Let me see if I've got this straight...

I recently bought a Dell computer, which came with Windows 7 pre-installed. I promptly replaced that with Linux, and then set up a virtual machine and installed Win7 from the disk I got. I'm not sure how, but my Win 7 has detected some anomaly, and now is telling me that I have a Win 7 that is "not genuine". Every time I start it up it wants me to connect to Microsoft to purchase a license for this pirated copy.

I also read recently that Dell is refusing to reimburse anyone for computers which came with Win7 pre-installed, since this came at "no charge".

Ok. I can accept this. I'd like to purchase 10 copies of Win7 at no charge, please.

A Call for Change

This might be construed as a nonmedical commentary, but it is and isn't at the same time. It's a call for a change in the fractured mindset we can so easily see in America right now. A call for a lowering, an elimination of the hate-filled language we continue to see and hear, espoused and encouraged by the various hate-mongerers out there.

We try to portray ourselves as a Christian nation which supposedly wishes to create a situation which follows the teachings of Jesus of Nazareth, who promoted the "turn the other cheek" mentality.

I do not see the Christian ideal evidenced by all the hate we see in the news on a daily basis. I don't see it in the opposition to some kind of universal health care --" yes, you may need health care, yes, you may not have insurance, but I will not help you get it, I will watch you die first."

This is not a healthy environment in which to raise our children. We cannot advocate hate, and acting on hate as a sensible way for us to live our lives. If we say that hate is Ok, then we say that it's Ok to spew hate at your doctor, your boss, your spouse, your neighbor -- where does it end?

We must begin to speak out, and speak out in unison, that all this hate-mongering, all this hate-tolerance is unhealthy, it's bad for our country, and no good will come of it.

Scribus in the Hospital - 3
over the top

It may have seemed that what I've already shown was as much as one could do, but you'd be wrong with that assumption.

Once we have access to something like Scribus, with all of its layout capabilities, you don't have to stop at lines, labels, barcodes, and text. Add images.

There are ways of doing all sorts of things. Behind the scenes, I have added a free program called Hoversnap to the mix, and now I can make screen captures of scan images, so I can add these to the chart.

I would quickly add that in the long run, these have no relevance. These chart pages get scanned into the EMR system, and as you can imagine are totally useless at that point, since they come out as they would running them through a fax machine. So why do them at all?

Education. In two directions. One is for the non-neurologists, who do not necessarily know what they're seeing on scans, and therefore don't generally bother to look at them, and admittedly the important pictures are typically a handful of hundreds. So I trim it down to the essence.

The other is for the nurses (and other non-physician staff). My note talks about what I see in the images, and the pictures show what I'm talking about. So everybody gets some education about brain scans and what they show. And people appreciate this – you know they do, because they go out of their way to tell you. Furthermore, this is round-the-clock teaching – even the overnight nurses get in on it.

As I said at the beginning, I am not advocating this, I am not suggesting this is what all doctors should do, it's just something I am doing, and I enjoy it and feel it's worth my time.

Scribus in the Hospital - 2

Here is what these notes look like. This, of course, is a bogus name and a more or less made-up history, although certainly neurologists hear this kind of story all the time.

The last post showed you the generic form used as a starting point, but here I have created a patient label. This was done in Scribus with a "script", a term used for a short program written in the Python programming language, which is able to interact with Scribus to carry out some operations, and do things like creating this rectangular-shaped label on top of the one you saw in my last post that said "Attach Sticker Here".

Rather than delete that other frame, I just create this one with an opaque white background.
The script prompts me for the bits that go in there, then makes the frame. I should add that the script automatically capitalizes the patient's name, and makes the font bold for the name on the label – if you can do it, why not?

After that, then I make the barcode for this patient's hospital number – Scribus has a plug-in to do this – then I just place and resize (it's 195 pts x 20 pts).

Something my actual template has that you didn't see in the last post is a frame all set up with "NEUROLOGY CONSULTATION" at the top, again, a frame with a white background. In this case, I want to hide the lines so we don't get visual interference and legibility problems. In Scribus, I'm using something called Story Editor, which is a simple text editor, simple as far as the text entry goes, but allows for assignment of various typographic features to the text. I know I talked about my narrative style in the last post, but as you can see, this is a bit truncated, with a lot of phrases instead of the complete sentences I would use in an office note, which is the only note there will be and therefore reads more like a letter.

