait a minute. The search estimate times are always much longer than the search actually takes. I think this is just to make you feel better...

Here is the result:

So that is 935 patients who have ever had a diastolic blood pressure of over 85. They have 4037 matching BP records in total.

Hmm....be more useful if we could find the patients whose last bp was >85. OK, every time I visit this I get confused and it does take a little bit of brain challenging logic. To do this, (R) click on the Report Output 'Blood Pressure' and select 'Options':

This form then opens. Read it through, then read it again...

It does make sense, but you probably need to read it every time you come here. The option we want is 'Before Match'. In other words, after you have found all the blood pressures but before you report on this, check only the last one and only include it if it meets the criteria as above.

So now, when we search we get:

So, 540 patients last BP was > 85. That seems a lot.... better get back to work and stop this blogging malarkey.

Save the search before you exit. Call it something sensible, and in the description prefix it with something (I use my initials) so you can find it again later. Ad hoc searches sort by the Description in the list, not by the name.

OK? Brief searching how to.

NVUG panel meeting in Birmingham tomorrow. Conference planning amongst other things. I am in Dundee currently, though, so a long way to go!

Drug check in F3

2008-08-25T17:49:00.004+01:00

When searching for a drug if you (R) click on it you can select 'Drug Check'. like so:

which, usefully, will run decision support checks against the drug before you have selected it.

Dealing with journal clutter

2008-08-07T14:20:00.005+01:00

The Journal list is a list of everything that has happened for that patient and, consequently, trying to use it for day to day stuff can be troublesome as it fills up with repeat issues and pathology. Cutting through all that to see just the narrative can be done by setting your 'initial filter' to exclude those items.

Right click on the 'Initial Filter' on the Navigation Pane and select 'Show items with no data'. You have to do this so you can select from all the possible items on the list to exclude or include them.

This done, you then go through the list and, holding down CTRL, left click to select items.

Then (R) click on the 'Initial Filter' again and select 'Save Selection as Initial Filter'.

You have to make sure you have a Filtered Journal List in your tabs in Consultation Manager for this to work. I have this set as my default tab on entry to the record, but I also keep the full Journal view in a tab adjacent to it.

New Computers

2008-07-24T11:27:00.003+01:00

PCT (or whatever they are called nowadays) has given us new kit :D. Lovely HP P2015 Laserjets and dual core Pentium Dells.

Nice.

Had to take my 23" Viewsonic home and swap for the 21" as for some reason the graphics in the new PC does not support the resolution needed by the monitor. The smaller monitor does not swivel, making harder to use in the consultation but at least I can read what is on the screen! The graphics card for some reason supports resolutions below and above the required one, just not the actual one I needed.. :-(

More SEF

2008-07-24T09:55:00.007+01:00

Back from Tuscany and only now recovering from the shock of returning to work. Tuscany fab. So now I have calmed down and had some time to investigate further it is apparent that this SEF Prescribing Safety problem is a much more complicated issue than it first appears.

First off, it is clear that the intentions are very sound - make our systems' method of drug alerting more in keeping with the requirements of our clinical practice. What is not yet clear is why the impact of this has been so negative.

End result anyway is that we have a system which was usable and reasonable (albeit with some flaws and omissions) with respect to drug decision support and now is dangerous and frankly irritating! I see in England INPS have prepared DLM 261 to deal with the issue, but here we are reliant on SEF approving a fix of some kind before we can move forward. That is OK, provided it is not too delayed. There are a lot of positives in the prescribing safety recommendations, and it would be nice not to lose them.

So I guess in reference to my last rather irritated post it would be fairer to reflect that there is no easy fix here, nor any easy way to apportion blame. This is difficult stuff to do and there are now a lot of people working on it. Let's hope we get something decent out of it in the next few weeks.

DLM260 and Prescribing Safety

2008-06-26T15:10:00.007+01:00

This DLM contains a lot of stuff. We do not yet have it in Glenburn, but given the upset I am not so sure I am looking forward to it!

The 'Prescribing Safety' implementation aspect has come from the Scottish Enhanced Functionality programme - essentially a method the Scottish NHS employs to ensure certain requirements are met by system suppliers or else the Scottish NHS will not pay for their systems. The main aspects of the Prescribing Safety SEF that have caused controversy amongst users are the appearance of a new dialogue asking for a 'Reason for Override' essentially, this against all 'High' level warnings. This is probably dangerous as it risks alert fatigue.

There are some other aspects of the DLM which have led to confusion so I will attempt here to explain medication decision support options to let you, the happy users, tweak the settings for your continued enjoyment and benefit. ;-)

ALT COS

Before we go any further, if you have never discovered the Consultation Manager, Options, Setup screen (accessed with ALT - C - O -S from the keyboard) then now is the time.

Which gets:

And you want to click on the 'Drug Check' tab which, for me (because we have not got DLM 260 yet) looks like this:

But with DLM 260 it is this:

The above screen lifted from the DLM 260 help file, which is available from here.

What has Changed?

Minimum Number of Days for Drug Check

There used to be two options here, as you can see from the original Drug Check form above. The first was for which Clinical Data to use for therapy decision support ('drug check'), and the second for which therapy records to use. They have removed the 'Clinical Data for Drug Checks' option entirely. Previously you could use an option of 'Currently Relevant' clinical data, but I am not sure (and few people seem to be!) what this meant. Now the system will check on all medical history, regardless of whether it is flagged in the system in some way as 'active'. (The only way I can see to flag a medical history item as 'active' is by using problems).

This change may have impacted on what you now see in your drug check warnings, as the system will now be including clinical data in its therapy decision support that it was not doing previously. To be clear, the clinical data checks apply only to Contraindications, Precautions and Prescriber Warnings - this is usefully referred to as 'Condition Checking' in FDB documentation. We have had some e-mail correspondence with clinicians affected by this. This screen shot:

was supplied, the patient being a fit young man. Why the warning? Well, because now ALL medical history is being queried and this man must have something in his history that is triggering the alert. But how do you find that out?? Click on the warning line itself, and it will expand to show you the triggering history.

Now you and I might think that 'Renal Calculus' is a different thing from 'Severe Renal Impairment' and I am sure that people at INPS think this also. I am also fairly sure that First Data Bank (FDB) who supply the drug dictionary and decision support think this is not a great alert either, but right now this is what it does. The other change here is the 'Therapy Data' for drug checks which has had the 'Currently Relevant' option removed and a default time period added. The help file says this:

'We recommend that all users set the date offset to 1 year. On receipt of DLM 260, all users who have an offset date of less than 30 days will be automatically changed to the minimum 30 days offset. For new users, the default Therapy drug check offset date is set to 1 year.'

In Vision 4 I am hoping to use 'Current Medication' as the driver for decision support, because 'Current Medication' is better modelled in V4 than V3 partly due to the different implementation of medication types. For the time being, however, in V3 (and V4) we are using a date offset. So for interactions and drug doubling warnings, Vision 3 will look back at the 'Date' of therapy items and check your newly added item against all items that come within that date range. I do not know at present which 'Date' it looks at, whether that is Date Prescribed, Date Issued, Date Authorised, but hopefully it is taking into account all 3. This screenshot:

shows an alert triggered for drug doubling although the patient last had a co-codamol prescription issued 4 months ago. This is doing what it should, and it is querying all therapy data in the past 1 year for checking for interactions and drug doubling. Again, you can click on the warning line to show the triggering medications:

Contraindications, Precautions, Prescriber Warnings

You can no longer turn these off, and if you had them off then Vision DLM260 will turn them back on for you at the level of 'Patient Specific'. 'Patient Specific' means the system will check all medical history for the patient and see if there are any relevant warnings, like the 'Renal Calculus' one above. The specificity of these warnings is being worked on by FDB (we hope!) so one day soon it will be better. Deciding if a patient has a thing is not as easy as you would think, in computable terms at any rate! You can set these to 'General' and 'all' also.

though I remain unclear as to what a 'general' warning is and still need to see if I can identify in FDB what exactly is going on there. I set mine to 'Patient Specific' and this is fine for me.

Interactions

They have taken away the option of turning off interaction warnings completely so you must see some of them. In Scotland you cannot only show 'High' warnings in interactions, you must show 'High and Medium'. These are actually level 3 and 4 FDB warnings.

"For Scottish practices, you can select High/Medium/Low, or High/Medium, to display drug to drug interactions, but you cannot select High."

You can in England, you lucky people :) So now we get all the 2 and 3 bar FDB Interaction warnings all the time, and cannot stop them. This is probably not so good, I think.

Drug Doubling

Drug doubling also has had the 'Suppress all levels' option removed, which is OK. You can still set it to Same Action group which is what most clinicians use IME (when they know it is there!).

The Override Confirmation Required Problem

So this setting makes Vision 3 give you an additional screen before being able to add the drug. In Scotland (again, for we are truly blessed) we are not allowed to turn this down to only High warnings. Which I think is the biggest safety risk of all.

