Instant Messaging

mchasemd:

Writing an instant messager is not tough work; tougher is getting it right.

For sure !

Would this be valuable in an in-office IM:  If  John Doe is your current pt, have the option to click to include a reference to John Doe in the message? That is, the pt's hidden identifier would be included in the message to allow the recipient to click on it to open the chart immediately.

Synapse does this.  Yes, it is really helpful.

Also, is there any reason to save the messaging long term?  Would it be useful to allow a click-to-save-to-pt's-chart option?

I think it is hard to say, depending on how the individual installs use it.  Instant Messaging probably should not be saved to the chart.  Instant Messaging does not replace messaging - if it needs to be on the record, that should be done in messaging/email.  

I think installs will have definite opinions on the logging of IMs.    Some will want it, some won't.  Most won't or shouldn't want it.  You may consider the options .. set logging or no logging as a default, but with the option of saving and not saving individual IMs.  Gmail, which logs everything, even has an "off the record" mode.

 

Because Medtuity can easily derive who is logged into each copy of Medtuity, would it be worthwhile to:

(1) Allow broadcast of the message to all computers running Medtuity?

 - I think larger institutions might find a security reason for this.  Of course, it could be over used.  I think it is easy to add as an option.

(2) Allow broadcast to a particular person?

- with all the logging in and out most EMR force you to do, you might as well leverage that.  This is most important for doctors and nurses that move around alot.

(3) Allow broadcast to a particular room?

- It's helpful.   Actually my secretary just finds out what PC is not-idle and that is how she finds me.

For the clinics using fingerprint logins, maybe allow for sealed messages that only open with a fingerprint scan ?  :)

For larger clinics, having a "FaceBook"-like IM environment might be interesting.   Hard to say. 

There are a myriad of ways of alerting the recipient that a message has come.  I think most apps don't take into account the subtleties of messaging a doctor or nurse that is seeing a patient.  Should there be a loud sound ?  Should it get louder if not acknowledged in x seconds ?   What options do the doctors have  for receiving messages ?  What about the secretary ?   Should the messages be sealed ?  Should the IM be texted to a handheld (hint) ? 

The best IM will also integrate with the office workflow / TODOs.

Lots to think about.  And I have to head home.

 

Dr. M,

Thanks much for your comments.

We already have alerts / reminders/ messages which go into the chart and are designed for patient care....reminder to call pt to get the HgbA1c before the next visit in 3m....health maintenance ...alerts regarding returned labwork...still waiting for that breast US after 2 wks...etc.

I'm intrigued with the workflow issues of instant messaging.

Again, thanks

mchasemd:

Writing an instant messager is not tough work; tougher is getting it right.

Medtuity does not have instant messaging but I've been working on something.

Leave it to Medtuity to open up the discussion on cool integrations of an EMR with IM.

mchasemd:

Would this be valuable in an in-office IM:  If  John Doe is your current pt, have the option to click to include a reference to John Doe in the message? That is, the pt's hidden identifier would be included in the message to allow the recipient to click on it to open the chart immediately.

This would be a great way to be able to keep IM secure, but still be able to communicate about patients.  Plus, if it was integrated it saves having to type a patient's number (which is what we do now) in order to talk about them on IM.

mchasemd:

Also, is there any reason to save the messaging long term?  Would it be useful to allow a click-to-save-to-pt's-chart option?

We don't want to keep ours long term.  Better to not have them for liabilities sake.  Although, we have occassionally been interested in saving the communication to the chart.  Not usually in the IM format, but possibly save it in editable format where it can be cleaned up and saved to the chart.

mchasemd:

Because Medtuity can easily derive who is logged into each copy of Medtuity, would it be worthwhile to:

(1) Allow broadcast of the message to all computers running Medtuity?

I guess this could be useful for emergency things, or when you need to restart the server for some reason.  However, should be a tightly held security permission I think.

mchasemd:

(2) Allow broadcast to a particular person?

The most useful part of IM I think.

mchasemd:

(3) Allow broadcast to a particular room?

This wouldn't matter to us since you usually want a person and not a room.

The one I think you missed that we've found useful is sending an IM to a group of people.  For example, a doctor needs some blood drawn in the room.  She can just send an IM to our lab group.  Or a doctor needs a referral done in a room.  She sends an IM to the nurses group requesting the referral be done in room XXXX.  Then, the nurse that's available replies that she'll do it and everyone else sees the IM.  Obviously many more like this.

We also love the MSN messenger feature that allows you to invite another person to a conversation that's already started.  With MSN messenger it only shows the newly added person the future comments.  It would be nice if you had the choice to only show future IMs or to show previous historical IMs as well.  This would be harder to implement without logging.

Finally (although I'm sure there's more if I thought about it), it's nice to be able to send messages to a person even if they're not online and they'll receive those messages when they sign in.

John,

Helpful stuff!