So I've finished my note, now what? It just so happens that the various computers the doctors use are hooked up to network printers on the nursing station, so I just print right to them, and as luck would have it, most of the time they use paper with pre-punched holes at the top since they're used largely for printing out lab results, so I print my note, sign it, and it's in the chart.

Oh, what about orders? I've done a few which also include orders in the left column made with Scribus, but mostly I like to write these out by hand, it seems to save time – also, I've noticed that you may think you know everything you want to order, then as you're putting the sheet in the chart, you realize that you need to add something else, and then something else... Usually what I will also do is to write in the time on the order so I can compare the two columns. Almost invariably it takes no more than 10-15 minutes from when I start the progress note to when I write the order on the printed out page. I don't think that compares so unfavorably with how long it takes to handwrite a similar note, and certainly speaking for myself, is a major legibility improvement.

One thing that happened, and you won't be surprised I'm sure, is that nurses were rather quickly coming up all smiles and complimenting these notes. It never is a bad idea to bring a smile to a nurse's face.

I should mention at the end of this post that while I try to do this as much as I can, there are days when I just don't have the time for this. I'm not compelled to put this much into these notes, since I also dictate a note anyway, and for example, last Friday when I eventually had a total of 8 new consultations to see, plus all the followup visits and other tasks of the day, I did maybe 3 or 4 this way. Generally speaking, though, I'd say it's about 80-90% done with Scribus.

Scribus in the Hospital

This is something I'm experimenting with lately. The idea was to be able to make my notes for the chart by typing them in. This raises a number of questions, like how much time does that take? Does this really work? Can you do it on some kind of regular/daily basis?

I'm certainly not trying to be an advocate of the concept or of how I do it. For many years in the office, I generally take few if any handwritten notes. I sit there with the patient, take their history, and type out my notes, then save them in the chart. I used to print them out and physically put them in the chart, but since we've had an EMR, they just get saved on the server. It's doable if, like me, you're a touch typist, and certainly leads to something anyone can read.

When I started it I wondered about how I would manage with the fact that word processor text entry is a linear process -- you keep appending what you've done, whereas if you're handwriting a note, you can skip around the page and go back and stick something up where it seems to fit better. But that wasn't such a big deal once I figured out a standard outline of sorts to use, and it isn't so hard to use arrow keys or whatever to skip up and down a bit. You can always reorganize later, if you want, but these are just working notes anyway.

The next step was doing all my own typing in the office. All of it. The official notes that go to referring docs, letters for this or that. It started out when we were having a bit of a backlog in typing, and it might take a couple of weeks for my transcriptions to come back. Meanwhile the patient calls, and I'm trying to remember what I said in my dictation, which I don't know until my typing gets done. Now that I do it myself, I finish all of it the day I see the patient, so it's in the mail and in the chart that same day. Let me add that my "style" if you will is a narrative style. I am not fond (putting it mildly) of these highly structured tabular/spreadsheet-like reports that are all too common from doctors' offices these days, where most things are in words and a few short phrases, and lots of medical lingo.

So when you do all this typing, you become pretty proficient at it. It may have been out of boredom, but I decided to experiment with hospital chart notes. While we have a LOT of the patients' information computerized, we still cling to paper charts, especially for the doctors handwritten notes. I dictate my consultations just like everyone else, but I've always written a fairly long note before dictating -- it helps me collect my thoughts for dictating as well as have something in the chart before the transcription gets done (actually usually within an hour or two of dictating most days).

For the heck of it I decided to create a progress note sheet, and did so with Scribus, so everything you see in that picture at the beginning of this post was created in Scribus, even the bar code, which by the way just denotes the type of page it is -- I gather that when these pages get scanned into the system the scanner uses the bar code to make sure each page gets to the right section in the chart.

In my next post, I'll take the next step, turning this generic page into the most legible doctor's note you'll ever see.