I often tell people that ClinicTracker became the EHR it is because it grew up in an academic medical center. Among other roles, I served as training director and head of clinical services for child psychiatry. If you work with trainees, you have to manage a whole different level of complexity in workflows, oversight, and reporting. You have to make it easy for supervisors to oversee cases and caseloads, check progress notes, and other reports, countersign documentation, and provide all kinds of data to the organizations that certify training programs. You also have to make sure that students see the required mix of diagnoses and patient groups. And you really have to prevent trainees from leaving the rotation without completed (and signed) paperwork. Any training director will tell you that it’s almost impossible to get overdue paperwork completed once a trainee has moved to another site.
In addition, you must use a system that students can learn quickly. I chuckled when a software vendor early on said that implementation took about a year and that we would need an on-site trainer. Many of our rotations were 90 days (so much for the full year) and I didn’t have money to hire someone to train our people on documentation and teach them to use the software system. I needed a system that students could begin using after about 10 minutes of explanation from our secretary. Many of our psychiatry residents came from countries where, at least at the time, computers weren’t common. Some international residents came with weak English skills. For all these reasons, it was silly to consider adopting a system that required a year of training and an on-site educator. We needed an interface that was intuitive to even the most computer challenged clinician.
You can understand how ClinicTracker became so easy to figure out and user-friendly. It had to be simple, or no one would use it.
I also envisioned a system that walked students (and my professional staff, for that matter) through documentation requirements, what some in recent years have called the Golden Thread of clinical documentation. As anyone who runs a state-certified mental health clinic knows, the various requirements are complicated and endless. Prior to ClinicTracker, we had to spend several hours training students on what they needed to include in admissions summaries, progress notes, treatment summaries, and the like. We also had to go over deadlines for each document or report. Those orientation sessions were tedious and ultimately rather useless. It’s one thing to listen to a lecture about documentation flow and another to do that in actual practice. With ClinicTracker, our clinicians went from dealing with a haze of due dates to simply looking at their desktop to see an exact list of their paperwork status.
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ClinicTracker’s influences from operating within a training facility didn’t end with engineering workflows and a manageable system of inputting information. When you’re training people in a clinical setting, you want them to collect all the information they need to make good clinical decisions -- not just what the office of mental health requires. If you feel it’s essential that students ask about smoking or alcohol history, then you need a system that requires them to gather that information. Same for trauma history, family psychiatric history, and the like. I really wanted ClinicTracker to help instill good interview habits. I had our programmer make it easy to identify fields that trainees would have to complete before they could file the paperwork. I knew we were making progress when trainees and new staff brought blank admission summary templates into the initial interviews.
Also relevant to working with trainees is striking a balance between relying on dropdown lists for paperwork responses so they know the kinds information you’re looking for versus providing text boxes where they can write out their response. I wanted a system that allowed people to write an observation or referral question, or a formulation that required some elaboration and showed some thought. Sure, dropdown lists are great for formatting factual information, but terrible at providing an opportunity for people to explain themselves, elaborate on a point, and form an argument. Supervisors and site visitors want to see the ability to think, not just a way to click on canned responses.
Many other ClinicTracker features found their inspiration from working within an educational setting. For example, many of our psychiatry residents were required to conduct clinical research as part of their training. Some of the psychology interns were keen on working on their dissertations and wanted to use data from our clinic. And, of course, I wanted to keep conducting and publishing research. That’s why we made it easy to export clinic data to files that a statistical package could scoop up for analysis. It was a dream from someone like me, who had spent years bending over file cabinets and writing information on data sheets (or paying someone to write the data), now simply telling ClinicTracker what information I wanted and bringing that into Excel or SPSS. It was awesome and led to a surge of publications that started with data just sitting on a disk.
One last example of how we tailored the system to handle training situations. Some supervisors wanted to write notes to their supervisees that were attached to the patient file but not part of the legal medical record. We had already developed a feature we called “therapy notes” that therapists could use for personal notes, but that had language (approved by an attorney) stipulating that the notes in the tab would not be printed with the rest of the record and should be considered as separate. Supervisors and trainees used that space to write notes to one another about the conduct of the case. Of course, they also used the internal, secure messaging system for communicating as well.