We now have logging of overrides, so presumably if the prescriber duly gets into the habit of doing ALT+P for bypassing the warning reason (as they will have to to make the system usable), this is audited. And if it harms a patient, the clinician will carry the responsibility for this but NHS Scotland can state 'We made sure they saw the warnings, so it ain't our fault'.

The paradoxical nature of presenting every warning to busy clinicians who work using heuristic thought processes is that over warning them is dangerous, because it is only when something breaks the pattern that it stands out.

So, I would think that Level 4 FDB warnings and Allergies should require a reason and that should be the interruption to your usual, every day prescribing process that stops you killing folk. This is (almost) what you can set it up for in England. But not in Scotland. So, what shall we do here? I think this is a question we need to take back to NSS / SEF / INPS / FDBE and probably other vendors.

Anyway, the point I am trying to get across to those of you in England is that you do not need to see this 'Add reason' form every time because you can change it in Setup to 'Only High'. Which is quite good, really. You can bypass the override reason with ALT+P or clicking on Proceed. But I think getting into the habit of hitting ALT+P is the way to go. If it is just for high level warnings then entering a reason might even be clinically prudent!

I would be pleased to have Scottish user's comments on the Prescribing Safety SEF (e-mail me), whether good or bad, and I will feed them back via SCIMP to NSS.

There are other aspect to Prescribing Safety that I am not going to discuss here just now, largely because I have to get some paperwork done and have a surgery to do! Download the Help file, it is pretty comprehensive. I am away on holiday for the next 2 weeks so no post to the blog. I am always hopeful that someone else might want to contribute to the site, so please contact me if so and I'll set you up access.

Consultation Management

2008-06-12T14:50:00.004+01:00

This form:

lets you define the attributes of the consultation. If you change the date here then every entry you make will carry that date. Similarly for the selection of a clinician.

Most importantly it also allows you to change and select an appropriate consultation type. This can be done quickly with the keyboard by pressing, repeatedly id needs be, the first letter of the Consultation Type.

Thus, 'S' for 'Surgery Consultation' or 'M, M, M' for 'Medicine Management'. It is good practice to use these types as best you can.

If you don;t want to start a Consultation with the patient, you just want a look at their records, then you can click on 'Cancel' here, which will display the record but not record a consultation against it. Pressing 'Esc' on the keyboard does the same thing.

You decide whether the Consultation Form appears at the end or the beginning of a consultation in Con Man Setup here:

So you can have it on open, close, both or not at all. Which is a matter of choice really, some find it easier at the start and some at the end. Unless you are doing exactly the same task every day with the record, I would recommend you have it appear at least once.

You can also bring the form back up to Update it by double clicking on the status bar on the bottom right of the Patient Record view here:

so if you need to change anything, you can!

RHS Advice

2008-06-03T13:53:00.003+01:00

Using the Right Hand Side of the prescription for an additional text advice is very useful but has no expiry date, which means it persists for ever more. I always start such advice notes with the Date on which they were added. Then, at least, it becomes apparant that it is out of date or no longer applies when you see it appearing 6 prescriptions later or, worse, copied to the repeat master text.

Expiry date on advice notes would be a good thing IMHO.

Drug Defaults

2008-05-29T10:08:00.002+01:00

If you don't have these on then every time you attempt to prescribe a commonly used item such as Paracetamol tablets 500mg you will have to amend the default quantity (it defaults to '8' from Normalex) and probably the dosage instructions as well.

So: sort out drug defaults. You (R) click on the drug name and select 'Drug Defaults' -> 'Maintain' to do this.

Agree the usual defaults with your partners and prescribers to avoid arguments. Drug defaults will apply across your practice - not just to you.

If you start setting these up in an opportunistic way then within a week you will have the 10 common ones and by 6 months you will have 80% of them done. And it saves so much time and hassle it is definitely worth the investment.

If you cannot remember Paracetamol 120mg / 5ml dosages per age group (and after 14 years of GP working I still have to check them!) then setting these up in drug defaults is a little bit of magic.

Prescribing

2008-05-27T14:56:00.003+01:00

I went to Campbeltown to do some training work on consulting with computers and Vision 3. Thanks to all the team there, but this drew to my attention to how many practices never quite get around to setting up Vision 3 therapy correctly and this just makes your life difficult!

The steps to succesfully using Vision 3 therapy functions are to:

Setup a Drug Formulary
Set users to select from formulary
Spend the time setting sensible and agreed Drug Defaults
Understand what Dosage Codes do and how to ignore them

The first is essential as it limits your initial choice of drug. Remember: a drug formulary is practice wide, not per user, and you can only have one formulary for each practice. In V4 land we are going to extend this functionality for multiple formularies per practice but, as you can imagine, this may get rather more complicated!

You can setup a drug formulary by hand, by trawling the action groups and double clicking to select or de-select drugs or you can use the Drug Dictionary Utilities to quickly create a rough and ready formulary which you can fine tune later.

Enable this per user in Control Panel, Security, Edit User, 'Select Drugs from Drug Formulary' and 'By Drug Name'.

Then you are no longer selecting from all the drugs in the dictionary but from a subset, thus 5 paracetamol preparations rather than 100!

Drugs Clinic Guideline

2008-05-15T17:37:00.003+01:00

Version 1.0. Designed in part to replicate the data collection required for reporting purposes.

Holiday

2008-04-29T09:08:00.002+01:00

Sometimes you just need a break. Back now though.

We have discovered Smart Priority Numbers for Vision 3 from Bradley Sieve. This is just the utility we need to sort out our mess of priorities, with our odd mix of 1s, 2s, 3s and more.

Not had the chance to play with it much as yet, but here is the main screen:

from http://www.tailormadeit.co.uk.

Clever :)

With Macro Express

2008-04-07T17:33:00.002+01:00

With Macro Express you can achieve the same thing more efficiently with respect to changing priorities.

This is the code:

Variable Set Decimal %D1% from Prompt
Variable Set Decimal %D2% from Prompt
Repeat Until %D1% = 0
Text Type: ey%D2%k
Variable Modify Decimal: %D1% = %D1% - 1
Delay 50 Milliseconds
Repeat End

and it will prompt you for how many items to change and to which priority.

Priorities .... again...

2008-04-03T09:17:00.006+01:00

So we have adjusted our priorities to be 1 and 2 for high and 3 for routine, and that is it. Unfortunately we have a lot of Priority 2 items that are really routine entries, as '2' was default for medical history items for some time. Consequently, my Medical Summary guidelines has had to use P1 items then P2 items of type 'Diagnosis' as below:

In Edit mode:

But this means we have a lot of data tidying to do over the next year (or more!). Data tidying is similar to painting the Forth Rail Bridge, but less risky.

So, how do you change 30 P2 items to P3?

Keyboard Express, of course. :-)

Get this from:

http://www.keyboardexpress.com/

This is a keyboard macro program, that can play back a series of keystrokes automatically and efficiently.

Having installed this I created a macro with this code:

<REPEAT:0038><SPACE><APP>e<ALT>y3<TAB><TAB><TAB><TAB><ENTER><DELAY:00.20><ENDREP>

which will change 38 items (REPEAT:0038) to Priority 3 (y3) from a filtered journal list view in Consultation Manager.

So now I can filter the view in CM to show the P2 items I wish changed, note from the Navigation Pane how many there are and adjust the number in Keyboard Express accordingly. Highlight the first one and then initiate the macro and in aout 20 seconds 30 + items go from P2 to P3.

It would be even more useful if this would work on a Guideline view, but I think I would need to use Macro Express, which captures mouse movements and clicks to achieve this.

Rec9

2008-03-25T09:47:00.006Z

Doing the anlysis for this QOF indicator this week and last. We do not use problem linkage to our repeats to meet this indicator - I have always found it too cumbersome. Although possibly once the overhead of adding problems for the majority of them has been done it would be OK to work with thereafter.

Anyway, we use an indication in the Dosage field. For example, "Take two puffs twice a day [ for asthma prevention ]".

We routinely, as far as possible, use the square brackets to enclose this 'indication' text and we have set up most of our standard drug defaults to include it so that it populates automatically. Clearly this needs tweaking from time to time, as not all drugs are taken for the same purpose.

When it comes to analysis of this, I run a search and export the information as dbf tables, then import it into Excel and do some simple counts on the data to produce a percentage score. By this method we currently get 79.6%! Damn! Although this method includes all appliances and monitoring equipment, which I understand can reasonably be excluded from the QOF target. I have been unable in the search to exclude the Action group for Diabetes monitoring agents - it produces an error which sets the field value to 'null'. This be a bug, methinks.

The search is this:

and yes, I know, you can do an initial patient list search and then load that group in.

V3 does not know when repeats were commenced. It knows when they were re-authorised, but not when they were started as every re-authorisation event stops (inactivates) the previous repeat master and creates a new one. The QOF requirement only applies to repeats started after 1/4/04, but in V3 terms this means anything re-authorised after this time. A 'date commenced' is intended as a separate attribute for repeat masters in V4.

