Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, November 20, 2014

RxNT in More Detail

I just finished my training session to use RxNT's e-prescribing software, so I thought I'd give readers a rundown of what it looks like and how it works.

The home page looks like this:

But you have the option of switching your startup page to Patient History, Scheduler, or Prescription Watch. Since I'm not using the EHR or scheduling software, I chose the Prescription Watch, which looks like this:

The Prescription Watch also has a patient search box (not shown) in the upper right hand corner.

When you enter a new patient, the only required information is name, DOB, address, and gender. But it offers all kinds of demographic options, which are helpful if you're using the program for charting. There's also the option to import all your patient information if you already have it in some suitable electronic form. And if you have multiple sources for a single patient, you can merge them.

I successfully sent off my first prescription with almost no difficulty. Almost, because it got stuck when I didn't enter the type of thing I was prescribing, namely, a tablet. I didn't notice that I was supposed to enter this, at first, and I wouldn't have thought it was necessary because the medication was listed as lexapro 10mg tablet, but apparently it needed that. Beyond that mild glitch, it was easy.

The trainer was pleasant and helpful and knowledgable, but it's really quite an intuitive system.

The other problem I was warned about, but didn't end up being a problem because I was warned about it, was that the various pharmacies that populate the list when you're looking for your patient's pharmacy each have a little check box to the left. It looks like, if you want to send the prescription, you just click on the box and it goes off to that pharmacy. But the box is just to add that pharmacy to your favorites. You need to click on the pharmacy's name to choose it and have the rx sent to it.

According to the trainer, you have to enter all the drugs you want on your "favorites" list individually, and there's no option to prescribe a drug and then click "add to favorites". The latter seems to be true, i.e. no click option, but I tried writing a new rx for a different patient (my dog), and instead of entering a medication, I clicked on "favorites", which should have been empty, but the search turned up lexapro, so I think the drug is added to favorites automatically. Same deal for the pharmacy-it was already entered as one of my favorites, with the option to remove it. I think, in general, there's a fair amount of redundancy in the system, which I consider a good thing.

Here's how lexapro comes up:

the little "?" on the left means the formulary status is unknown. There's a legend for the symbols:

The bottom of that same screen has several sections. The drug info:

Clicking on the blue highlighted phrase brings you to a screen with all drugs in that class.

Sig builder lets you create any administration method you like. Reference gives you a patient education monograph, patient counseling messages, and warnings, all of which can be printed out for the patient. Interactions gives you the obvious, but you set your level of interaction tolerance to mild, moderate or severe, depending on how many messages you can stand. It includes drug-drug warnings based on the patient's other meds, food interactions, and age- and diagnosis-based warnings. If you want to override an interaction, you don't need to justify it with a reason, like some other systems require. It just checks a second time to make sure you want to prescribe it, and then lets you do so.

The drug info also gives you recommended sigs:

And the option to create a new sig.

At the lower right, there's a list of alternatives-the same as the drug class list, I believe, with formulary information, I suppose based on whatever you've entered about the patient's insurance.

When I clicked on one of these drugs, it highlighted the drug, but didn't substitute it for lexapro, so I guess that has to be entered separately.

Oh, and there's an "add drug" button, if you want to send more than one prescription without starting from scratch.

I really like the delayed Rx feature:

You can do a one time rx, but schedule it for some time in the future. And then you can specify whether you want it placed in your "pending" queue that day so you can check it before sending it off-necessary with controlled substances, or you can just approve and transmit it without ever looking at it. Whoosh! And you can do the same with repeated prescriptions.

This feature is incredibly convenient. It also makes it easy not to see your patients very often, if that's how you want to manage your practice.

Some drawbacks to the system:

-If you send in a prescription, and then realize it was the wrong one, and you delete it, you need to call the pharmacy to tell them, because it doesn't automatically get deleted from their system, only yours.

-You can use the claims history to find other meds the patient is taking, with the patient's permission:

And you can add those meds to the patient's active list. You can also manually enter other meds you know the patient is taking. But if you delete a medication you didn't prescribe, it's completely lost to the system, unlike ones you did prescribe, which are retained in a list of deleted meds, and can be re-prescribed without having to enter the whole thing from the beginning. So if the patient is taking, say, prilosec, and has some adverse reaction to it, you can delete it from the system so you know the patient isn't taking it anymore, but the only way to record the fact that the patient took prilosec and can't tolerate it is if you write a little note to yourself. And there's a "notes"section that's independent of the chart notes, which you may or may not choose to use.

-There doesn't seem to be a screen that simply lists your patients, but I may just need to play around with it longer to find that, or it may be there only if you're using the EHR system.

-There's a "status" column in the list of recent rx's. If an entry is highlighted in green, that means the rx went through. Yellow means it's pending, and the system will keep trying as long as it's yellow, and red if it didn't go through. But there's no flashing light or message to let you know that a rx didn't go through, so if you take care of your prescribing first thing in the morning, you might not find out that a prescription didn't go through until the next day. You also can't sort the list of recently prescribed meds by field, it's just chronological. So you can't request that all the red statuses get lumped together where you can see them easily.

