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TRAKIT-A

Computer-Assisted

Personal

TO-DO

LIST

Howard

W. Rashba,

MD

From Dowd Medical Associates, Reading, Massachusetts

ABSTRACT. Physicians seeing patients continually

en-counter unresolved problems that must be followed up to

render good medical care. There are always patients to

call the next day, laboratory data to check, consultants to contact, clinical subjects to review, etc. It is not easy to remember all of these items, especially those that

require action in the distant future. In this article

TRAKIT, a computer-assisted system with which to

or-ganize all of these things to do, is described. The use of the system conserves office time, improves the quality of clinical care, fosters positive doctor-patient relationships, and might help prevent malpractice suits. The system is

simple, inexpensive, easy to use, flexible enough to meet the needs of any individual practice, and does not require the physician to modify established work habits.

TRAKIT has been found to be an invaluable aide in a

primary care pediatric practice. Pediatrics 1989;83:1007-1010; computer, physician organization.

During the course of each workday, the physician frequently encounters clinical problems that cannot be resolved immediately at the time of patient contact. It is often necessary to wait for laboratory results, to obtain advice from consultants, or to review a clinical subject before making a diagnosis. On other occasions, it is important to follow-up a patient’s status before closing a case.’ Some

pa-tients with chronic or recurrent problems require

ongoing monitoring and guidance. Finally, every physician has a few patients who seem to constantly need things done for them. To successfully process these items that remain active throughout extended

periods of time, one must be able to recall many

pieces of information encountered at various times in the past.

Pen and paper “to-do” lists often used for this

Received for publication June 10, 1988; accepted July 14, 1988. Reprint requests to (H.W.R.) Dowd Medical Associates, 107 Woburn St, Reading, MA 01867.

PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by the American Academy of Pediatrics.

purpose, have significant limitations. Single-day

lists fail to record, store, and recall long-term items.

These lists become overwritten after a few days’

use and need to be repeatedly recopied.

Alterna-tively, items can be entered chronologically into a pocket notebook. It is difficult with this method to locate items that were entered in days or weeks in the past. Also, chronologic entries are not

necessar-ily organized for efficient processing. A third

method is to enter items into a pocket calendar on the date one expects the item to be processed. Pocket calendars do not provide sufficient space to accommodate the usual number of daily entries in a to-do list. Furthermore, incomplete items need to be hand copied to future dates. Finally, because it

is impractical to photocopy notebooks and

calen-dars, the data in these systems is at risk of loss if

the notebook or calendar is misplaced.

Personal computers have data management ca-pabilities that overcome the shortcomings of these manual systems. In this article TRAKIT is de-scribed. TRAKIT is a simple, inexpensive, user-friendly computer-assisted system that provides a

list of things to do. It can facilitate follow-up and expedite daily work in any medical practice.

TRAKIT

The TRAKIT system uses a standard MS-DOS (IBM compatible) personal computer, a dot matrix printer, and PC OUTLINE, a commercially avail-able idea-processing software package (Brown Bag

Software, Campbell, CA). The software organizes

and stores data in an electronic outline. A wide selection of functions are provided to enter and edit data, rearrange items within the outline, and to generate printouts (Personal Computing, Sept 1988, pp 79-83; InfoWorld, May 12, 1988, pp 52-53). A pop-up calendar program is integrated into the

system to make it easier to assign due dates to

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con-1008

COMPUTER-ASSISTED PERSONAL LIST

trol the software and rapidly move the typing cursor

around the outline of the screen.

The outline structure of the TRAKIT database

is shown in Fig 1. The first section of the outline contains the current list of things to do. The

TO-DO NEXT WEEK, EXTENDED F/U (follow-up), and PRENATAL VISIT sections hold clinical

items that will be used at various times in the

future. The SUBJECTS TO REVIEW section

con-tains reminders to obtain further information about problems encountered during patient contacts.

In Fig 2, the way in which TRAKIT manages

information is shown schematically. Initially, the system generates a list of things to do by printing out section A of the database. This printout is used to help coordinate clinical activities during the next

two to three days. After processing, items are either

deleted or redated for consideration at some point

in the future. New items or notes are entered in pen. The list is photocopied each day.