While we are on searches, if you save your search using a description prefixed with some initials, then it makes them easier to locate in the adhoc search list. e.g.:

So then I import the tables into excel and I get this:

The formula for counting how many have the square brackets is:

=COUNTIF(D2:D4358,"*[*]*")

79.69%

damn

Still, be fixed by end of month and really we are achieving this already, but it would be nice and reassuring to have a spreadsheet that clearly shows it.

And from Karen

2008-03-12T13:36:00.001Z

Karen Lefevre e-mailed me to say this re the post below:

"You can copy the current guidelines that Vision has for each of their management plans. Under 'Guidelines, 'Select Guidelines', all of the Management Plans start with '@'. Being careful to copy this to a different name these can then be edited to fit what you want.

I've also used this to copy and alter others such as the Maternity Management plan as we found this was missing some things we wanted and had other fields we didn't want. Looking at these can be useful to see how to set up the special formats also."

Thanks Karen

A Data Grid for Results

2008-03-11T11:15:00.001Z

In the land of Renfrewshire we are somehow denied the ability to have electronic results transmission. This is sad, and has been such for the whole 11 years I have been using Vision. Oft promised, never yet delivered. Peter Wiggin's practice has had electronic results for years, but this was a bespoke arrangement with a local lab. The rest of us seem to have to wait for SCI to get its house in order, and the most recent DLM from Vision is meant to at least enable the technology, if not the business process. We are stuck, I suspect, waiting for someone with the decision making clout to actually enable the change technically, so we can use it locally. This, of course, will never happen until we get the time and energy to find the people responsible and make the change occur. Until then, we have to manually enter paper path results into our bells and whistles clinical system. Making this an easier task is best affected using a data grid entry form in a Vision 3 Guideline.

Management Plans

If you Right Click on any topic header in the Medical Record Overview (the navigational click-able hierarchy on the left) you can select an option of 'Management Plan' for any entity. Thus:

Clicking 'Management Plan' opens:

Which is functional but far, far too busy for routine use.

What to do then?

So, we fix it by making our own custom guidelines with simpler data grids that follow the reporting order on the lab form. Here is a biochem form:

And for getting the staff to enter it successfully I have created this grid:

And this one:

Making these

To add these you start by creating a new guideline in the usual way:

And in 'Edit' mode you click on the New Data Grid icon:

Which opens this form:

You then select items in the order you wish them to be entered, which in our case attempts to correspond to the order they appear on the pathology form. So, our grid design for U&E looks like this:

I have left everything as reporting a 'Value' but there are display string options you can apply to see a long format, short format or 'Special' which has some obscure syntax.

In Design mode in the guideline it looks like this:

and at run time, when used for real, should let our staff enter the results from the form in a more stepwise and logical fashion than before. It also has the advantage of letting us see the results in a more filtered way, although I still find I refer to the scanned paper copy and until we get electronic path results this is always likely to be the case. Mind you, the grumbling about mail manager in its current iteration does not inspire me to rush to change!

2008-02-28T11:57:00.000Z

Had a Chat to Patient

Please do NOT use this code as a header for clinical work you do. It is not appopriate or correct. It is OK to use this code when you do have a chat to a patient - about the weather, their fmaily or pets, their holiday plans etc. And, indeed, we do want to use it for this because then we can make a view which just shows us these 'chats', which is nice and personalises our consultations a bit more.

But, if you fill up 'Chat' codes with actual clinical work, then this will be of no use to us.

What to use instead

Generally, try and use a SYMPTOM code of some kind. These are all in Chapter 1 of Read.

and, more often than not, you can find them by using a 'keyword', often prefixed by 'co' for 'complaining of'. For example:

Enter 'codizzy' as the keyword:

will get you this Read Term:

Often you can just enter the first word of the symptom, e.g. 'cough' and an appropriate Read Term will be found:

gets you:

and if you double click there or press F3 you get a picklist of terms:

Which is even better.

It is OK to type everything else you do under this header code, though all numerical values and measurements must be recorded in the right place, e.g. Blood Pressures. This is as before.

So

As a general rule, only use 'Chat' to record a 'chat'. That is what it is for; not for recording clinical work.
Try and find a single code that fits the main or first presenting complaint of the patient, often from Chapter 1.

Read coded feverish child consult

2008-02-12T12:53:00.001Z

It's all codes, bar the '3-4d' bit of free text. Took me about 2 minutes to enter.

Vision in Vista

2008-02-10T20:25:00.000Z

Seems to work OK. You need to turn off User Access control. I wouldn't recommend running your live system off of Vista though, just a local copy!

And you need to use the Vision32.exe to get it to go. I think.

How to Add 'Therapy Advice'

2008-02-10T20:20:00.000Z

Using the Right Hand Side (RHS) of the GP10 (FP10 in England, and 'Prescription form' to everyone else!) is an immensely useful function. You can do this from the 'Notes for Patient' button on the Add New Medication forms, but you can also print out therapy advice on the RHS without having to add a drug first.

To do this, select to Add - Advice from the Consultation Manager (CM) menu:

This then displays the 'Add Advice' form.

Then we need to change 'Type of advice given' to 'Therapy:

And then add our advice:

Ok, now we have done all that we can 'OK' the form. Then Press F9 and we can see it in Prescription Manager:

and F9 again, prints it out.

Ta da!

I am busy this week as my partner is off on holiday and our 2 day a week doc is off a little earlier than she intended for maternity leave :( No more blogging till the week after, I think. Though, as the government seem to want us to work every evening and weekend (wasn't that what the 2004 contract was meant to stop?!) I will probably be able to blog all the time as I will never be away from the work computer...

grumble grumble.

Consultation Types

2008-01-24T11:30:00.000Z

About

Every encounter or 'Consultation' that we have with patients in Vision should be categorised using an appropriate Consultation Type. For example, 'Telephone call to a patient', or 'Surgery Consultation'.

Where does this get recorded?

Vision 3 lets us choose the Consultation Type from the 'Consultation Form' as shown below.

Depending on how Vision 3 is setup for you, you may see this form at the start or end of a consultation. Highlighted above is the 'Type of Consultation' field, and it is this one we need to change to a type that reflects what type of encounter occurred.

What type should I use?

Vision 3 has a large number of Consultation Types available. We want to try and only use a few of these as outlined below.

Administration

Use this for patient administrative tasks such as social security reports and typing of letters.

Acute Visit

Used by clinical staff for recording Home Visits.

Casualty Attendance

Should be used for storing any A&E attendance correspondence or coding.

Clinic

May be used for the Drugs Clinic, or other specific Clinics that are run. We are unlikely to need to use this often, as we do not run with separate chronic disease clinics.

Discharge Details

Useful for updating the medication record or adding Read Codes from a discharge letter from hospital or Out Patients.

Emergency Consultation

Used by clinical staff for emergency consultations. We may elect just to use 'Surgery Consultation' for all of these, as with the Book on the Day appointments it is difficult to define some consultations as Routine and others as Emergency. Nevertheless, some consultations do appear to fall into this category and it should be used when the clinician considers it to be appropriate.

Letter from Out Patients

Useful for consultations that are storing or coding outcomes from Out Patient departments, including prescriptions.

Medicine Management

For medication changes, re authorisations and reviews.

Out of Hours, Non Practice

May be used for recording NHS24 and GP OOH contacts.

Repeat Issue

Should be used by reception staff when issuing repeats.

Results Recording

For recording bloods or other test results.

Surgery Consultation

Used by clinicians and health care assistants for face to face encounters with patients.

Telephone Call to / from a patient

Used for recording telephone encounters. This could be usefully used by reception staff also. Use 'Telephone call from a Patient' for phoned visit requests, even if it is the patient's carer making the request.

Third Party

Any encounter about the patient but without them being present.

Selecting the Consultation Type

This can be done with the mouse to drop down the menu:

But, more usefully, you can quickly get to the correct one by pressing the first letter of the Consultation Type. e.g. Pressing 't' will change the type to 'Telephone Call from a Patient' and pressing 't' again will select this next type beginning with 't', i.e. 'Telephone call to a patient'.

Changing the Consultation Details

By double clicking on the 'Status bar' at the bottom right of Vision 3 Consultations Manager, you can make the Consultation Details form appear again.

Why all this matters

This is important because:

When we scan a record we can see what types of encounter the patient has had with the practice
We can sort and filter by the consultation type to show, e.g. only Results Recording
Our Home Visit report ignores Repeat Issues, Medicine Management and Administration encounters to try and keep the information we have on the printout succinct and useful
It keeps our records accurate and clear and makes them medico-legally much more robust

Fixed?

2008-01-17T09:36:00.000Z

Well, thanks to INPS who have investigated our odd problem carefully and continue to do so. We have no clear explanation for it although 4 such errors were identified and all occurred in the same session, so something odd was going on. Third party applications maybe? Seems unlikely as nothing new or run that day, and only David Brown's filer writes directly via the API. Colin recalls that an error was noted that day that required a server re-boot.

Who knows??? Anyway, INPS are taking away a backup tape to look into it further. Certainly seems out of the ordinary and also appears that no significant harm or corruption of our stuff has occurred.

