Managing my EMR Results InBox

My practice has been using the EPIC electronic medical record for 5 years now, and it’s taken about that long for me to figure out how to tweak the system to make myself more efficient, and for the system to evolve to a place where I could tweak it myself.

Case in point – Quick Actions.

EPIC’s most recent upgrade includes little self-made macros called “quick actions” that turn repetitive tasks into a mouse click. I’m using quick actions to manage my results in basket in much the same way you may be using Rules in Outlook to manage your email.

Some of my macros are actually little work-arounds for a system that is not yet entirely integrated and a patient population that has not yet embraced online results communication. About half of my patients sign up for online results – I’m working hard on the rest…

Like many of you, I like a clean inbox, but need a place to park messages that are awaiting some future task for completion. I’ve decided to use the “results notes” inbasket for this purpose, so you’ll see some of my macros moving messages there.

I now have the following Quick Action options whenever I view a lab report –

  • Normal Pap – creates a standardized normal pap letter, sends it to my secretary to print out and mail and inserts a little addendum note to the encounter that results were sent.
  • Left message – After I’ve called and failed to reach a patient about a lab result, adds “left message ”  addendum to the patient’s visit note and moves lab result to my results note in-basket, where it will sit till she calls me back (or I call her again, don’t get me started on the phone tag game…).
  • My Chart – Inserts a little note into the patients EMR that her results were released to her via My Chart – an online patient communication system that sort of lives outside my EMR with incomplete integration, so I put that little note in so I know I communicated results to her. It’s faster than searching through the My Chart inbasket later.
  • Hold for HPV – Moves mildly abnormal pap results into my results notes inbox where it will wait for the HPV result, which comes a few days later.
  • Failed mammo – creates a reminder letter to patients who have failed to get their mammogram, the order for which is sitting in my “overdue results” basket, and sends the letter to my secretary to mail it. I then delete the overdue message from my inbasket.

Any other EPIC users out there have Quick Action macros that are working well for them? If so, feel free share them with us in the comments section .

Flatbread with Eggplant, Peppers & Olives (Coca de Recapte)

This traditional Catalan flatbread is based on yet another recipe from Williams Sonoma Barcelona cookbook. Coca recapte are savory pastries made with meat or fish and vegetables, the combination of which depends, apparently, on what is in the larder. Or, as Catalan food blogger Anna at the Good Food Room describes it :

Recapte” is Catalan for “Alright, after a hard work’s day, let’s see what we have left and how we can turn it into a meal”…

Well, this coca recapte was made after a hard day’s play following an early evening swim and a day spent antiquing, playing scrabble, biking and hanging on the front porch. In true Barcelonan style, we did not eat till well after 9 pm. Not quite the same as a visit to Spain, but just as nice.

Flatbread with Eggplant, Peppers & olives (Coca de Recapte)

I love the technique for cooking eggplant in this recipe – roasted the same way you roast peppers. This coca recipe uses baking powder, but other coca recipes I’ve seen used yeast. In the future, I think I’ll make this using Mark Bittman’s pizza dough recipe.

For the dough

  • 1 2/3 cups all purpose flour
  • 1/2 tsp salt
  • 2 tsp baking powder
  • 1/2 tbsp olive oil
  • 1 egg yolk
  • 3/4 cup water

Topping

  • 1 red pepper
  • 1 green pepper
  • 1 medium eggplant
  • 1 large sweet onion, very thinly sliced
  • 1 clove garlic, minced fine
  • 12 black olives, pitted and coarsely chopped
  • salt and pepper to taste
  • 2 large ripe tomatoes, thinly sliced
  • 1 tbsp butter
  • 5 tbsp olive oil, plus a tad more to grease the pan

Preheat oven to 450 degrees fahrenheit. Place peppers and eggplant on baking sheet and roast, turning them so they char evenly on all 4 sides, about 45 minutes.

While veggies are roasting, slice and caramelize the onions. In a cast iron skillet, melt 1 tbsp butter in 1 tbsp olive oil over moderately high heat. Add sliced onions, turn down the heat to medium and saute, stirring frequently, until onions are caramelized, about 10-15 minutes. Cool.