Once the printout has become nearly illegible

TRAKIT-Personal TO-DO LIST Howard W Rashba, MD

April 14, 1988

A. TO-DO LIST Fri 4/15

1. TODAY!!!

a. WD’s chart-finish note 2. CALL PATIENT

a. CM 945-7588 asthma 3. OTHER THINGS TO DO

a. MS-letter to neuro 4. STAFF TO-DO

a. Insurance ref for JS 5. PULL CHARTS

a. 88/04/08 JB hear test nem 6. CALL PROFESSIONALS

a. Dr Pore LB 7. CHECK W LAB

a. DS check theophylline level 729-9856 8. CHECK W X-RAY

a. MJ checkcxr4/12 662-1476

9. HOSP

a. look at blood smears on LD 10. PRENATALS DUE

a. a. 88/04/10 Jones Mel Hosp gi 852-7422

B. TO-DO NEXT WEEK

1. MS 332-4523 cough

C. EXTENDED F/U

1. 88/04/14 AD hearing test 935-8014 2. 88/09/10 TC hgb fep on iron

D. PRENATAL VISIT NOTES

1. 88/05/04 Smith glpl B/W 944-7951 a. worry re food intolerance b. amino

E. SUBJECTS TO REVIEW

1. KS goats milk

2. KB exercises for the back

Fig 1. TRAKIT database. Outline is in boldface. Abbre-viation: F/U, follow-up.

with markings, the main database is updated with information from the printout. Completed items are deleted from the outline in the computer. New entries are added and redated items are edited and rearranged as necessary. Items added to the EX-TENDED F/U and PRENATAL sections of the outline are tagged with the approximate date when the entry is expected to become active. A computer function sorts these entries into chronologic order. The entries are then reviewed by the physician, who moves those items considered to be active to the TO-DO LIST section. Items in the TO-DO LIST are next rearranged into the appropriate or-der for efficient processing. The updated database

is saved on disk for future use. The database is also

periodically copied on a second disk to safeguard against loss of data. Finally, a fresh copy of the

TO-DO LIST

section is printed out for use in the office.

CONTENT

AND

OPERATION

OF TRAKIT

TRAKIT was designed by the author for his personal use in a two-physician, office-based, gen-eral pediatric practice. During a typical day, the author sees 30 well and sick children in the office, answers 15 phone calls, and visits several newborns and children in the hospital. The system has been used for the past year to help manage information generated by these patient encounters.

The content of the TRAKIT database was ana-lyzed by reviewing six consecutive monthly backup copies of data (Table 1). The database typically contained 57 items. These included 26 TO-DO LIST items, five TO-DO NEXT WEEK items, 16 EXTENDED F/U entries, five PRENATAL VISIT notes, and five SUBJECTS TO REVIEW. Both the LONG-RANGE F/U and the PRENATAL VISIT sections had entries that remained inactive for as much as 4 months. The LONG-RANGE F/ U section tended to increase in size across time

because of data reassignments to items regarding

patients with recurrent problems. Examples of the

types of data in TRAKIT are given in Fig 1.

The mechanics of the system were analyzed by monitoring the various operations during a 34-day period that encompassed 26 working days (Table 2). An average of 8.4 items from the TRAKIT

system were processed each working day. Of these

items, 3.6 were transient in that they were entered

and acted on between database updates. The other

4.8 were reminders from the computerized

data-base. An average of 5.6 new items were encountered each day. Each new item required approximately 5 seconds to record on the to-do list printout.

The database was updated every two to three days. Each update involved approximately 14.6

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1

save to

disk

(

I

Fig 2. Overview of TRAKIT operations. PRINT OUT

) (1) TO-DO LIST (Section A of database)

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UPDATE TRAKIT

DATABASE 10 delete items

20 add items 30 rearrange

items

COMPUTER MODE

20 minutes

TABLE 1. Average Number of Items in TRAKIT

Database*

Item No. of Items

A. To-do list 26

B. To-do next week 5

C. Extended F/U 16

D. Prenatal visit notes 5

E. Subjects to review 5

All items in database 57

* Items C and D retained for 4 months. Item 6 increased

across time because of date reassignment of items involv-ing patients with recurrent problems. Abbreviation: F/U, follow-up.

ditions, 12.4 deletions, 2.0 date reassignments, and

7.0 relocations of data within the outline. An

aver-age of 19 minutes was required for each update. The total time per working day required to main-tam and operate TRAKIT was determined by add-ing the total database update time divided by 26 days to the time taken to initially record new items. The mean daily time requirement was eight

mm-utes.

DISCUSSION

Using TRAKIT

TRAKIT is an information management system

designed to help a clinician recall, organize, and

process important clinical items. An important fea-ture is that the physician does not need to modify established work habits to use the system.2 Except for 20 minutes every two to three days, TRAKIT operates in the familiar manual mode. The physi-cian is free to work without needing constant access and proximity to a computer. Data selection and organization remain within the physician’s

per-‘I,

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USE TO-DO LIST PRINTOUT IN DAILY PRACTICE

MANUAL MODE

2-3 days

TABLE 2. TRAKIT Mechanics*

Mechanics of Database No.