It's a bit odd this

2008-01-10T11:10:00.000Z

So, Monday was busier than it first appeared, but such is the way of General Practice. It's all that unpredicatability that we love it for .... :-(

Anyway, to the point. This:

why am I seeing a Drug name appearing in a Read Code box as this code?

Strange things are afoot?

HNY

2008-01-07T09:33:00.000Z

Yep, Happy New Year folks. Bout time I got on with some work, really...

So, my laptop died over XMAS whilst trying to install a Hauppage TV USB Stick. The hard drive just went dead. :-( So, this means I have had to spend real money on a new laptop, which will be Vista not XP. And I understand it is possible to run V3 on Vista, but you have to do some footering with stuff to achieve this. We shall see.

Meanwhile, Contract Plus keeps chucking up reminders to me in a useful and usable fashion as we hit the last quarter of the QOF yr. Also chucked up a 'You need to PAY for this now' type of reminder which I shall delegate to my partner. Though I understand it is not hugely expensive.

Had a 'Vision cannot communicate with the appointments server' error on starting Con Man this morning, but easily fixed by restarting Vision.

Other than that - 3 house calls, 11 Rx requests and 11 pts to see. Actually not too bad considering the end of the Festive period. So far. It is very gloomy in January, opening the curtains to darkness, rain and wind. But hey, it's all about the attitude. My todo list is not getting any shorter though :-(

I use:

http://www.rememberthemilk.com

for a rolling to do list. I do not use Outlook, not really on any matter of principle - it is just not something I particularly like.

XMAS Guideline

2007-12-20T09:34:00.000Z

Did this:

to try and capture the informal stuff we do and also to capture X-mas cards and gifts.

Found a code entered which said:

8C85.11 GIFT 'biscuits'

which, as coding errors go, is almost funny.

Though, on reflection, that is perhaps a bit geeky and sad. :-(

Anyway, we have fixed this now by using this guideline and have pointed the keyword 'gift' at:

9N57.00 Admin reason for encounter

and then staff free text the pressie / card / whatever. No pheasants though. I have never been a doctor that worked in area where patients brought me such things. Not sure it is really my style of practice anyway. grumble grumble....

Contract Plus

2007-12-20T09:24:00.000Z

Colin installed this for us. It is very good, isn't it?

Still have to pay for it though, but it is not prohibitive by any means.

I like the alert boxes, which are much more functional than the standard V3 yellow popups - very good at focusing your attention on what needs done for QOF purposes. And the daily analysis is excellent, with our projected for 31/3 reflecting a lot of annual work that was doen in 03/07. This means, in case you had not worked it out, that our predicted points for 03/08 drop by about 60 from today's level. :-( Still, at least we now have an easier way of identifying what work needs done to deal with this.

Also: messaging. Contract Plus does patient and non patient related instant messaging. Initially this is very 'in your face' - i.e. modal and non movable pop-ups, but there are options for changing this behavior to a more passive method (and indeed, with draggable (?sp) windows).

Still playing around with it, and not yet comfortable with how to use it. Has a lot of user options and tweakability, which is good but demands some learning.

Be saying goodbye to Spark and eJabberd though, I think.

2007-12-11T14:32:00.000Z

To Attach a 'Full Patient Record' Printout to Docman in Vision 3

Why?

The requirement is to attach to Docman the usual paper printout of the computer record that a practice would supply when a patient transfers out. The value of this is that with a Docman to Docman transfer, the 'Full Patient Record' will be included in the transfer.

What Does Vision 3 do?

The Vision 3 built in approach is to use the Patient Report 'Full' from Searches and Reports as shown below:

Note that the V3 Help files states:

'But there are some details the Full Patient report omits which strictly speaking by law the patient should see on the printout – the patient's Previous Surname, and the Second Forename and Other Forename (other than the first forename). It also does not record whether the patient is cared for by a carer. Note they are not allowed to see the name of the carer on a printout, just a Yes or No if cared for by one.'

and does provide workarounds for this.

Get a Virtual Printer Driver

It is suggested that your PCT IM&T department will deal with installing the 'virtual printer driver', as there are several different formats available.

Once that is done, move on to the next step.

Print the Report to the Virtual Printer Driver

The process to print is to select the 'Full' report and the patient as shown in the screenshot above and then click on 'Print':

Change the output type to Printer:

Then click on Print Options and change to your virtual printer:

Click Print again, and the again and the report will be sent to the Virtual Printer, again creating a file which can then be attached to Docman.

The batch file

2007-12-09T22:17:00.000Z

It's a busy time of year, isn't it?! Must...post...more...

Anyway, here is the contents of the batch file as referred to in my last post:

subst o: /d
subst p: /d
subst O: F:\
subst P: F:\data

so, you replace 'F' with whatever your encrypted drive maps to.

How to set up encrypted Vision 3 on a USB Drive

2007-11-20T09:24:00.000Z

It is possible to setup a copy of your current V3 data onto a USB portable storage, typically a USB hard drive but if your V3 data + program is small enough, you may be able to squeeze it onto one of the larger capacity solid state drives or storage cards i.e. a 'USB Key' or 'dongle' or even onto a Flash or SD card.

If you do this then you MUST encrypt the data files (at least) as, although they are hard to assemble without access to the Vision program itself, it is far from being an impossible task for anyone with some database knowledge. If you lose unencrypted patient data - the USB drive is stolen or left on the train - then you may find yourself in some medicolegal difficulty. A recent directive suggested that, at the very least, if you lose such data you will be required to write to every patient involved and advise them of this. And then deal with the complaints. And then deal with the fallout if any actual harm occurs..

Thankfully, we have an excellent open source encryption program called Truecrypt which not only will encrypt your files for you, but will also run from the USB drive and automount (with a password) when you plug the drive into any Windows PC. So, how do we do this?

Choosing a USB Drive

I would recommend you select a drive whihc does not normally require external power - i.e. one which gets all its power from the USB socket itself. By default, Flash memory card like SD, MicroSD etc do this, but some USB Hard Drives do require an external power supply so you need to be selective in your choice.

Capacity wise it is unlikely that your V3 data is going to be more than 20 to 30 GB, and typically all portable HDs are at least 40GB, more often 80GB or more nowadays so this is not an issue. Our O:/ drive is 3.53 GB so a 4GB USB stick could take the whole lot, but then we are a conversion from GPASS practice and have yet to acquire the years of Vision data that others have accrued.

You can, of course, not take over the data/attach and data/wordproc folders which are often pretty large, and this can cut down the total volume of data which may let iq queeze onto a smaller drive.

Get a USB drive with enough capacity for your O:/ folder
Make sure the USB drive can run using only the power from the USB port

Install True Crypt
Next you need to get Truecrypt from:

http://www.truecrypt.org/

This is an Open Source (though not quite GPL) encryption program which does two important things:

Creates a virtual encrypted disk within a file and mounts it as a real disk.
Encrypts an entire hard disk partition or a storage device such as USB flash drive.

Open Source part of it means, effectively, you can use it at no financial cost. So that is good!

So, install it. Run it and you get this:

Try not to panic!

You need to create a text file on your USB drive that will hold all the V3 encrypted files. So, use Explorer to create a text file on the USB drive - call it something like 'visionsafe.txt' or similar.

Now we need to get TrueCrypt to turn this into an encrypted file of the appropriate size. So:

Click 'Create Volume' and in the next form take the default setting of 'Create a standard TrueCrypt volume'. Click 'Next' and then navigate to the file 'safestuff.txt' or whatever you have called it.

Click 'Next' again for encryption options. Just accept the defaults, unless you have a Scooby about what you are doing! Then you select the size of the volume. This should be at least as large as your current V3 O:\ drive.

I am just using a 2GB USB stick to demo this, so I have selected 512MB. Clearly this is not enough - you will have to use between 5000 and 12000 MB depending on your V3 install.

Click next and type a password, and then confirm. Use numb3r5 4nd l3tt3r5 for this.

Click next, and then Format. It will take a few minutes:

and then finish, and that is the volume created. Click cancel to finish.

So that is it created. Now we need to setup a 'Traveller disk'. This is in Tools -> Traveller disk setup on TrueCrypt. Here is what I did:

So you point it at the root of the drive you are using. and select 'Auto-mount' This adds 'Mount TrueCrypt Volume' to the autorun options when you insert the drive. Point the Mount settings at the file you want to mount, and give it a drive letter - here I am using 'E:'.

Click 'Create'.

So now when I insert this USB drive I see:

and Double Cliking on Mount TrueCrypt volume opens the password window. Type this in and OK it and the encrypted file will mount as a virtual drive mapped to E:/

Then you your a batch file to map O and P. This is sitting on my laptop, so I will need to update this for you later in the week!

Vision 4 is hosted

2007-11-19T09:41:00.000Z

Yes, yes. It is. But it is hosted in the same way that this web page is hosted, or accessing your webmail is hosted. In other words, the data and the program is effectively held on remotely hosted servers and you access that with your web browser. So, you log into Vision 4 and the web browser grabs the code it needs to access the data off of the Vision 4 servers. It runs with Oracle 10G at the data centre, then employs Java and Flex at the client to deliver the user functionality.

