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Re: [Gnumed-devel] Changes to GuiMain - Suggestions (ctd)

From: dguest
Subject: Re: [Gnumed-devel] Changes to GuiMain - Suggestions (ctd)
Date: Tue, 07 May 2002 21:18:48 +1000
User-agent: Mozilla/5.0 (X11; U; Linux i686; en-US; rv:1.0rc1) Gecko/20020417


I like the automatic generation of the notes with the word wheel as you describe below ... except for history taking. My problem with it is that it forces you down a previously determined track even if it is your own individual track. My approach is to let the patient spill out their history in their own unstructured way and then go back and expand on certain points. I touch type and try to eyeball the patient as they give the initial history. It is prefererable to keep symptoms at one per line to aid adding new items, annotating existing items and moving the data around. I have added the history component from one of my typical consultations as an addendum. The dashed lines are the annotation of the initial symptom and are added on the second and subsequent runs through the history.
My patients almost always have two problems and often up to four or five. I 
have played around with the best way of recording the data in these 
multi-problem consultations and do not have a perfect answer. I think 
encapsulating each problem in its own section of the page is the best approach. 
I prefer [S1O1A1P1; S2O2AOP2] to [S1S2O1O2A1A2P1P2]) but use a line of tildes 
as a demarcator on the first run through the history.

My preference is still for a three window approach, 40% width is sufficient for my note taking as mentioned but I agree that the 60% width is necessary for displaying other data for the reasons you state below. My difficulty is placing the third box so that I can see the summary items of the information that I am seeking, whether they be correspondence, pathology or previous notes. I _do not_ want to obscure my current consultation screen or reduce width of the "Detail info" display window. As a first draft my preferences are:-

| Short patient id line | | Scratch Pad | |---------------------------| | |
|---------------------------|   |   Warnings /  Reminders                       
|                           |   
|                           |      Ico|Ico|Ico|Ico|Ico|Ico|Ico|Ico
|                           |   
|    Current                |   |   Summary screen                              
|    consultation           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   
| | | | |----------------------------------------------------|
|                           |   |      Detail info                              
|                           |   |      Display screen                           
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               
|                           |   |                                               

I am not a great believer in the value of voice dictation or video taping the consultation. My notes are a summary of the consultation not a re-enactment. (It was only barely sufficiently interesting the first time through.) I agree that one day computers will record all this information, lay it out neatly, make the diagnosis and prescribe the correct medication. At that point the doctor will be superfluous. Unfortunately that will also be the day that the patient is superfluous. "Open the door, Hal!"
"Sorry Dave. I'm afraid I can't do that."


richard terry wrote:

To further re-iterate on the reason for the two column approach to the screen design. The reason one needs about 60% of the screen real estate on the left hand side, apart from the previously given reasons below, is that it is an ideal size to reproduce a 'page' of information to display. Eg one can display most of an A4 letter in this area, an Xray image, a drug monograph, a graph with decision support attatched, drug interactions etc. These visually fit well there. If you go for a three column approach as suggested by david it simply doesn't work.

The remainder 40% on the right hand side is also ideally sized so one can fit most lists of things, reminders, the scratch pad.

On Tuesday 07 May 2002 8:59 am, you wrote:
Can I make a suggestion. Obviously everyone is going to have slightly
different Ideas. Could those who have eg David's comments send me a sketch
of the relative sizes of the screen you wish to be apportioned to whatever,
and I will do some mucking around in VB to see how your ideas link to
functionality and the incorporation of decision support.

I think it is vital that this prototyping be done so as to incorporate any
new ideas with merit, or to show others how their idea can either already
exist in the paradigm or be traded off against some other functionality.

a Simple box sketch would suffice, I've time this week and over the weekend
to muck around with it.

David, I think we have the opportunity here to do more than just 'record
data items' in a vertical column. The whole idea of the 'word wheel' as
used in my program is to minimise typing and to provide contextural
information when needed in an intelligent way.

I would assume that in the distant future consultations will be
automatically videoed, translated on the fly, the computer will sort out
what the doctor said, what the patient said, what was presenting symptoms,
what was doctor assessment, and put them logically into notes. However this
is a long way off.

In the meantime we can get much more out of progress notes than just list
them in a column.

Consider that during a consultation I might write the following.

