Before moving on, let’s consider the issue of conflicting Phrases, memorization, and customization again. You may have predicted .GE would be
Gastroenterology. However, .GE returns “gastroenteritis” in our file, and .GI is
“Gastroenterology.” Sometimes there are logical conflicts, and you do actually have to remember nuances. I can give you many other examples. There can be no universal solution for every instance. Is .HL “hearing loss” or “hair loss”? Is .IC
“intermittent claudication” or “interstitial cystitis”? Well, if you’re in ENT, HL should be “hearing loss”; but in Dermatology, HL should be “hair loss.” In
Urology, IC should be “interstitial cystitis,” but in many other specialties it should be “intermittent claudication.” The real answer is, if you guess a Phrase and its return doesn’t make clinical sense to your practice, please change that Phrase to what does make sense for your practice. In reality, we can have it both ways.
Dermatology can have a different .HL than Otolaryngology. Don’t get frustrated
when you come across these inevitable conflicts. You’ll learn how to change or edit Phrases in Chapter 43 if you don’t already know how.
A Closer Look at SmartLists in SuperPhrases
SmartLists are an integral part of any Phrase file. They offer you choices to fill in the blanks. The SmartLists used within the SuperPhrase file are, as mentioned, easier to review in the online version of this text. Within this book, while studying the SuperPhrases themselves, usually you will see only a SmartList reference number. You can use the online Red Book to cross-reference any list to see its contents. For instance, the Phrase .PEXRECTAL returns, “Rectal exam:
{:15057}.” While you can intuitively understand what might be on List 15057, to see the available choices, use the online version to locate List 15057. It offers the following choices:
negative without mass, lesions or tenderness deferred, not clinically indicated
declined by patient tenderness noted ***
no tenderness noted lesion noted ***
internal hemorrhoids noted external hemorrhoids noted
thrombosed external hemorrhoids noted *** o'clock anal fissure noted
rectal mass ***
sphincter tone normal
stool guaiac negative stool guaiac positive
PROSTATE EXAM: {:10188}
***
You will often see nested lists within lists, such as List 10188 (prostate exam, above). You can cross-reference that easily online: all SmartLists have active hyperlinks to view the detailed content. The nested list offers additional choices describing the prostate exam, but again you could infer that easily.
For illustration, at the end of this chapter, I include some of the SmartList
contents for the example we did earlier, our 61-year-old diabetic patient. You can readily see why publishing 100 pages of these lists is simply not practical, nor particularly useful. To view this SmartList sampling, please flip to the end of this chapter. You can find all the SuperPhrase SmartLists in the appendix at the end of the book, by name and number, but not listing the full content, except of the single example referenced above.
You’ve noticed that SmartLists within Phrases are displayed inside curly brackets and preceded by a colon. Sometimes you will see a list description before the list number, but the description is optional. Only the number is required. Similarly, you may see a defaulted choice after the list number, preceded by two colons;
this tells you what the default choice is, though not all defaults are displayed in the SuperPhrase file. Thus, {caregiver:15061::mother} refers to List 15061, which is a list of pediatric caregivers; “mother” is the defaulted choice. You could also see this list displayed as {:15061::mother} or simply {:15061}. All are valid references. Figure 1-2 is an example of what you would see in EpicCare using the Phrase .BROUGHT, a Phrase for pediatricians describing who brought the patient to the clinic. Learn more advanced information about SmartLists in chapters 43 and 44.
Figure 1-2 The Phrase .BROUGHT brings in SmartList 15061, with “mother” defaulted as the most common selection. Some SmartLists contain defaults if there is an obvious most likely choice; if necessary, you can de-select the default easily with a left mouse click.
More About SmartLinks in SuperPhrases
Before looking at the SuperPhrase file in more depth, you’ll need to know a little more about SmartLinks. As I said earlier, SmartLinks provide automatic up-to-date information related to the patient, or sometimes information related to the user. They also allow use of appropriate pronouns and insertion of laboratory results. These are useful shortcuts when creating charting tools for office visits.
Part 5 of this text contains indispensable information about the power of SmartLinks, and it lists out all the common ones for you. Instead of frequent sentences that begin with “The patient complains of … ,” you can use SmartLinks to place the appropriate pronoun, with initial capital letters where needed: “He (or She) complains of …” This makes for better looking, less repetitive text that appears less obviously “template” driven. Here is a list of some of the most common pronoun SmartLinks you’ll see in the SuperPhrase file. You can learn more about how to insert them into your own Phrases in chapters 35 and 36.
.CAPHE [“He” or “She” with initial capital letter]
.HE [“he” or “she” without capitals]
.CAPHIS [“His” or “Her” with initial capital letter]
.HIS [“his” or “her” without capitals]
.HIM [“him” or “her”]
There are also SmartLinks that automatically insert the patient’s laboratory
results into your note or into a letter. These must be created by your organization but are very simple to build, and no implementation is complete without many such “LastLab” SmartLinks. Thus, your own implementation team will design appropriate SmartLinks for you to use. Depending on the build in your
organization, here are some simple examples of LastLab SmartLinks that you might have available for daily use:
.LASTCBC [patient’s most recent CBC results]
.LASTLIPID [patient’s most recent lipid panel results]
.LASTTSH [patient’s most recent TSH results]
.LASTRENAL [patient’s most recent electrolytes and renal functions]
(Etc … You can use your imagination to see the potential of these.) SmartLinks can display information relating to the patient’s current medication list; problem list; encounter diagnoses; orders written; past medical, surgical, family or social history; and much more. Examples are:
.PROB [problem list]
.CMED [current medications] or .ACTMED [active medications]
.ALLERGY [allergy list]
.PMH [past medical history, as recorded in the History section]
.PSH [past surgical history, as recorded in the History section]
.FAMHX [family history, as recorded in the History section]
SmartLinks can be used inside Phrases, SmartText, and even inside SmartLists.