Remove roasted vegetables to a brown paper bag to cool about 15 minutes.

While the roasted veggies are cooling in the bag, make the flatbread dough. Sift flour, baking powder and salt into a bowl. Make a well in the center, and add olive oil and egg yolk. Gradually add water, mixing into the flour with a wooden spoon. Turn dough out onto a lightly floured surface and knead for about a minute until soft, smooth and elastic. Form into a ball and place into a large lightly oiled bowl. Cover with a kitchen towel and leave in a warm place for 30 minutes until dough puffs slightly.

Peel cooled roasted veggies, discarding the stems, seeds and skins. Slice into thin strips, then toss gently with onions, garlic and olives. Season generously with salt and pepper. Set aside.

On a lightly floured surface, roll out dough to fit a lightly oiled 12 by 9 inch baking pan.  Press dough into pan and trim edges if need be.

Cover the base of the dough with the tomato slices. Brush with 2 tbsp olive oil. Arrange the veggies evenly over the tomato slices and drizzle with remaining oil. Bake until edges are starting to brown, about 25 minutes. Remove from oven, let cool slightly, slice into squares and serve warm.

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Coca Recapte around the web

Manhattanhenge 2011

So incredible, to see the orb of the setting sun, heralded by its own reflection on the skyscrapers on the far West Side, slide into the air between the canyon walls of 42nd St, where it hovered for a few precious moments, aligned perfectly with the east-west grid of Manhattan, before sinking into the horizon over New Jersey.

Even more incredible, that the sunset was visible at all, given the thunderstorm that swept across the island less than an hour before. We almost didn’t go.

So glad we did.

Manhattanhenge occurs twice a year. Try and see it at least once in your lifetime.

How to Save Money on Birth Control

If you live in New Hampshire, or some other state that is withdrawing Planned Parenthood funding, you may need to find an alternate source of affordable birth control, at least until the states get their heads screwed back on straight. In the meantime, please, don’t stop your birth control because you think you can’t afford it – the costs of not using it are much, much higher.

But what can you do to make the choice to use birth control even more cost effective?

Birth Control Pills

  • Buy them cheap locally.  Walmart, Target and Kroger sell very low priced birth control pills – only $4 to $9 a pack. It’s only a few brands (Trinessa, Sprintec and Trisprintec), but ask your doctor if it makes sense to switch if cost is a barrier for you.
  • Stick to generic and Tier-1 brands.  If your insurance covers birth control pills, try if possible to stick with tier 1 brands or generics – your co-pay will be much less.
  • Get a 90-day supply. Ask your doc to write for a 90 day instead of a one month supply, and use mail order instead of your local pharmacy – in most cases, you’ll get three months’ worth of pills for one co-pay.  If your insurer uses CVS-Caremark as their online pharmacy, your local CVS may dispense a 90 day supply for a single co-pay.

Nuvaring

  • The manufacturer has a coupon worth $15 off on up to 6 prescriptions

IUDs

Condoms 

  • Condom prices are quite reasonable at Target, Costco and Walmart  – as low as $8-10 for a 36 pack of some brands. While you’re at it, ask your partner to pay for them.
  • Trojan has coupons

Emergency Contraception

  • Don’t forget that the morning after pill is there if the condoms breaks or slips off. Plan B is offering a $10 off coupon on their website.

Depo Provera

  • Pfizer has several programs which could allow low income women who qualify to get free Depo Provera.

Spermacide

Today Sponge

  • Not as cheap as condoms, but less expensive if you join the Spongeworthy Club and buy in bulk.

Use Pre-Tax Dollars to Pay for Birth Control

  • Put enough money to cover your annual birth control costs into a health savings account with your employer and save on taxes while preventing unplanned pregnancy.

Got a tip for getting birth control cheap? Tell us in the comments section below.

 

 

New Hampshire De-Funds Planned Parenthood, Forcing Them to Stop Dispensing Birth Control

The New Hampshire state legislature has voted to defund Planned Parenthood’s pharmaceutical services, and Planned Parenthood Centers in that state have stopped dispensing birth control.