So, what this means is that you do not *need* to have a remotely delivered desktop as per current VES and other terminal service / Citrix etc style solutions. You can have a very fat client in your practice (i.e. your own personal computer) and even your very own Local Area Network and locally based server for all your practice stuff. Or, you could have a very simple web terminal that only ever accesses your Vision 4 data and nothing much else. Or you could have a Citrix style remotely delivered desktop from which you then run Internet Explorer and get into Vision 4 that way.

It depends on what you want, what you are capable of and perhaps willing to support and what your PCO allows you to do.

This is very Web 2.0. No, really. It is about a web service delivered program, in the same was as e.g. Google Docs or Zoho or any of these web based software applications function. This is why Microsoft were so worried by the rise of the internet and the web, because their futurologists could see that it threatened both their operating system market (the OS is irrelevant when all you need is a web browser) and their monolithic Office system (when web services let you choose which features of a word processor you want and when).

So, "Panic not!" colleagues who may have felt panicked by being 'forced onto a hosted system'. The model is superb from a GP business POV and from a PCO POV. We can have LANS and local desktops to run our non NHS stuff, the PCO can pay INPS to supply us with Vision 4 services.

We don't have to worry about backing up or repairing our Vision 4 data, because it is all held on the data centre.

2007-11-15T12:16:00.000Z

Notes on Max Brighton

(These are my notes of MB's presentation to NVUG - not verbatim!)

'Mood change at CfH'

News and Marketing

The News....:

GPASS

'GPAS gives smokers a hard time' - glitch in GPASS mistakenly made smokers being advised to smoke were Rx Viagra - BBC SCotland

EMIS Branch performance struggles
CSC computers in data centre failed - compensation paid to NHS
System One failure on 18th September 2007
GP2GP and INPS

Case Studies

Phil Koczan on BT London hosted system
Regional News Bulletins on a regular basis
Exhibiting in HC 2007 - looks nice!

CfH In the News
GPSoc

A lot of work into agreements, close work with CFH team
Who Pays What?
All annual support costs willbe paid for centrally except for system support charge £650 pa.
Hosting

GPSOC will pay for all Vision hosting charges
An agreed path to hosting to CfH standards
GPSoC web site is very good!
Slides illustrating costs

SCR is proving to be 1st real test of data privacy and consent
List of INPS GPSoC product commitments
Agreed set of requirements at the outset

CAPGP

New assurance process
Stricter testing regime
All systems re-accreditation within one year

Support Obligations

90% of all calls in 3 mins
Incident resolution / bugs / responsiveness 'transaction monitoring'
Availability 99.98% hosted to CfH standards

Helpline

Average response time to helpline 170 seconds currently. CfH standard is higher - more folk! Below 140 seconds for last 5 months
60 helpline analysts - training / retention
Calls per practice per month <6
Split to Country based helpline teams

GPSOC Hosting

Resilience of system is the key

London Dockland connected two diversley routed to N3
2nd Data Centre at LHR linked to Docklands through fibre optic network
555 Hosted practices, increasing by approx 2 a week
Sure some practices will continue to have LAN hosted

GPSOC how does it work?

PCT must sign call off agreement with INPS
Schedule A to the call off agreement lists the GP practices and what products they take
There is an agreement between the PCT and the Practice

CFH News

27/4 NAO review again
30/5 Mike suggested Primary Care complete by 2010
2/5 InformatioN governance take 10 years to complete
29/6 BMA Votes for no co-operation - 'perhaps should gree to co-operate and do it properly' (my comment - yup :-))

Money

Vision 4 5.8M quids so far
More developers on V3 also

Sites

2007 Gains 167, lost 23 including closures and merges.
Losses in North and NE
2200 Vision practices (My comment - well done)
104 new ones in Scotland
Data Centre opened in Scotland and gone well - thanks to Mark Norman and others
Not much movement in England overall
91 conversion from GPASS - others from iSOFT
26% market share in Scotland

CEGEDIM

Based in Paris
Parent organisation
Acquired US company 'Dendrite'
Cegedim is big company!

LSPs

London Vision 3 is contracted interim solution
re-contracting underway - takes time
Vision 4 added in 2009
+ one year testing and acceptance timeframe so not till 2010 for V4 live to users?
Fujitsu Clear intention to host V4 as core solution
Everywhere else in England - GPSOC is king. CSC do System1
Original rational for LSPs is changing - ?? Hospital SC etc

Scotland

Progress has been good
Tayside - continue to do well
They won the EHI award
Deputy PM opened the offices in Dundee

Wales
NI

gained sites fro iSoft

Battery running out
MUst get better laptopl

2007-11-15T11:35:00.000Z

Notes from NVUG Tom Davies

TD commenting that Scotland / England may not do GP2GP the same.
EPS / ETP 'slowly being rolled out'.
C&B - here today!
SCR - spec changed several times, difficult for this to be developed, UG will support company in ensuring large areas of work do not interfere with other development
GP at a crossroads, partnerships being threatened, Birmingham putting GP out to tender..
Passionate about ownership of data.
OOH - single server not the answer
NVUG - 'fiercely independent'
Web site, engage membership, roadshows well supported
Alan Selwyn, David Anderton, Gary Mahn, Brad Cheek new panel members
Brad Cheek - Wellclose Square http://www.wellclosesquare.co.uk/
INPS - relationships good and honest
27 % of Vision practices on hosted symptoms
Produce a buglist for nex year!
We want Vision in all 5 regions of England

NVUG Award for INPS Employee of the year

Mark Norman

Congratulations Mark!

More Pics

2007-11-14T20:58:00.000Z

Paper Chains

2007-11-14T19:48:00.000Z

20 or so delegates today for a beginners and new users theme. Seemed to go well. My presentations now complete, as far as they can be at this stage. Now starts the paper chains of assembling the delegate packs. As I type Richards Neep and White are busy assembling the manuals to support their talks on using Access and Excel with Vision Data.

Sadly internet access is a little unreliable from here currently, so attempts to live blog the conference may be yet scuppered. Fingers crossed.

Reception Desk

2007-11-14T09:36:00.000Z

NVUG Annual Conference - Day 1

2007-11-14T09:18:00.000Z

Hi all

quiet for a few days as busy writing presentations, working in Dundee and trying to have some kind of home life also! Anyway, day one of NVUG Conference - this for newbies.

Setting up Reception Desk

Not a busy first day delegate wise. We should have put on abus from Dundee and Aberdeen. Maybe a boat from Orkney...

Presentation One

2007-10-30T11:15:00.000Z

Is done bar the animations and transitions, but the content is there! There is so much to therapy in V3 that it is hard to know where to draw the line when talking to new users. Any hints and tips on the things that threw you when new to Therapy management in Vision 3? All suggestions welcome!

Sort a search

2007-10-30T11:12:00.000Z

Quickie off the forum:

To sort a report's output, click on Edit then 'Report Output' to find the sorting options. As below:

and then the options display:

busy busy busy

2007-10-25T10:48:00.001+01:00

So, I am in Dundee every Wednesday and every Friday just now as we go through medication requirements in detail. This is good to do, but means I am in Dundee every Wednesday and every Friday and squeezing in additional work round the edges of the practice and home. Also, I have 3 presentations to prepare for NVUG. And my personal accounts from last year still need finalised. And the kitten is having some litter training 'issues'. And the builder never appeared so kitchen conversion is set back yet again....

All this by way of excuses as to the lack of blogging!

There has been some interesting discussion on the sorting of medication records on the Vision forum. I am sorta involved in this for V4 development and I am reading it and taking it all in. I cannot promise that it will all be delivered out the box, but as I will be using the system too I am also keen to see such neat and useful functionality. These things (like sort by indication) are on the list of stuff to happen, but what I am not sure of at this stage is when they will happen. The basic design and framework of Oracle, Java, Flex should make supporting clever functionality like this a) easier and b) nicer to the end user. So, happen it can and happen it will.

But when? dunno just yet. :-(

Add to Address doesn't work

2007-10-16T10:41:00.001+01:00

Further to Patient Details tab discussed below, there was then a coincidental discussion on the mailing list about the 'Add to Address' button for phone numbers. Apparently, it does not actually add the phone number to the address. To do this you need to go into Patient Registrations, where unwary GPs should not venture.

Ho hum :-(

tabs: Patient Details

2007-10-11T09:36:00.000+01:00

Continuing the theme of looking at the tabs I use, here is Patient Details:

I like this tab as an easy way of finding phone numbers and addresses, mostly, and also adding and checking numbers. There is a school of thought that clinicians shouldn't have to do this stuff - keep phone numbers up to date - but my feeling is that it is everyone's job to make sure the data we hold is accurate and complete. hmmm, maybe a sore point ;-)

Anyway, ranting over what have we got? Names, addresses, identifiers and phone numbers. You can add, edit and delete numbers from here and add them to an address or to a patient.

Look at the tabs at the bottom of the form:

Identifiers lists all other IDs, like hospital codes and so forth. I don't use this but maybe you choose'n'bookers do?

