I use an iPad for many things including access to our NextGen EHR application (see how I connect to NextGen on an iPad). There is no native NextGen app (yet – check my article for information on a third party NextGen iPad app coming soon), and so the program is not designed for touch input. Using a stylus is a better solution than your finger in many cases.
I have been using the Griffin iPad stylus.
It has a good thickness (similar to most pens), and is a good length. It is shorter than most traditional pens, but not so short that it is difficult to hold and write.
The most common use of the stylus is to select radio buttons or check-boxes within the NextGen templates. This way the small stylus can easily get the box you are going for without inadvertently checking the surrounding boxes. Even still I often unpinch (reverse pinch) to expand the area to make the buttons a little easier to hit with the stylus.
Plus when using a capacitive stylus there are fewer finger prints on the screen.
Another solution is to allow patients to sign their consents on the iPad. You have to have a stylus to sign your name on the iPad, it’s just to difficult to have patients try to sign their name using their finger (it’s not natural).
FYI – there’s no way to allow patient’s to sign their name on an iPad in the NextGen application. In an upcoming post I’ll show you how we allow patients to sign their consents on the iPad.
Recently I saw this post about a new stylus that is a bit longer (more like a regular pen), but it is unavailable for purchase at this time.
Every time you create a document in NextGen, it pulls a file and inserts it into the header, and pulls another file and inserts it into the footer.
Of course the default is the header includes a NextGen logo image, and the footer includes NextGen’s address.
One of the first things you will want to do is get rid of this stuff and setup your documents with your own brand.
In the EHR, you can click tools -> document builder.
A window pops up and there is a file folder called Sub_documents. browse these files to find both the sub_footer.NGN file or the sub_header.NGN file. Edit and Save these two documents to include the new information in all your new documents.
Most dermatologists draw a picture of a body, or body part in the chart, and then make a dot, or an “x” to indicate that certain lesions exist on the patient. Sometimes we use a form, with pre-printed body parts. Then we indicate that all the “x” marks are Actinic Keratosis, or that the “x” is a Basal Cell Carcinoma.
The NextGen solution is to be able to pull up body images into a patient encounter. You then have a toolbar at the top of this image window that has a few colored dots that correspond to different lesion types.
When you select a colored dot, you can then click on the body map and the dot shows up in that location on the body map. You can keep clicking on the body map to indicate additional lesions.
You can then select a different colored dot and click on the body map to indicate locations of different types of lesions.
The problem is that this isn’t ready to go out the door. The body images included in NextGen are of various sizes. They do include pictures of what looks like real body parts with colored skin tone, muscle definition and shadowing, but most dermatologists would not be used to mapping on these types of images.
The NextGen trainers have a “how to setup” document written on an old version of NextGen back in 2008. The trainers also can e-mail you their four colored dots. This document teaches you how to create the toolbar embedded into the image window that allows you to select the different colored dots.
I found the colored dots to be of poor image creation, with some areas of transparency and some areas of white surrounding the colored dot.
I also think it would be easier to have many many different colored dots, even some labeled with text to indicate different lesion types. There could be a plain red dot, a red with ?BCC, a red with ?SCC, a red with ?NMSC (non-melanoma skin cancer). Then you could map on the body image a more accurate assessment.
NextGen advises to not modify templates until you use the system for a few months. They want you to use it as they intended, and let you see over time what exactly works and doesn’t. I can understand the thought process behind this, but I also believe that software should be consumer driven.
The best software is constantly being improved with user input. To my knowledge the NextGen Dermatology templates have only gone through two iterations. Dermatologists, and medical staff in Dermatology offices are going to have the best ideas for the direction of the product. This supersedes any physician advisor hired by NextGen for input on their templates.
I’ve been working in Dermatology (specifically Dermatologic Surgery and Mohs Surgery) for ten years. I document the medical/surgical visits every day. I feel as though I know what I need to document, and my workflow. It only takes a quick glance at a template to recognize that it will or will not work.
I feel a little more confident in creating custom templates for Mohs Surgery and Dermatologic Surgery because I’ve worked for a number of years suggesting improvements for the MARS program. While this software company has Implemented many of my suggestions over the years, I feel there are many inadequacies and could still use further improvement. I’m excited to have the features of NextGen that allows the ability to pretty easily have full customization. I can finally implement every feature I’ve wanted on a robust back end.
So really I’m just updating the NextGen Mohs templates based on the years of iterations I’ve already done.
I am also very confident that I can improve templates to complete the other tasks when seeing a patient, chart abstraction, rooming a patient, documenting various medical dermatology visits, documenting laser and other cosmetic visits, pathology reporting, etc.
I think every dermatologist has used a paper form to help them document a visit. And I would guess that many created this form themselves, and many others took an existing form and modified it for their use. Modifying the NextGen templates is no different and I see no reason to wait. Do it before you go live to decrease training time and to insure it doesn’t get put on the back burner. Otherwise, before you know it, you’ll have been using subpar templates for a year.