(Planned Parenthood) provides its services on a sliding scale based on income, with 70 percent of patients paying nothing or near nothing for birth control pills because they earn less than 150 percent of the federal poverty line.

What is New Hampshire thinking? Here’s what Raymond Wieczorek, a council member who voted against refunding Planned Parenthood’s state pharmacy contract, had to say –

“If you want to have a party, have a party but don’t ask me to pay for it.”

What Mr W doesn’t seem to realize is that the he will be footing the bill for the party in the long run if unplanned pregnancies result from this short-sighted move. And if it’s abortion he’s against, then de-funding birth control is just plain dumb.

 

Sandwiches with Goat Cheese, Red Peppers & Anchovies

In Catalan, they say it Entrepans amb Formtatge Fresc, Anxoves i Pebrot.

In Barcelona, one would make these sandwiches on a toasted baguette. Here at the cottage, I was in the mood to make bread, so instead we used Pan Cubano, fresh from the oven.

Nothing like rubbing a fresh tomato on warm bread, then drizzling it with olive oil, sprinkling a bit of salt and putting it together around a few anchovies and slices of goat cheese and warm roast peppers.

Down it with a cold beer, then hit the hammock for an afternoon nap.

Sandwiches with Goat Cheese, Red Peppers and Anchovies

This recipe is from the lovely Williams Sonoma – Barcelona cookbook. The book was a gift from the mother of a Barcelonan exchange student who stayed with us last year, so I figure that’s testimony enough to the recipes’s authenticity. Makes 4 sandwiches.

  • 2 medium or 1 large red pepper
  • 8 olive oil packed anchovy fillets
  • Baguettes, cut into 4- 6 inch lengths
  • 4 large slices goat cheese
  • 4 small ripe tomatoes
  • Salt and pepper to taste

Roast the peppers on a cookie sheet under the broiler, turning them so they char evenly on all 4 sides. Remove to a brown paper bag to cool, then peel them over a large bowl, saving the juices and discarding the stem, seeds and skins. Slice into 1/4 inch strips and set aside.

Slice the baguette into 6 inch slices, then again horizontally into halves. Pop under the broiler for about one minute till lightly toasted.

Slice each tomato in half, then rub the cut sides onto the toasted baguette surfaces until only the skins are left , then discard the skins. Drizzle the baguette halves with olive oil and sprinkle with salt and pepper to taste.

Divide the cheese slices among the bottom halves of the baguette lengths, followed by the red pepper slices and anchovies. Cover each with the top halves, and serve.

 

Yoga May Help Menstrual Cramps

In a nice little study* published in this month’s Journal of Pediatric and Adolescent Gynecology, yoga practiced throughout the luteal phase of the menstrual cycle diminished the severity of menstrual cramps. The poses used (cat, cobra and fish) were those that supposedly treat pelvic congestion.

Since the control group did not exercise, the study did not really control for the placebo effect of the yoga intervention, or for the fact that exercise has already been shown to decrease menstrual cramps. A better control group would have been given yoga poses that do not address the pelvic area (sort of like sham acunpuncture), and a third group could have used some other form of exercise, perhaps pilates.

Placebo effect or no, yoga is fun, the poses used are easy to do and if it diminishes menstrual cramps without the need for medication, I’m all for it.

* Effect of Three Yoga Poses (Cobra, Cat and Fish Poses) in Women with Primary Dysmenorrhea: A Randomized Clinical Trial

How to Get a Sooner Doctor’s Appointment

A friend of mine had a hard time getting in to see her doctor for an urgent visit last week. Reeling from an unexpected and sudden family upset, she was depressed and anxious, unable to sleep or function, and her therapist was advising an antidepressant.  She called her family doc, who works at a large hospital-based multispecialty group, and told the woman at the call center that she wanted to see the doctor on an urgent matter. She was given an appointment 6 weeks in the future.

Summoning her courage, my friend told the woman her story – and that she was really worried about herself and did not think she could wait that long.

“Sorry, that is the best I can do” was the reply.

Increasingly upset, my friend told the woman that if she had to wait that long, she just might kill herself in the interim.

“That’s your choice, Ma’m”, was the curt response.

“Thank you”, said my friend. “And what is your name, please?”