Family is excellent as it lists all family members and allows you to double click on them to open a consultation. Great when mum comes in with 3 weans in tow.

Not such a great pic as all the detail has to be pixellated! It shows Address, Forename, Surname, DOB, CHI.

The 'Carer' tab lets you both see who is the carer of the patient or who the patient cares for. And to add or edit these things:

And lastly some Patient Preferences, which presumably changes with different regions of the UK. Preferred pharmacy is in here though, which is great to have for Drug Clinics. Perhaps in V3 you are using this for nomination in ETP2?

Anyways, I like this tab because it has all this useful stuff on it. I use CTRL+D to get to it quickly. As an aside, I do not like nor use the Patient Select tab. I always found it changed the behaviour of F3 sufficiently that I could not work with it. But hey, it is probably just me. Maybe everyone else loves it!

More on 'Paul's Favourite Tabs' next week!

Anyone else want to write stuff for the blog? If by some remote chance you do, please let me know. It is not difficult, and almost good fun. ;-)

Long Format Syntax for No Drug Allergies

2007-10-04T09:29:00.000+01:00

Following on from earlier post this week, 'Nell' kindly supplied the syntax to make the grid look better when displaying no known allergies.

Here is the syntax:

And here is the result:

Medication Review reminder that is not

2007-10-02T11:52:00.000+01:00

This, this morning:

so a patient with NO repeat masters and the system is prompting me to do a medication review. Well, I don't wanna do that.

Here is why it has appeared:

So, patient has an outstanding reminder from a medication review previously done. V3 does not query the status of current repeat medication to determine if a review is reuqired. V4 might just do this, which would be nice.

Anyway, if you delete the review reminder:

then the yellow reminder text thing goes way.

phew!

Show No Known Allergies in a Guideline

2007-10-01T13:36:00.000+01:00

If you record No Known Allergies from the Alert Pane by double clicking the line as shown below:

then to display that record in a guideline or report (a report is a guideline that prints!) you need to select 'Absence of Condition' like this:

and it will then display...

'Negation' is not done well in Read - the 'not got this' codes are often under the chapter headings that imply 'got this'! Vision 3 has a special SDA for recording Absence of Condition, and it uses this for allergy negation.

Apparantly negation it is not too hot in SNOMED-CT either....but then no one understands SNOMED-CT, so maybe we won't notice ;-) (tho presumably you can use a post-cordinated term to negate anything??!! Kinda like the V3 Absence of condition SDA...). But I have not explored negation in SNOMED-CT to any degree, so this may well be apocryphal.

To change the display string in the report so it shows something more meaningful like 'No known allergies' then you need to change the second Read term in the form to e.g.'1151 No Known Allergies', tho' then it still says in big letters 'ABSENT'.

which is a little recursive and thus a bit odd.

So you could just add it as medical history, then it will list in the medical summary assuming you elect to display that priority, but then it will not turn off the alert option in the alerts pane...

Or, you can put it into a grid and elect to use the Long Format:

which is not very pretty either. P'raps someone nice could tell us magic syntax for the Special Format to make it look prettier?

tabs

2007-10-01T09:33:00.000+01:00

One of the best things about Vision 3 is the ability of the user to customise the interface for their own needs. Consultation Manager allows every user to set up their own set of views, choosing which panes to show and also allowing any number of customised 'Tabs'. My tab set is as below:

and I think it may be useful to talk you through them...

Appointments

OK, I always work with the appointments tab in my setup. I don't know of any clinical staff who don't use this. I have a keyboard shortcut of 'CTRL+T' to get to this quickly - you need to put an ampersand in front of the letter in the Tab View Options (Right click the tab to get this up):

So I can always quickly get to the appointments tab with CTRL+T. Keyboard is good - take time to learn it.

Have a look also at the tabs on this form - you can quickly see AM, PM or ALL appointments, review 'Other' surgeries (although this view does not persist), and find free slots into which you can book the currently selected patient.

But mostly, you can see what work you have done, what you have left to do and how long you are taking!

We also use an appointments book for messages, tho it looks a little weird this morning for some reason yet undiscovered:

but normally it works fine! I think someone had the wrong session type in place for the message book this am and has undone that error, replacing it with a weird looking thing!

I also like the bit at the top that tells you how many patients you have seen, and current time:

which is even nicer when it shows all pts seen and thus time for coffee and cake. ;-)

The check box that says 'booked' on the above, shows that some of my forms display a little oddly, sometimes truncating text. This is because I like to run my 'puters with large fonts (currently at 1680 x 1050, clear type, font size Large). I can live with this, but it is not normally a 'feature' of Vision 3 to truncate text in forms.

Places to go, things to see

2007-09-26T14:04:00.000+01:00

Quiet again, sorry. Doing yet another review of medication requirements for Vision 4 amongst other things, and off tomorrow to a very fine conference indeed in Oxfordshire with the PHCSG who are the 'Primary Health Care Specialist Group of the British Computer Society'. This is usually a slightly off centre take on medical informatics issues and their impact in GP land. Also, some beer is involved. So unlikely to be busy posting here again this week.

On the subject of conferences, the programme for NVUG Annual Conference in Stratford is being finalised and looking good. That is on November the 14th, 15th and 16th of November with day one (the 14th) primarily being for New Users. More info at http://www.nvug.org.uk.

Also coming up is the SCIMP conference (where we discuss scimpy things, fnar fnar) in Dunblane which looks excellent. Details here. The program clearly has Scottish bias but it is also turning into one of the largest applied medical informatics conferences in the UK. Go SCIMP!

On that note I am doing some of the judging of the Best Use of IT in Practice awards for SCIMP and am being informed ever so gently that I was meant to have that done last week, so I better get on with it.

later...

All the forms

2007-09-20T10:43:00.000+01:00

If, in Con Man, you do 'Add->Select Data Entry Form', you can navigate a hierarchy of all data entry froms including all the Clinical Entities (SDAs!). Below is a very big picture of them all. The intention is to have fewer of these in V4 tho. Thankfully. :)

You may need to click and possibly save then zoom the picture to see it in its full format. If you want to...ah, go on...what else you gonna do?

It is a very long picture!

More on SDAs

2007-09-18T12:33:00.000+01:00

SDAs then are a necessary evil (though, perhaps 'evil' is a little strong), to allow us to record the stuff we do properly. You can change how Vision behaves with respect to SDAs, and you can always force V3 to use the Add Medical History form for any code, regardless of whether it is associated with an SDA.

In Consultation Manager Setup, on the 'Patient Record' tab, you can elect to make Vision always select and use the SDAs or to use SDAs at all (but let you choose which one). Essentially, Vision 3 knows that certain Read Codes are used to record information best held within an SDA. So, when you enter one of these codes, V3 will know which SDA to present you with to best record the data.

In theory.

And, to be fair, it works most of the time. But some codes are necessarily represented in more that on SDA. e.g '242.00 O/E Pulse Rate' has 3 possible SDAs associated as below.

I work with V3 set to 'Record in SDA' but not to 'Automatically select best SDA'. Though maybe I should change it, but this is how I have always worked. I found that on occasion it presented me with a different SDA from the one I wished, but cannot now find an example of that. So, this being a living blog thing (wooh!) I will switch my setting to 'Automatic' and work with it for a couple of days and see how I get on.

'242.00 O/E Pulse Rate' when set to automatic gets me straight to this:

which is what I would have wanted.

OTOH, 'lmp' always brings up Pregnancy Dates, when mostly I want to record when it was, not that the patient was pregnant.

You can always force V3 to Add Medical History by either using ALT, A, L or F11. For those moments where you really want to avoid the SDA...

Dosage Codes

2007-09-13T13:31:00.000+01:00

Question on the forum about this. Here is a quick 'howto'.

Dosage codes are shorthand ways of getting dosage text instructions into therapy items. So, you type 'bd' and it expands to 'twice a day'.

Very good :)

To access the list of them, and add, edit or delete them, you need to open up a Therapy Add form - i.e. do F4 then F8 in consultation manager then Right Click in the Drug Name box. Like this:

You can 'Add' or 'List'. 'Add' gives you this form:

which is relatively straightforward.

List shows this horrible listing in a datagrid that was written when the UI specialist was perhaps on holiday:

It is, however, perfectly functional. You find the code you want to edit or delete, and Right click on it. e.g:

The one that causes annoyance is 'OF' which expands to 'Every Fortnight'. Post from Mark Morgan of INPS (thanks Mark!) then says if you prefix the word with ' i.e. an inverted comma, known to us (just) over 40 yr olds as an apostrophe (and we multiply things, not 'times' them. Oh, its all changed since I were little, grumble, grumble etc..) then you will get the word you type, not the abbreviation. e.g.:

that is a good tip. :)

SDAs

2007-09-12T08:55:00.000+01:00

So, a V3 Structured Data Area (SDA) is simply a place where you can add details about a thing, like a result or a finding. Always, in V3, attached to a Read Code. The BP example below shows that Blood Pressures have many attributes, but will be captured against a single Read Code (although you can choose one from lots of different codes for each entry).