Daily

Total items processed 8.4 Transient items 3.6

Deletions 4.8

Additions 5.8

Update

Additions 14.6

Deletions 12.4

Date reassignments 2.0

Rearrangements 7.0

* Ten updates done in 26-working-day period. Daily time

taken to record items was 45 seconds. Mean time needed for update was 19 minutes. The total mean maintenance

time per day was eight minutes, computed as update/ time per day plus recording time per day.

sonal control and discretion. The overall database structure is completely flexible and can be

custom-ized to meet the organizational needs of any

mdi-vidual practice. The computer is used only as a tool to facilitate operations that are clumsy, difficult, or

repetitive with manual to-do lists.

A minimal degree of computer literacy is required to use TRAKIT. Because the process of outlining

is familiar to all, a novice can learn to use the software in a short period of time. The specific

software package used here is distributed as SHAREWARE. Potential users are encouraged to copy and try the program; a registration fee is required only if one decides to use the program. PC-OUTLINE runs on any MS-DOS (IBM or corn-patible PC, XT or AT) machine. TRAKIT could

also be set up using idea-processing software

avail-able for Apple II or Macintosh computers (Info-World, Dec 15, 1988, pp 52-53). Therefore, a

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sys-1010

COMPUTER-ASSISTED PERSONAL LIST tern on readily available equipment without making

a large investment of time and money. The best way to learn to operate a computer is to use it to run an application like this one.3

Benefits

of Using TRAKIT

One of the most hectic times at our office occurs at the start of morning office hours. It is easy to delay or forget important old business that is not actively demanding attention. The TRAKIT-gen-erated to-do list helps the physician to begin each day properly focused on all of the problems that need to be addressed. The more important items are consequently handled early in the day. For example, it is far more efficient to check on a sick child in the morning than to find out that the child continues to have a high fever at the end of office

hours when the parents decide to phone.

The to-do list also allows the physician to leave the office on time. Because information is appended to the list during the work day, it is not necessary to sift through charts, phone messages, and notes at the end of the day as a reminder of who is sick, what laboratory data is outstanding, and what

prob-lems still need to be resolved. The physician can

leave the office with all of the important

informa-tion about the practice in hand. Office business can be completed after attending an emergency at the hospital or having dinner at home with the family. Finally, when working away from the office, the to-do list functions as a clipboard for the various pieces of information that need to be processed or posted in patient’s charts the next day.

The single most important feature of the TRAKIT system is its ability to store and recall

information. Typically, the database contained 57

diverse reminders of things to do. In particular,

entries in the EXTENDED FOLLOW-UP and

PRENATAL NOTES sections remained inactive for as much as 4 months. Without a reminder, many of these items would have been forgotten. By prompting timely follow-up, the system helped

en-sure that many important clinical matters were properly dispatched.

Risk management is an increasingly important part of medical practice. Activities believed to help prevent malpractice suits include identifying

dis-gruntled patients, keeping clear and complete

med-ical records, properly using informed consent, and maintaining current standards of medical care.4 By preventing problematic patients and important clinical data from being lost in the shuffle, TRAKIT may provide another protective mecha-nism against litigation.

Patients universally appreciate efforts by their physician to stay in touch with them and to render complete, professional service. The most common comment after follow-up phone calls was, “Thank you for checking up.” The TRAKIT system there-fore helped support the positive doctor-patient re-lationships that are vital to clinical practice.5

Daily operation of TRAKIT required approxi-mately eight minutes. It is likely that most clini-cians spend at least that much time per day trying to stay organized. The time necessary to maintain the TRAKIT database is therefore a nominal in-vestment for the multiple advantages and functions provided by the system.

ACKNOWLEDGMENTS

I thank M. William Schwartz, MD, Susan Rashba,

Mary Miller, and Sandra Morris.

REFERENCES

1. Schesser R, et al: The effectiveness of an organized emer-gency department follow-up system. Ann Emerg Med

1986;15:911-915

2. Shortliffe E: Computer programs to support clinical decision making. JAMA 1987;258:61-66

3. Schwartz W, Hammer L: Use of microcomputers in the division of general pediatrics. Pediatrics 1983;71:328-333 4. Richards EP, Rathbun KC: Medical Risk Management:

Pre-ventative Legal Strategies for Health Care Providers. Rock-vile, MD, Aspen Systems Corp, 1983

5. Peabody FW: The care of the patient. JAMA 1927;88:877-882

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1989;83;1007

Pediatrics

Howard W. Rashba

A Computer-Assisted Personal TO-DO LIST

−−

TRAKIT

Services

Updated Information &

http://pediatrics.aappublications.org/content/83/6/1007

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

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1989;83;1007

Pediatrics

Howard W. Rashba

A Computer-Assisted Personal TO-DO LIST

−−

TRAKIT

http://pediatrics.aappublications.org/content/83/6/1007

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 1989 by the

been published continuously since 1948. Pediatrics is owned, published, and trademarked by the

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has

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www.aappublications.org/news

Figure

Fig 1.TRAKITviation:database.Outlineis in boldface.Abbre-F/U,follow-up.

References

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