Silence. Then –

“Just a moment”.

“You can come Tuesday at 11:45 am”.

When my friend told her doc what had happened, he was appropriately appalled, and advised her that the if this ever happened again, she should ask to speak to his nurse or to him directly, an option my friend told me she had never even considered.

Which made me realize that not everyone knows what to do when, for whatever reason, they can’t get a soon-enough appointment with their doctor for an urgent matter.

What To Do If  Your Doctor’s Appointment Isn’t Soon Enough

We can talk some other time about what is happening to health care, why that secretary up there should be fired, or how call centers, for all their efficiencies of scale, can become too far removed from the action of a doctor’s office to function effectively. None of which will get you in to see your doctor.

So here’s some practical advice for when you need to get in to see your doctor on an urgent medical matter and his/her office staff gives you an appointment that you believe is too far into the future.

1.  Be up front about why you need the appointment, as my friend was. This will help your doctor’s staff to triage your appointment appropriately, and most of the time, will be all you need to do.

2.  Ask if you can see one of your doctor’s associates or the nurse practitioner sooner. It may be more important to you that you get seen that who actually sees you.

3.  Ask to speak to the nurse of office manager. Don’t let a secretary, as experienced as he or she may be, determine your medical fate.

4.  Ask for a call back from the doctor. He or she will get you in if needed. Or maybe the problem can be handled over the phone.

5.   Email your doctor. Direct communication works best if its available to you.;

6.   Contact patient services. If your doc’s practice is attached to a hospital or medical school, contact patients services at that institution and ask for their assistance.

Mind you, these tactics are not appropriate if you’re just trying to make things more convenient for yourself. In fact, they may actually backfire, since you may annoy the office staff for a non-urgent reason.  In that case. your best bet is to turn on the charm and worm your way in. Even better, call daily looking for cancellations, and be willing to come at the last minute if something opens up.

Take a different approach for a new patient appointment

If you’re looking for a sooner new patient appointment, you’ll need to take a different approach, since your doctor and his nursing staff are under no obligation to take your call if you are not an established patient. The office manager may be willing to speak with you, however, so it’s worth a try asking him/her to call you back. If it is a specialist you’re trying to see, ask your referring doctor’s office to facilitate the appointment. If the practice is affiliated with a hospital, contact the physician referral service – they should know which practices have availability so you can get your urgent matter handled. Calling daily in the mornings looking for a cancelled spot is also worth doing. If you’re friendly enough, you’ll make best friends with the office staff, and they’ll remember you next time a cancellation occurs.

If all this fails, seek care in an urgent care center in your area, or, as a last resort, the Emergency Room of your hospital – but only if it’s a real emergency.

Summer Corn Pudding

Most recipes for corn pudding get published in the fall, evoking images of the Indians and the Pilgrims gathered around the Thanksgiving table. These recipes are a great reason to use the leftover corn you had put in the freezer in July and then forgot you had until you found it while cleaning out the freezer in November.

Here’s what I say – forget the frozen corn. Make the corn pudding in July using sweet corn fresh off the ear. And don’t waste the recipe on leftover corn – buy the corn special just for this recipe. It’s worth it. Serve it with reheated ribs and barbecue sauce that you had found in the freezer. Add green beans, and if the weather is right, it can become your first rooftop dinner of the season.

Oh and did I mention I didn’t actually make this? Mr TBTAM did! But I helped reheat the ribs and set the table.

Corn Pudding
(Modified from Fonda San Miguel: Thirty Years of Food and Art, by Tom Gilliland, Miguel Ravago, and Virginia B. Wood, in Epicurious)

If you make this, I recommend cutting the peppers in a large dice rather than strips above, because the strips make it hard to cut the pudding onto squares, which is why it sort of just looks like a delciious clump on the plate…

2 pounds fresh corn kernels
Whole milk as needed (up to a cup)
6 eggs, separated
1/4 cup sugar
6 tablespoons butter, softened
3/4 cup all-purpose flour (substitute corn flour for a gluten free option)
1 teaspoon kosher salt
cayenne pepper to taste (about a pinch or more to taste)
1 teaspoon baking powder
1 cup (4 ounces) shredded Cheddar cheese
1 poblano chile, roasted, peeled, seeded, and cut into 1/4-inch strips
Half of a red bell pepper, cut into strips