This stuff is becoming very important informatically speaking, as it determines the shareability. SDAs are sometimes (though not specifically by Vision users!) referred to as 'archetypes' (or templates, where they use more than one archetype. sort of..) and for good or ill every system supplier in the UK has gone off and done their own thing with them. Which was fine, until the new networked world hit and we had to start sharing stuff. Which is why GP2GP has taken so long to get going. A Vision representation of a Blood Pressure will not be a GPASS one will not be an EMIS one, and so on...Work by NCDDP in Scotland and CfH in England on Clinical Content Models, plus the OpenEHR stuff is all looking at this.

Quote from Ian McNicoll I like courtesy of Derek Hoy (thanks Derek! oh yeah, and Ian!)

"The information model is the crux of current electronic clinical records but, by being application or message specific and usually proprietary, it hampers interoperability."

OK, so this is more than you need to know. What I am getting at is to show why SDAs exist at all and are needed. Medicine is complex and needs, inevitably, a complex model to underpin what we do electronically. The complexity is largely hidden from the user in V3 but it is impossible to hide it all. Thankfully, people in general practice are usually smart enough to cope. There are somewhere in the region of 400 SDAs in Vision, if you count all the result ones.

It is a good idea to get to know how and when to use them. Honest. :)

More later.

ways to do it

2007-09-11T09:43:00.000+01:00

Some folk coming from GPASS get annoyed coming to Vision because of the requirement to enter a Read code before you can do anything. It is, I agree, challenging to go from one method of electronic recording to another. And I have had, and continue to have, endless debates about the value of narrative versus codes in recording the consultation. But, hey, that is not for today...

In fact Vision lets you do GPASS style recording, pretty much. You do need to enter a code first, but it can be a fairly broad code and you can attach it to a happy little keyword like 'addstuff', say onto '1....00 History / symptoms' as a heading.

Then you can just type away merrily. And, of course, you can enter more than 512 characters. ;-)

But Vision 3 does like structured data entry; it tries hard to encourage it. And generally when you have a value or an examination finding you should stick that in the correct place - the horribly named (especially to scare newbies) 'Structured Data Area'. These little beasties confuse folk terribly, particularly when you are used to dumping everything into a narrative either on paper or text box. But essentially they are just ways of recording stuff you do in a logical fashion, with less ambiguity than narrative and in a way that allows you to search or report on this information.

In fact, GPASS also has SDAs but they are not as well modelled (in my opinion! - though I miss SPICE for workflow and simplicity!). It also has the troubled BP data entry with multiple methods recording in different places in the database and no error trapping. But when you enter Systolic and Diastolic into a specific box or boxes, this is a structured data entry. Vision allows for more complexity and detail in the recording, but it also allows for this to be very simple. And has error trapping, and one place in the database for recording it. Write once - Read often.

So, if we do this:

Then it is no use to QOF, no use to CDM in general and little use in 10 years when you want to list all the BPs for the patient.

If I just want to record BP simply but correctly in V3 I need to use the SDA. You can get to it by doing ALT, A, B for 'Add -> Blood Pressure' (or use the mouse if you must!)

As is often the case with Vision, you can do things many ways. This is good - we all consult differently - but also bad (for beginners, who want to know the one true path...). You can also record get the BP SDA up by typing 'bp' into the Read Popup on a Journal screen.

Anyways, here it is again:

So all you need to do is enter systolic, tab to move to the next field, diastolic, and then OK. Done. You can, however, also record lots more stuff about your BP measurement and I tend to do so routinely (but you don't have to!). You can navigate the form using the keyboard quite quickly, with a little practice.

So here I am recording which arm (important clinically sometimes) and which cuff, good to know in obesity particularly.

Takes some learning to use the keyboard, but you do not need to make the effort to do so immediately - you can take your time as the defaults are fine for most purposes.

Anyway, I have to go do some real work...

A big boy did it then ran away

2007-09-04T11:10:00.000+01:00

It was annoying us that in Journal views where some receptionists are making entries, the initials on the view made it look as though a clinician was responsible. So, e.g. Joanne (one of our reception staff) goes into the journal to record a special request message, and this then appears with the initials 'PAGM' after it so, at first glance, it looks like I did it. But, it wisnae me!

The fix for this it to make staff who are using the journal to make entries be set as type 'Other Health Care Professional', as 'Receptionist' roles are assumed to be non clinical, thus entries made by them are the responsibility of an allocated clinician.

So, change this. And now her initials appear.

You can check the actual logged in user who made the entry by (R) clicking and selecting 'Audit Trail'. But not best convenient ;-).

Med Reviews update

2007-08-30T11:29:00.000+01:00

Are averaging about 30-40 a month. 3000 patients on the list. Search looks at birth month, on current repeat masters, no med review in QOF reference date. Save as a group. Open in Con Man as a list and work through each, check safe and sensible, reauthorise all for 1 year, tidy up medreview reminders as discussed previously, add a 'Med Rev Done' record, move on. can do 30 in about 90 minutes.

Setting up Recalls for QOF

2007-08-29T15:59:00.000+01:00

This is the latest iteration of a recall process. I am not entirely happy with it as it is difficult for non technical users to really get their heads around. Being able to use Vision 3 searches well is a bonus, but not a skill everyone intuitively acquires. Anyway, ever onward. Oh for Contract Manager.....

Chronic Disease Areas

We will use Vision 3 Recalls for managing recalls (invitations, screening) for the following QOF areas:

Asthma
COPD
CKD
Thyroid Disease
Mental Health
CHD
Hypertension
Epilepsy
Stroke / TIA
AF
Dementia
Heart Failure
Diabetes

The following areas are not managed using the Recall system:

Palliative Care
Smoking
Obesity
Cancer
Depression
Learning Disabilities

Chronic Disease Registers

Although Vision prompts you to use these, we do not use them for our patients with chronic diseases. The actual QOF registers are 'virtual', that is determined by a series of QOF rules based on Read codes. Thus if we use the Vision Disease Register entity for managing any of our QOF stuff we will not be using the actual QOF cohort we need to look at and thus not doing what our contract requires us to.
To create a 'Disease Register' group, we need to use the Monitoring Audits, identify the line that shows the register and save that group.

Why Recalls

The Recall system can be used to ensure that patients are sent invitations for review of these chronic diseases. It will allow us to confidently record 3 invitations and, if required, 'Failure to Attend' events which the qualifies the individual to marked as an 'exception report' for that disease.

General Process

Every patient with one of the above QOF areas will have a Recall record added and maintained for that area, generally based on their Birth Month.
Recall searches run monthly will identify who has QOF recalls for that month.
These lists are then reviewed manually to identify those suitable for review in the surgery, those who are housebound or in care homes, and those who do not require calling in at this time.
Invitations are then sent either by letter or phone and recorded into Vision.
Those who do not need recalled at this time have their recall deleted and a new one added with the next date on which they should be called.
Searches should also be run to identify those patients who still have outstanding recalls from the previous month, with previous invites. These lists also need manually reviewed and then actioned according to their status. Possible outcome will be to add another invite, to delete the old recall and create new (assuming QOF requirements completed) and other queries which may arise.

What is important!

MM and PM will manage most of the recall admin, primarily MM.
Everyone needs to manage the day to day recalls. In particular, when a patient has been seen for a condition, they should have their recall deleted and new one created for the following year.

Creating Recalls

We need a process of ensuring everyone with one of the QOF diseases above has an annual recall set. The initial process of setting these up has been completed, but we need to identify those patients who do not have recalls present but do have the conditions. This can occur from new patients joining the list, or new diagnoses.
These searches should be run monthly.
When new patients join with the QOF diseases a recall should be added for their conditions. This should be based on birth month, and use the standard Recall codes used by Glenburn as per the Recall and Invites Guideline. MM should do this after the notes have been summarised or when the condition becomes apparent.

Finding Patients with No recalls

Monthly we should run the searches below and review the patients found. These searches identify patients on the QOF disease registers with no 'in year' recall.
Each search requires you to first identify and save the appropriate group from the clinical monitoring audits and input that group into the search. When we enter a new QOF year you will need to change the date of the search - it should always run from 1st April of the QOF year inclusive.
Patients identified in this way should then have recalls added using the Month of Birth for this QOF year using the agreed Read Term from the guideline for this condition. The first example below is CHD but the process is the same for each disease area:

CHD

Identify the CHD register from Clinical Audit Monitoring Audits: CHD1
Save this group
Open the Search and input this group. Search is 'RECCHDX' and is in 'Paul's Searches'
Change the date if into a new year! The search should run from 1st April of QOF year Inclusive
The search will identify which patients from this group do not have a recall for CHD present for this QOF year.
Print out the report. The patients are also saved to the group 'RECCHDX No Recall for CHD'
This list should then be reviewed by MM and recalls added as appropriate.

All searches for this are under 'Paul's Searches'. Ensure you have the correct Input group, recall code and date before running the search.

Run searches for all areas as above.