When switching from paper charts to a Electronic Health Record (EHR) you have to decide what, if anything, will be transferred into the EHR.
There are three main points to think about. 1.) What information is most important to have in the EHR. 2.) How to input the information (scanned images or field input). 3.) The order and timing of chart abstraction.
Only you can decide what is important to abstract, but typically at minimum you would want allergies, medications, and history of disease. The NextGen chart abstraction template has the things that NextGen feels is most important.
I didn’t entirely agree with their choices, and I also thought a form that matches our history questionnaire form would decrease the time it would take for each chart abstraction. This is an important point. Taking a little bit of time and expense to modify the chart abstraction template is going to give you better data that you are going to be relying on for years to come, and creating a chart abstraction template that allows you to more quickly input data is going to save you a lot of time and expense (in labor) on a greater order of magnitude. You are going to be using this form thousands of times, so increasing the efficiency by a few minutes on each abstraction is going to be a huge time/expense saver.
Some practices decide that scanning their charts and having dozens of files input into each patient record is how they will do their abstraction. This way the provider will have the entire chart available, however not in a very valuable way.
The other way is to take the most important parts of the chart and enter them into the appropriate fields in the EHR. This makes the data valuable and part of the record that will always be visible. This is more time consuming up front, but the information will be utilized better and for a longer period of time.
The last point is to decide whether to start alphabetically with the A’s and just abstract every chart, or to only abstract those charts of patients that are scheduled. Every time a patient is scheduled for an appointment that chart is pulled and abstracted.
We went to Southlake Texas for our Core EHR training.
I’d first like to say that I really enjoyed Southlake Texas. The training location is amidst hundreds of shops, many great restaurants to choose from for breakfast, lunch, and dinner, a movie theatre, bookstore, and a nice hotel. We flew into Dallas/Fortworth, and took a taxi to the hotel. We didn’t need a car, as we were able to walk around this large outdoor shopping complex easily from our hotel.
The core EHR training was difficult at times because a good portion of the training is going through the templates to understand how they function. And of course the training is geared toward internal medicine, or family practice. I was trying to follow along looking through the dermatology templates, but there are many specialty specific things that didn’t match up.
We knew ahead of time that this would be the case, so we scheduled a Webex for dermatology specific training with a trainer who knows the dermatology templates.
During our dermatology specific training there were several times when the trainer had to apologize for the inadequacies of the template. Other times when I asked questions about how to document a particular item, or why the system allowed you to document inconsistent information (pathology template allows you to have a diagnosis different than the ICD code selected), she was stumped.
The training is essential, and it gives you a base so you understand how things work. I really feel that playing around in your test database is the most useful training method after you have these basics.
Once you play with the system, you’ll quickly figure out what works, and how it is best modified. I’ve decided to extensively modify the NextGen dermatology templates.
NextGen releases KBM versions, which transform the look and flow of the user interface.
At one time, a version had a consistent look and feel. In addition to the primary care general templates, specialty templates were developed to match. In KBM 7.9 The interface has been redesigned with a different navigation structure, new graphics to give an updated look, and a change in workflow. Unfortunately this was not done for all the specialties.
FYI: The patient info in this screen shot is not real.
While it is “nice” to have the updated look, I first did not think it would matter very much. We could certainly make the “old way” work just fine. But then I started seeing that some “general” templates Are launched in the workflow of a Dermatology case. So you see the old system, and then you launch the smoking use section of social history, and up pops a window that has a complete different look and feel. But the thing that makes this a big problem, is the navigation isn’t consistent between the two interfaces. This change in workflow throws off a user, and does not allow for a seamless workflow.
NextGen allows administrator users to not only add a large amount of configurations, but also allows you to create custom templates.
The problem with custom templates is that you create the look and feel as well as the fields. So the navigation and graphics on the template are apart of that particular template. Just like NextGen updated some templates, but not others, when a new KBM is released, the base templates that you didn’t customize will be updated, and your custom templates will remain. So you probably would want to re-skin your templates as well to match the new look.
The other option is to create copies of all the templates that you use. Standardize them (which should have already been done by NextGen, but isn’t in KBM 7.9), as well as create custom templates, if necessary, to match. When NextGen updates their KBM, the system will see that you are using all custom templates, and while it will update templates you do not use, your templates will have the old, but consistent look, with a workflow your users are accustomed to. Not getting the latest looks with updates is a bummer. Everyone likes to see visual changes with software upgrades, and sometimes those layout changes really could be beneficial.