Preheat oven to 350 degrees. Lightly grease a 13-by-9-inch baking dish with butter or oil. Puree the corn in the food processor with just enough milk to make a smooth puree (we used a little over a half cup). With the machine running, add egg yolks, one at a time, and process 30 seconds after each addition. Keeping machin running, add the sugar a little at a time and process until mixture is lighter in color and sugar is dissolved, about 3 minutes. Add butter and process until smooth. Transfer to a large bowl. In a separate bowl, combine flour, salt, and baking powder; fold into corn mixture. Beat egg whites until soft peaks form and fold into corn mixture, alternating with the shredded cheese. Pour into baking dish and top with strips of chile and red bell pepper. Bake in preheated oven for 45 minutes, or until golden brown. Serve warm or at room temperature.

An Even Easier and Less Fattening Corn Pudding

We got the whole idea of making corn pudding from my mother in law Irene, who made this much simpler and just as delicious recipe, also from Epicurious. I’m making Irene’s version next time – it’s also less calories..

Gardenias

I wish you could smell these gardenias, whose aroma is a truly one of nature’s gifts.

These gorgeous blossoms were brought to me by one of my Greek patients, who grows them on her terrace in Astoria.  Every June she brings cuttings for me when she comes for her annual exam.

This year, she tells me one of her gardenia pots broke and rather than her having to replant the bush, do I want it for my garden?

I am so there.

Stay tuned in a week or so for some shots of her terrace garden, which I cannot wait to see.  I am confident that it will put mine to shame.

Supreme Court to Docs – You Have No Privacy

The Supreme Court has sided with Big Pharma in their challenge to the Vermont Law limiting the pharmaceutical Industry’s access to physician prescribing information.

The nation’s high court handed down a verdict Thursday in the Sorrell v. IMS Health case, striking down by a 6-3 vote a 2007 Vermont law that that bans the practice of data mining — the sale and use of prescriber-identifiable information for marketing or promoting a drug, including drug detailing — unless a physician specifically gives his or her permission to use the information.

Apparently, Big Pharma’s right to “free speech” trumps my right to privacy. How getting access to my prescribing information has anything to do with free speech is beyond me.  In the twisted logic of the pro-business, anti-citizen Supreme Court –

Speech in aid of pharmaceutical marketing… is a form of expression protected by the Free Speech Clause of the First Amendment.

The Vermont Law Did Not Go Far Enough

By limiting its restrictions on data sharing to Pharma marketing, Vermont set itself up for the SOCTUS decision by making it appear that they were unfairly singling out marketing uses from other uses of prescribing data.  In my opinion, I don’t think anyone should have my prescribing data without my permission.

The AMA’s Role in Releasing  Physician Prescribing Information

The Vermont Law would not have been necessary were the AMA not selling physician information (the so called AMA Physician Masterfile) to the data mining companies, who then merge the files with pharmacy data and sell it to Big Pharma so they can use it to track physician prescribing patterns and target their marketing messages. Lucky docs don’t even have to be an AMA member for them to sell their data.

Now, the AMA is coming in like the White Knight, supporting physicians’ right to restrict access to their data –

While the AMA supports the appropriate disclosure of prescriber data, the AMA firmly believes that every physician has the unequivocal right to decide whether his or her individual prescribing data is shielded from pharmaceutical detailers. To help physicians exercise that right, the AMA created the Physician Data Restriction Program (PDRP), which enables physicians to “opt out” of such disclosure quickly and easily, while still allowing their data to be available for academic and governmental research.

“The PDRP is available to all U.S. physicians – both AMA members and nonmembers. Since its launch in 2006, nearly 28,000 physicians have used the PDRP to restrict their data….Interested physicians can register online or by calling (800) 621-8335.

Please. They’re the ones selling our data in the first place.

Looks like the wrong lawsuit was filed in the first place. It’s docs who need to be suing the AMA.

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Additional Reading

Medblogger Response to the Ruling

Dr Wes “When Speech Trumps Privacy“