Finding Patients for First Invite

Monthly we need to run the 'Recalls for Calendar Month All QOF' for the month ahead - i.e. In August we should run the searches for September.

We can run this search in advance as required (and should do so to avoid being unable to send invites x 3 to people due recalls in March for the 07-08 year!!!).

This list is then printed out and should ideally be reviewed by the GPs and PNs and MM for comment, then MM can do final revision.

Tasks from this list are to:

Change recall dates to future ones when the patient does not require an invitation
Ensure housebound patients reviews are allocated to someone to complete.
Ensure patients being recalled have the specific condition
Review each patients QOF related criteria and identify and complete these criteria as far as possible.
Send and record a 1st invitation for each area in question when the patient has to be seen.
Again, when the patient's QOF criteria are complete the patient's recalls for each completed condition should be deleted and a new recall entered using the patient's day and month of birth.

When Patients are Seen

When a patient attends the surgery (or has their QOF related information collected and recorded) they do no longer require an in year QOF recall. Any that apply should be deleted and a new recall added for the following year.

Finding Patients for Second Invite / Third Invite

Monthly we must run searches to look for patients who still have QOF Recalls outstanding from previous months. Remember - patients who have had their QOF criteria completed should have their recalls deleted and new ones added for the following year. Thus patients who have recalls remaining from previous months can be assumed to not have attended (or have been actioned) and they will need their notes reviewed.
The searches are located under 'Paul's Searches' but you will need to change the date each time!

Sending and Recording Invites

When a patient does require an invitation for a QOF review, this should be done using Vision, Add Correspondence and an appropriate letter.
The invite should be recorded using an appropriate Read Code as defined in the Vision Guideline and Recall Spreadsheet.

Letters should be recorded as Medical History and Priority 9 only. Do not record a letter sent using a 'Recall' - there is no need to do this and it simply adds more spurious recalls to the record. Verbal and phone invites can also be added using the guideline - please free text the invite number if known.
Where a patient has received 3 invitations to attend and has not done so, the patient should be brought to the attention of one of the doctors for consideration of adding an Exception code for that QOF area.
Patients with multiple QOF reviews should ideally receive only one appointment for all these items to be looked at.

Managing Specific QOF Disease Area Requirements - Some Searches

Hypertension

BP4
Requirement is to have checked the BP of people with HBP in 9 months from QOF year end. This means we (for QOF purposes) must have checked their BP after 1st July.
Hypertension recalls for QOF therefore should be set to July or later. Those with a birth month of April, May or June should have their recall set to July, August and September respectively.
BP5
Requirement is that patients with hypertension last BP measured should be <=150/90 after 01 July.
Patients with HBP and last BP in previous 9m > 150/90 can be identified from the monitoring audits.
A search should be run on these patients every month to identify those whose last BP reading was over 4 weeks previously and who do NOT have a future recall date. This assumes that every patient who has a high reading has follow up arranged for no more than 4 weeks - in other words, if over 4 weeks since last they are lost to follow up and should be invited back. If they have a future recall (but still before 31/3/2007) then they can be assumed to be going to be picked up by the monthly recall searches anyway
The search requires that you Save the Monitoring Audit for BP05 Negative last 9 months patients as a group as 'BPNEG9M' and use it in the Hypertension search 'Last BP over 4w high for review'
This group then needs reviewed by someone (MM, PN, GP?) to ensure patients are getting some kind of review. If no apparent review then they should be contacted and asked to attend again.
This will mean they should get 1st, 2nd and 3rd invites accordingly.

Asthma

ASTHMA8
Diagnosis from 2006 - need to look at the group in monitoring audits and review the patients individually.

ASTHMA6- review in past 15m

If we actually aim to do a review every 12 months then we can use the monitoring audit group of MONITORING: ASTHMA 06 NEGATIVE2: % of eligible patients with asthma with NO asthma review in last 12 months, save them as 'ASTNEG12' then run the search to see which of these people have no recall in QOF year. This report will print out with all recalls in the patient's record - sorry! We only want to look at the asthma ones tho :-).

Also Run the 'Asthma 6 No recall Due and Letters' search to identify which patients from the due group have had invites, and what they were. If a patient on the due report does not appear on the letter report then they have had no invite sent and they must have their record checked. Similarly some of those with invites may have been missed and any that are outstanding need actioned from here.

COPD

COPD9 - Confirmed by spirometry

Monitoring audit identifies these patients. Get them in!

COPD Generally

We can run a search to identify who has been missed for recall. Save the COPD register from the monitoring audits as a group named 'COPDREG'.

Run the COPD search. This identifies patients who have no future recall for COPD and this should be the group who are have been invited (or missed for invite). If they have a future recall, we can assume that the usual recall searches will pick them up.

quiet

2007-08-28T10:39:00.000+01:00

Hi all, quiet here innit? Sorry, been busy. Thanks to Kathie for prodding me to action :)

Medication reviews remain a big bug bear for me, and I am trying to sort them in Vision 4 so they make a little more sense and are ideally less intrusive yet more clinically useful. Depends what folk want I guess. GPASS does Medication Reviews as a check box on the Repeat Masters screen. And that is it. 'Tick. Medication Review Done'. Not a lot of scope there for doing better stuff, like managing Epilepsy Reviews or other condition specific reviews, nor for allowing clinicians with special interests or clinics to use medication reviews as a tool within their own niche field.

Anyway, at the end of the day it is a QOF requirement first and an extended clinical requirement second. Explaining to people what they are doing in V3 is hard enough!

So, what do folk want out of medication reviews? Any pressing concerns? Just a 'tick box'? Or something more elaborate? V4 is a clever system, so we can potentially do quite clever stuff. But, medicine being complex, the cleverer we make it the steeper the learning curve for the users. Or, at least, the understanding curve. Coz we can make it do lots of stuff behind the scenes, and for most users this will probably be fine and deliver on the QOF MED requirements, but if you want to change its behaviour, you need to have a clue how it is working in the first place...

Med Reviews can be done simply already. It is doing them better that is the challenge!

e-coli

2007-08-15T09:14:00.000+01:00

Paisley has been stricken by the E.Coli 0157. Nasty germ. Impact here has not been insignificant with several of our patients affected either directly or indirectly by this disease. Not, thankfully, any fatalities from our list but people unwell and in hospital. And positive cultures.

So, Vision wise, useful stuff is:

Get keywords onto Read Terms sorted. So, prefix 'stool' to various useful Read Codes:

Specifically I use 'stooltolab' for samples being sent and 'okstool' (or 'stoolok') for 'Faeces normal'.

Symptoms wise, 'codiar' and 'covom' and, lastly, 'd+v' get '19F2.00 Diarrhoea' and '1992.00 Vomiting' and '19FZ.11 Diarrhoea & vomiting, symptom respectively:

Gastroenteritis was discussed in a previous post, but 'geinf' gets me 'A081200 Gastroenteritis - presumed infectious origin'.

We can map 'ecoli' to 'A070.00 Escherichia coli gastrointestinal tract infection' and hope it is not a term we have to use too often.

Mostly we get to use 'oewell' (a favourite keyword) for '212A.00 O/E patient well' and 'advok' (another favourite) for '8C9..00 Reassurance given'.

Another useful one is 'idc' which I use for '65P..11 Contact - infectious disease' which, whilst not ideal, suffices for trapping those folk who like their deli meats from our local Morrisons. :-(

DXS is useful too...but I am working on my laptop where DXS is not running. Back in the surgery tomorrow though.

DLM 235

2007-07-31T10:08:00.000+01:00

DLM 235 has arrived and now our topics drag and drop is broken :(

Stuff on the forum about this and 237 is near which will fix it. Annoying though.

Topics are normally a nice way of organising the recording of stuff in your consultation when the patient has more than one thing they wish to discuss. Which is generally always...

totw: dates and sums

2007-07-30T10:35:00.000+01:00

Back. Rained a lot in Brittany. Pah. Italy next year, I think. Still, nice cider, pastries and cakes. :)

Shamelessly plagiarising the forum, this tip is well worth knowing. In some date and value entry boxes on forms you can use shorthand notation and calculations. This is very useful for, for example, working out quantities with reducing doses. i.e. '8 a day and then reduce by 1 tab every 2 days to zero' can be calculated as '(8+7+6+5+4+3+2+1)*2' in the quantity box. (72!).

You can also do this with dates in some places. So 't+2w' will work out 'today + 2 weeks'. Same for months - though this uses calendar months, so if you do '31/1/2007+1m' it will take you to 28th Feb 2o07. Different GP systems have implemented this month increment in different ways, I think.

'DOB' unsurprisingly gets you the patient's Date of Birth, but for some reason does not work with sums, at least in therapy.

Holiday....

2007-07-09T09:14:00.000+01:00

I am off on holiday for 2 weeks from Friday to here:

so expect things to be kinda quiet on the blogging front. Though always looking for other authors - contact me if you would like to join in!

In Vision you can block off holidays using Events in Appointments. Though here we just do it by hand...

Remove consent for ECS

2007-07-06T10:17:00.000+01:00

This is done in Patient Registrations, on the Consent tab.