The biggest problem, or perhaps it’s a solution, is that NextGen is updating their KBM again. Their website features KBM 8.0, which has a whole new look and feel. This is great, that they are constantly innovating their product, but they didn’t finish updating KBM 7.9 Specialty templates, before moving on. Maybe they didn’t plan on updating these templates. Maybe KBM 8.0 is a complete package and standardizes all the templates. KBM is prominently displayed on their website, but it hasn’t been released yet.
As we are in the process of setting up our EHR, it is very difficult to move forward without knowing the KBM 8.0 details and how future KBM releases will integrate with custom templates. If we don’t get KBM 8.0 soon, we will be left with developing custom templates, as well as reorganizing workflow of the old templates, and possibly reverting KBM 7.9 general templates to match the old Dermatology templates from KBM 7.8. This will result in a brand new install that is two versions old, and cost us a significant amount of money. Then when KBM 8.0 finally comes out, we will have to decide on investing more money and time to updating our templates and workflow.
What should we do?
Before moving forward I need to find other Dermatologists using NextGen and see if they have already created custom templates and a cohesive workflow. Perhaps we can work together, thereby decreasing our costs.
Currently there is no native iPad app for the NextGen health records software (03/31/11).
There is a mobile website, where you can log in and access basic information and even do minor tasks, but it is meant for quick occasional use. It isn’t capable of replacing the standard interface. The nice thing is that it can be accessed via the iPhone, iPad, Android devices, or any other device with a browser. You can also use any computer (desktop, laptop, etc.) to access NextGen.
There is another way you can use NextGen on the iPad, through a remote desktop type application. Citrix, Logmein, PocketCloud, and other apps allow you to see and control any computer. Once you connect to your computer you can use any program, so you can launch any EMR on the iPad. In this case we can use NextGen on the iPad.
While this does allow you to use the complete version of NextGen, it is often a slower response of the application, and it is a little clunky trying to use a non-native iPad program. The interface isn’t optimized for the use of your fingers, or even a stylus, and fields that you would right click to expose a dropdown selection are more difficult, requiring you to use a pretend on-screen mouse that you control to send signals to the remote computer. The biggest obstacle is that the windows that open up are not optimized for that screen size, and sometimes scrolling and manipulating those windows is very difficult.
I believe this is a better solution than the mobile site, when you are using an iPad. You can deal with the slower response and the challenges of using a remote desktop application for a short period, but this way you get full use of the EMR.
So currently I use PocketCloud when I access NextGen from my iPad. And suggest using the mobile website to access NextGen from my iPhone.
There are rumors that NextGen is building a native iPad app. This full featured app would allow you to use the iPad as your main device in the office while seeing patients. I believe this is probably the number one feature request of all users, particularly new users who have not yet purchased hardware for their point of patient care.
There are several other EMR suites that are now offering access via an iPad, and more and more announce their plans to eventually create a native iPad app. If NextGen wants to remain one of the best EMRs I believe they will also have to develop a native iPad app, and sooner rather than later.
At the beginning of our implementation, we were given user names and logins for an elearning system that helps train you on your new system you are about to use.
What a great idea we thought.
When you log in there are currently three main topics (later more will be added). We were told to focus on the EPM or electronic practice management section first, as that system will be installed separately prior to our EHR or electronic health records system. When you open up the EPM category, a flood of subcategories open up. Within each subcategory is anywhere from one to twenty training sessions. Many of these are 15 minute training sessions, but there are a good number of 30 min and 45 min sessions as well.
That’s a lot of online training sessions.
But, it’s a big program. I’m sure there are a lot of features that make it great, but if you don’t know how to use them, you’ll miss out. I diligently started into the training.
As I am going through the training, the system will teach you about a function and then pop up a multiple choice question. Ahh, the system wants to make sure I’m paying attention and perhaps it’s setup this way to provide feedback to the company that the users are able to learn the objectives of the session based on the material presented.
If you get an answer wrong the system gives you the correct answer plus an explanation. Someone put a lot of work into creating these sessions. But it is also taking a lot of work to complete the sessions.
While I am involved with the setup, and therefore must undergo the training for our new EMR system, my wife, who is the practice administrator, is really the main person going through the EMR setup.
She was given a project manager who requires weekly meetings to review how the training is going and schedules all the different events that need to occur over the course of time till launch. She also schedules all the different training sessions that are required.
When we purchased the system, the contract had costs/hours associated with training sessions that required the company to fly out to our facility, and/or the client could fly out to one of several training locations. These are typically three day sessions. We were made aware of five main training sessions, two of which had to be at our facility. There was also an option of doing one ore two of these sessions via webex (an online meeting).
Apparently there are more training sessions required than what we originally thought. Maybe as many as 10 as opposed to the original 5 we thought. Our project manager is looking for space available for training via webex, but is having difficulty due to inadequate numbers of training staff. Her suggestion is thus to have us travel for an additional three day training session.
Most of the difficulty in implementing our EMR is completing the required training and finding availability to attend training sessions.