S: URTI symptoms
0 :ENT NAD, febrile, cough, chest - left basal crepitations,
A: left basal pneumonia
P: Amoxycillin 500 tds, paracetamol etc
   FBC for wcc
   review 10/7
(incidental items might have occurred as well:)
Scripts given for dichotride for stone
Reminded faecal occult bloods due 0 given form.

Now, your progress notes already have a fair bit of 'auto-generated' text,
namely the script data, the request forms for
CXR, pathology forms for FBC,
scripts for the medications including what they were for the doses, repeats
etc, and info re the reminder. All this was generated just by your

As for the SOAP notes, much of that can be auto-generated as well because
the information is contextual eg the minute you start typting UR, up pops
the word wheel options around symptomatology (cause the program knows that
in the editing area you are typing on the symptoms prompt line), so often a
minimal one key press allows you to select the symptoms. Once you hit the
enter or tab key and end up on the Objective line, again, contextual
information is presented in the word wheel using YOUR LANGUAGE, ie the
computer has learnt from previous consultations how you describe patients
symptoms with URTI's, so again a short pick list is easy to choose from, or
you can add new terms if needed. In reality we use the same language over
and over again. Hitting
enter brings us the Assessment line, which operates
similarly etc. The Plan line can be further refined so that typing Amo
brings up the word wheel with amoxycillin (which the system recognises as
an antibiotic hence includes the doses etc, so just the act of selecting
amoxycillin 500 will autogenerate a script for the caps (as this is an
adult, or syrup if it were a child at the approprate dose for age), so you
may not even have to switch to the script module.

At the same time the system is monitoring what you are doing because once
the symptom line got the URTI symptom the decision support guidlines start
to swing into action using Ken's information set and underneath the editing
area start to appear guidlines for managing and treating URTI's etc.

All this is acheivable using current technology and databases. Malcolm
Ireland and I (malcolm is an academic GP/practicing GP/head of HUDPG IT
department in NEwcastle/has IT degree f
rom uni) sat and played with this
stuff back in 1996/7 and even using vb3 it was easy to implement.

Note that you need about 60% of the width of the screen to acheive this.
the remainder on the right being used for your lists of meds/path etc, the
scratch pad, and reminders about overdues.

The reason you need this space is as follows:


| Subjective   | URTI;cough;runnynose;fever;
|Objective     | T38;unwell;left basal chest crepitations;increased RR;
|Assessment | basal pneumonia;left;urti;
|Plan            |  CXR;FBC;Amoxycillin 500tds;Paracetamol;Review 10/7

----------------------------------- decisions support txt: current
recommendations for the management of urti's are.. bla bla bla

                               :  where seco
ndary infeciton is present
                               : first

line agents are amoxycillin (covers xyz bacteria
                                bla bla bla    (click here for more
detail). (note the font size/colour is different so it doesn't distract
------------------------------------- (and underneath this there is still
room for a list containing info you need to pay attention to but havn't yet
- there  are 3 outstanding pathology reports for this patient
- letter from cardiologist Dr All Heart not yet read
- missing immunisations: fluvax, pneumovax

Inputting data in this format is incredibly quick, and if saved in an
appropriate fashion lets you pull back alot of detail for research. The
computer can also monitor wether you take the time to access the decision
support info, the same area under the editing ar
ea automatically can pop up
disease/drug interactions at the same time (eg having noted you put the
patient on drug X, it may recommend that because the patient is on drug Y
that it's dosage is reduced, or that because the patient has renal failure,
a drug dosage is reduced.

yourself to either small vertical columns, or screen wide text boxes you
really restrict your screen real estate.

Putting some notes in in this manner can allow you to input a whole lot of
info automatically eg if the Objective line contains BP=120/70, this is
automatically parsed and stored as systolic/diastolic if W=79.4 etc the
weight is automatically stored.

Anyway, Have to see some patients as is nearly 9am.

Hope this helps

PLease send me you ideas re shapes/functionality so I can muck round with

continuing abdo pain
- frontal, mild, constant, paracetamol helps
poor sleeping
- dozes for an hour
- wakes repeatedly through the night
- will stay awake for 1-3 hours each time
-- now sleeping in separate room to wife
- tired in morning
- slight improvement in late afternoon
edgy, cannot relax
- only feels good when out doing heavy manual work in garden

generally unwell last six months

seen by Dr W.
gastroscopy - mild distal oesophagitis last Monday
colonoscopy 3 weeks ago
- haemorrhoids, few pelvic diverticulae

initial nausea on  Lipitor
now settled

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