The only time I used Messenger was when my son was in Iraq.  It was a convenient communication tool when he had a two hour break between patrols. (He was a "battlefield medic"; now out of the service and applying to med schools; good MCAT score....for anyone on an admission committee).

We already automatically message/flag through the tracking board all blood draws, medication administration, treatments/injections.  Would you use an IM tool, for example, to message Dr. Jones that Dr. Smith is on hold, line 5, wanting to talk about John Doe (and click the message, click an icon, and Doe's chart is up....sort of activity?

The tool would be domain-specific, definitely.  Would want that for security. Also, it would be Medtuity-specific...integrated into the product to allow, if convenient, a pt's chart to be instantly opened.

I'm thinking more that we need a toolbar icon where, if clicked, it would save the thread to a chart.....maybe allow editing first.

Thanks much for your input,

 

 

>>> "It would save the thread to a chart.....maybe allow editing first."

Where exactly would it be saved ?  Can I doctor save it ?  Can the Nurse / Secretary ?

>>> We already automatically message/flag through the tracking board all blood draws.

And the person whom draws blood gets notification without looking ?  (instant notification).

 

mchasemd:

The only time I used Messenger was when my son was in Iraq.  It was a convenient communication tool when he had a two hour break between patrols. (He was a "battlefield medic"; now out of the service and applying to med schools; good MCAT score....for anyone on an admission committee).

I've lived on IM for years.  It's like my facebook, before facebook was facebook and before facebook added IM.  It's the way I stayed connected with old friends.  Not applicable to doctors in this way, but I love IM.  Once people learn the protocols of IM (ie. don't say good morning every morning on IM) then it's great.

mchasemd:

We already automatically message/flag through the tracking board all blood draws, medication administration, treatments/injections.  Would you use an IM tool, for example, to message Dr. Jones that Dr. Smith is on hold, line 5, wanting to talk about John Doe (and click the message, click an icon, and Doe's chart is up....sort of activity?

Even more likely is probably a nurse that IMs a Dr. saying that patient X (include link to chart) is on the phone wanting a refill.  Can I do it?  Then, the Dr. can link directly to the chart (or even a specific note possibly) and answer the question.  Just thinking out loud, but maybe the IM could include the Dr.'s signature so the nurse could copy the IM orders for a certain RX or lab into the chart with the Dr.'s Signature.  Not sure exactly how that would work, but could be interesting.

I just did 2 posts on IM and EMR on my blog that will be posted tomorrow and the next day.  The one posted on Monday brainstorms a few more features that could be cool in IM.

Techguy:

Even more likely is probably a nurse that IMs a Dr. saying that patient X (include link to chart) is on the phone wanting a refill.  Can I do it?  Then, the Dr. can link directly to the chart (or even a specific note possibly) and answer the question.  Just thinking out loud, but maybe the IM could include the Dr.'s signature so the nurse could copy the IM orders for a certain RX or lab into the chart with the Dr.'s Signature.  Not sure exactly how that would work, but could be interesting.

When a call comes in for a script refill, whoever answers the phone/take the message, simply clicks the "ribbon on the finger reminder, alerts, message" icon. You pick the doc, you pick the pill bottle icon, you start typing the pt's last name, pick from the matches and OK.  It goes into the doc's messages and alerts.

Doc sees the message (but this is the Medtuity normal alerts/reminders messages.....not the in-your-face IM type messaging), and clicks on it.  The pt's chart is loaded automatically in the background but the physician might never have to look at it because in the small messaging window are tabs that show the pt's current meds and allergies.  You can very quickly write a new script or refill a prior script. The option to print or fax the script is present too, but the doc might just "reply" to the nurse with the script contained in the reply message.  Because the script is "written" with Medtuity's script writer, the pt's current meds list is updated.

Regarding the physician's signature, because of the audit trail/login of Medtuity, we treat the order as an authenticated order by the physician.  That is, if you get a message to call in a script for lisinopril from Dr. Jones, then you know that if Dr. Jones shows as the sender, then Dr. Jones was logged in and sent the message.

So tying the EMRs script writer to the messaging window is important, but with the pt's medication/allergy history too.

And this brings to mind an item which you might like to blog about-  message-chaining.

Message chaining came to our attention a couple of years back and we instituted it.  Consider the problem and I will take an example we experienced:  A pediatrician would write for a dexamphetamine-style drug for a patient.  A day later, the mother would complain that the dog ate the script and ask for another one.  The physician gets the message, feels suspicious, and wants to talk with the mother.  She writes another script but in the message, tells the staff to have the mother come back for a hallway visit when she picks up the script.  Now we have two messages.  Mother stops in, grabs the script, says her kids are in the car, and runs out with script in hand.  So the front office staff answers the message with another one:  "Pt rand out with script. In a hurry. Kids in car. Said she would call back.".  In a day, she does call back but this time she calls to say that the medication bottle was on the countertop  next to the sink and one of the kids knocked it into the sink.  The capsules  were ruined. Plesase write another.