By way of example, let’s look at some SmartLinks on an EpicCare patient named Roger Ztest. Even though he is fictitious, the example serves to show how the
various SmartLinks can populate your charting with incredible amounts of important information. You will be able to see LastLab Links as well. You may have seen such SmartLinks many times embedded into SmartText you use every day. These can also be used free-standing in any charting note. One note about SmartLinks: in various EpicCare fields they may format differently. Fields with rich-text format (RTF) often display SmartLinks in grids, whereas fields with plain-text format show the same information in plain-text only. The information itself is
exactly the same – only the formatting changes. So on your screen you may see a difference from what is displayed below. I have shown the plain-text view here.
To begin a note about Roger, we might use .ID, which returns:
Roger Hall is a 71-year-old male.
To note his current allergies, .ALLERGY returns this information:
Penicillin class – skin rash and/or hives
Bee stings – asthma and/or shortness of breath Roger’s Problem List, .PROB, returns this:
Patient Active Problem List:
HYPERPARATHYROIDISM [252.00]
ASTHMA, PERSISTENT, MILD [493.90]
CALCULUS, KIDNEY [592.0]
Look at the difference with the SmartLink .PROBL. The “L” means the “long”
version of the Problem List: it adds the Comments and date-onset. It is useful to store as Comments the details about how that problem evolves over time to be used creatively as the basis for a “plan of care” directly on the Problem List.
Patient Active Problem List:
HYPERPARATHYROIDISM [252.00]
Comment: chronic elevated calcium but asymptomatic since 1997 ASTHMA, PERSISTENT, MILD [493.90]
Date Noted: 05/04/2001
Comment: well controlled seasonally on inhaled steroids CALCULUS, KIDNEY [592.0]
Date Noted: 04/28/2002
Comment: passed spontaneously, 95% calcium oxalate (psst … maybe that hyperparathyroidism isn’t so asymptomatic …) Roger’s Current Medications: .CMED
Current outpatient prescriptions:
METFORMIN 850 MG OR TABS 1 PO BID LEVOTHROID 100 MCG OR TABS 1 PO QD LOSARTAN 50 MG OR TABS 1 PO QD
(Please ignore the fact that this fictitious person’s medical data is non sequitur;
this is poetic license on my part. There is no real patient information in this text, and often the actual data is not medically accurate.)
Roger’s Past Medical History: .PMH Past medical history:
ALLERGIC RHINITIS NOS Comment: Late summer, early fall, presumed ragweed IRRITABLE COLON
Comment: Primarily stress related, cramping, diarrhea
PULMON EMBOLISM/INFARCT 1994 Comment: discontinued anticoagulation 1995 Roger’s Past Surgical History: .PSH
Past surgical history:
REMOVE TONSILS AND ADENOIDS Age 4 APPENDECTOMY Age 20 LAPAROSCOPIC CHOLECYSTECTOMY
Roger’s Family History: .FAMHX
Review of patient's family history indicates:
Healthy Mother Healthy Sister Heart Disease Father
Comment: onset age 57
Alzheimer’s Disease Grandmother
Roger’s most recent diabetic test results, .LASTDIABETES, returns:
GLUC 155 02/25/2004 HGBA1C % 9.0 09/15/2004 MICROALB 56 05/10/2004
(This SmartLink is designed to pull the three most recent diabetic-related lab values, such as glucose, HgbA1c, and microalbumin. It is an example of a configurable LastLab SmartLink; it may not exist or may look different in your organization.)
510-213-5486 (home) 416-271-9900 (work)
SmartLinks also can enter information about YOU, the user, and the current time and date. .ME returns your own name (e.g., John Smith, MD). .NOW returns the current time, .TD returns today’s date (e.g., 4:42 p.m.10/16/2006). Please take the time to review Part 5, which contains more information about the many
clinically relevant SmartLinks in EpicCare, along with some advanced information on their use.
I must take a moment to get on the soapbox about the value of SmartLink data.
Earlier I referred to “patient-level data.” The above SmartLinks keenly illustrate this concept. The data must exist, and they must be accurate, up-to-date, and filed in the proper location within EpicCare. If the Problem List, Allergy List, Current Medication List, Past Medical History, etc. are incomplete, outdated, or not on file, then these SmartLinks will return inaccurate, outdated, or incomplete information (or, if no data is filed they literally return, “No information on file”).
Hence, it should be everyone’s responsibility to maintain this critical “patient-level” data at all opportunities. We all share the Problem List; everyone
contributes to its accuracy. Encounter-level data is information that is relevant only within the context of a single encounter: the history of present illness, the physical exam, impression and orders (though some of this information may become promoted to patient-level data). Patient-level data transcends
encounters over time (though, of course, it evolves over time); this type of data should be entered in the proper fields within the application. Then it is available for all users in predictable locations, and it can be accurately retrieved
instantaneously with these simple, critical SmartLinks. Another way to say this is,
“Garbage in, garbage out.” If you have lousy Problem Lists, then viewing that Problem List and using SmartLinks to pull information from it will be low-quality, non-value-added activities that detract from medical quality and patient safety.
Well maintained patient-level data provide tools for dependable, reliable, efficient information extraction, improving quality and safety. It’s everyone’s job.