Interface proposal

This is a proposal for the clinical interface for the standard office visit in OpenEMR. It is somewhat specific to Primary Care in the USA, but it can be a starting point for specialty modification. Please use a full screen view in your browser to see the whole page. The purpose of these suggestions is to let OpenEMR FACILITATE THE THOUGHT FLOW of the doctor:patient relationship, thus improving the quality of care. Mouse clicks are minimized. All of the clinician's entries are visible throughout the visit. A single interface provides all tools needed by the clinician for simultaneously documenting the visit and directing the patient's care.

The "clinical" dropdown menu is replaced/supplemented by the table menu on the right. This menu contains all the functions required by the clinician while face to face with the patient from "Hello" to "See you in 3 months." Each option on this menu requires only a single click to activate, saving time over the 2-click dropdown menu. The abbreviated entries [customize in globals] take only a small amount of real estate on the right margin; icons are not required for the literate user (which we pretend to be) who becomes proficient in the use of the interface. Each choice brings up a view/report of the visit note in the left frame to whatever degree it has been completed and a popup frame in the right half. Entries to the note always appear in the same order regardless of the order of input [customize in globals]. The right half of the screen displays the interface for data entry specific to the menu item chosen. The interface provides a uniform feeling throughout the many functions.

If desired, the table menu could be parsed into S.O.A.P. elements. (After 4 decades of SOAP, I am ready to move on. Apologies to Dr Weed.)

This is the initial new visit page before any choices are made:

Next is the CC chief complaint:

Then the HPI is added with the possibility to clone from last visit

ROS can bring up either of the existing ROS forms or allow for free text or CAMOS. This could be set in the individual user's preference with links in the popup to the other entry forms.

PMHx Should allow entry of data from existing "Issues" on the summary sheet and allow for new entries. This would include cut and paste of "problem list", "meds list", "Allergies", "Social", "Immunizations", and "Surgery/Procedures". These are "History" items not "Issues". When I have an issue with a patient, I try to resolve it.

VS vital signs:

EXAM Popup would be a text box. One could use a template import here or CAMOS.

Lab In For ordering in house labs. Popup contains a search field for available office procedures and a link for instant messaging to MOA, nurse.

Lab Out This popup has the interface for ordering from external lab (LabCore, hospital, etc.) and instant message interface for phlebotomist.

Imaging Pops up an interface with selection box for imaging selection with space for clinical comments. Instant message to clerical for pre-authorization info. Output choices are printer, fax, or electronic interface.

As I review this note with the patient in front of me, "Imaging" reminds me that I need an ultrasound of the liver.

Dx This function is transplanted here from the fee sheet and searches from ICD codes. One may enter data here by clicking on elements of the problem list. It also should have a text box for comments (e.g. "improving" or "apparent hepatic involvement" etc.)

Proc for procedures. Selection box for injections, immunizations, minor surgery, smoking cessation counseling, etc. Many of these could be templated.

Rx Prescribing for the visit:

Other and Pt Ed are text boxes and also have selection boxes for preloaded material. "Low fat, low salt diet" or "Printout from Mayo on tennis elbow" etc.

RTC Text box with multiple choice for common followup intervals. 1 week, 3 months.

The summary page of a completed visit

Now one is ready to Bill -> This brings up the fee sheet with Dx entries already entered. ICD codes can be associated with CPT codes in this interface.

Sign should bring up the interface for the clinician to lock the visit/encounter.