So message-chaining is where one message is linked to another, in a  chain to allow the reader to quickly review the chain.  It is done automatically when one responds to a message.  In our reminders-alerts-messaging window is a tab called History for looking at the history (or message chain).  It's a really useful feature when you need it but most of the time, can be ignored...thus a tab so that it is unobtrusive.

Another feature to consider is allowing one staff member to review messages of another staff. Some physicians do not like to review their messages with great dispatch...kind of a prickly problem that an EMR designer should consider.

Another feature to consider is how and when the message will  appear.  Some you want to appear as popups.  The in-your-face message.  And I don't mean by that the system creating an in-your-face alert that the pt needs his prostate checked. Those messages should not be in your face.  In your face might be, "The ER called and Mary Jones is there. They have a question about....".  So an alert level should be pickable when creating an alert.

Some alert levels are for convenience and are picked to be in your face, but only when the chart is opened.  Some physicians like to put in a quick alert to themselves such as "Be sure to ask how Mary's doing since her husband died in 6/08" that appear only when that physician opens the chart. It takes only a second, appears only when that physician opens the chart, and avoids embarrasment of not remembering such a traumatic event for the pt.  (Of course there are other ways around that issue such as also looking to the social history).

Another consideration is being able to print all reminders and alerts that have been generated for a patient if a legal issue ever arises.  The timeline can save a physician's butt, but all of our offices are paperless, and so the yellow sticky note does not get put into a paper chart.

 

 

 

These are very cool ideas. I would think IM should be able to store messages, as required. The message history should be viewable in patient context as well as all messages.

Medtuity features do sound nice.

Do messages have to be stored for a certain length of time for audit or other legal purposes?

However, what do you think about using 3rd party IM services like AOL or MSN? those services may not be secure and chatting about patients on those networks may not be exactly kosher.

 

Abhidon,

I think AOL and MSN are fine if you want to ask Mary to order more 4X4 guaze, K-Y, paper towels and TP.

My problem is when the subject crosses over to a particular pt and you want the option to have the pt's chart come up, to write a script, to record a conversation to the chart, etc, etc.  It would be too hard with a commercial product.  One is integrated and the other is not.

abhidon:

However, what do you think about using 3rd party IM services like AOL or MSN? those services may not be secure and chatting about patients on those networks may not be exactly kosher.

We use MSN for our IM and are quite happy with it.  You are right though.  You can't talk about PHI on those services.  You can however say pt 1234 needs an MMR in room 2.

Of course, integrated with the chart with direct links to certain areas of the chart would be much better and more secure for sure.

We developed a lan based instant messenger 3 years ago at the request of our clients. Our Medinformatix clients that are using it have found it to be such an essential tool we now include it with all of our EMR implementations. If our competitors knew how vital it has become for our clients, they would all be including one.

- start shameless plug - By limiting the access to members of the network only, we eliminate the risk of extraneous chatter with outsiders. We addressed the remote site issue by adding a terminal services client. To add to the flexibility of the program, we incorporated the ability to launch it from an HTML page in addition to an icon in the system tray (which can also be hidden to restrict access to users logged into a specific program only). The HTML access feature makes it accessible from any intranet site, or from a hosted application. I'm not here to sell the program (although you can go to our website at http://messenger.acentec.com to read more about it and download a free 30 day trial). - end shameless plug-

I was hoping to test it.

I see the IM clients didn't auto discover each other.

On the two PCs I loaded it on .... there were some GUI features missing.  Maybe I need a reboot ?

see the image.

 

Jeff Mongelli:

We developed a lan based instant messenger 3 years ago at the request of our clients. Our Medinformatix clients that are using it have found it to be such an essential tool we now include it with all of our EMR implementations. If our competitors knew how vital it has become for our clients, they would all be including one.

Jeff,

This is a really interesting observation.  Can you give us a sample list of scenarios where the IM has been invaluable to your clients?

Dr. Murdoch,

It shouldn't require a reboot, but it shouldn't look like that either. If a reboot doesn't work, try re-downloading the program and re-installing it. You should not have to uninstall it first. If that doesn't work, then I sent you an email off-line. We can hop on your system and troubleshoot it. Even on a single pc with no other stations installed you should see the entire gui. 

Thanks for trying it out, I hope you like it and it helps your practice.

Hi John,

I've emailed a couple of clients to get more feedback, but here is some feedback from some of them:

Great, now my doctor can ask me for coffee while he is seeing patients...

We've almost completely eliminated overhead paging.

Physician - I can have my nurse step in immediately when I'm in with a patient.

Physician - My front desk im's me when I am in a room and a call comes through that I am waiting for. They don't have to leave their desk to get me. I have mine configured to just blink in the toolbar instead of popping up on screen.

I know one of our groups has commented on the document attachment feature making it easier to route important mail or faxes to the physicians, although I think they are referring to non-patient related documents.

Not that this ever happens, but you can send a boradcast message to everyone if the server needs to be rebooted....

I've asked for some more specific cases and will post them as I receive them.

Thanks.