-I'm a little confused about the sig builder. I tried to create a new sig, which was lexapro 10mg 1 po 5 times per day. And it let me do that without any comment about maximum dosage. Since I just entered the sig, but didn't try to prescribe it, I'm not sure if it would have questioned me if I did try to prescribe it.

-This one is on the state of NY, not on RxNT, but when you prescribe a controlled substance, which I haven't done yet, you go through a screen that asks for your hard or soft token, so that's already a pain. But then, in addition, you have to complete the whole I-STOP business, which seems like big time overkill. I think the company is trying to hammer out this issue with the state, but I'm not holding my breath.

I haven't yet attempted to go through the identity proofing/two factor authentication process, so I'll post again to let you know how it goes.

Wednesday, November 19, 2014

Chocolate, Again

About 2 months ago, I posted about my chocolate addiction, and the potential mental health benefits of chocolate.

It seems I was more right than I knew.

In a recent study, Enhancing dentate gyrus function with dietary flavanols improves cognition in older adults, published in Nature Neuroscience,

A team led by researchers at Columbia University Medical Center randomly assigned 37 healthy volunteers aged 50 to 69 to receive either a high-flavanol (900 mg) or a low-flavanol (10 mg) cocoa drink, developed by candymaker Mars Inc., once a day for three months...
After three months, the researchers found noticeable improvements in both the health of the dentate gyrus and cognitive test performance among those who consumed the high-flavanol drink.... “If a participant had the memory of a typical 60-year-old at the beginning of the study, after three months that person on average had the memory of a typical 30- or 40-year-old.” (From Psychiatric News Alerts)

Unfortunately, 900mg of flavanol is more chocolate than most people can consume in a day (MOST people, not me), so it's unrealistic to expect chocolate to improve your memory. But it made me wonder if candy makers like Mars are planning to branch out into chocolate as health food.

Mars manufactures all of these chocolate products:

I checked out the Mars website, and sure enough, they have a department called, "Symbioscience", "a technology-based health and life sciences business focused on evidence-based product development."

One of their products is CocoaVia:
CocoaVia® is daily cocoa extract supplement that helps support healthy circulation, which contributes to healthy aging by promoting cardiovascular health. CocoaVia® supplement is made with our patented Cocoapro cocoa extract and delivers 250mg of cocoa flavanols per serving – guaranteeing the highest concentration of cocoa flavanols in a dietary supplement. The cocoa flavanols in CocoaVia® are scientifically proven to help support healthy circulation, important for cardiovascular health, cognitive health, exercise performance, blood flow, heart health, and skin health. 
This statement has not been evaluated by the Food and Drug Administration.
This product is not intended to diagnose, treat, cure or prevent any disease.
Here's a link to their research publications, so you can check out their "scientifically proven-ness". I don't know what to make of any of it. It's industry-does that make it bad science? Maybe I should suggest they look into marketing the cannabinoid components of chocolate. No matter what, though, it's gluten free.

Sunday, November 16, 2014

The Evil Emperor MOC-Or My Review of a Review Course

I seem to have strayed from my Lord of the Rings metaphor for my Board Recertification journey. But I signed up for the Beat the Boards online course, and I decided to do something I've never done before-use flashcards. I'm not sure why I made that decision, but maybe it was because I wanted to try out flashcard apps.

But before I move on, here's a picture of Charles Middleton as the Evil Emperor Ming the Merciless from the Flash Gordon (hence the "flash" cards) series of 1936.

I used to love that show, even though the special effects were laughable-you could see the strings holding up the spaceships.

And here's Max von Sydow as the Evil Emperor Ming in the 1980 Flash Gordon Movie:

And finally, here's the incomparable Ben Kingsley playing the evil Nizam in 2010's Prince of Persia movie, which, as far as I know, has nothing to do with Flash Gordon or MOC:

Turns out, there's a reason I've never used flashcards. I guess I've never understood why I should bother to write bits and pieces of information down on some index cards when someone else has gone to the trouble of writing down the same information in whatever text or source I'm trying to copy it from. Cut out the middleman, I say! I thought I might be inspired to try it this once using smartphone apps, just for the tech-y coolness appeal. But it's at least as much trouble to type things out on my phone as it is to write them on an index card. Well, so much for Flash Gordon.

However, I HAVE been attempting to study for boards. I have a three-pronged approach.

1. Meet every two weeks with the same friend who I studied for Step 3 and the first round of boards with, to go over questions.

2. Watch the Beat the Boards videos and follow along with the written materials on a regular basis. Once in a while when I feel like it seems pretty regular, right?

3. Review the Med-Quick guide from Beat the Boards.

Here's how Beat the Boards is measuring up.

1. The question bank is probably the best learning source, assuming, as they claim, that it accurately reflects the content of the boards. There are supposed to be "100's" of questions, but there have been some repeats, so far. There's a flashcard mode and a test mode. I've only done the flashcard mode, which tells you if you're correct, gives an explanation, and allows you to save the question for later review. I believe the test mode is supposed to simulate testing conditions, and is also the part that gives you CME credit.
    I find I don't agree with some of the answers, so again, I'm taking it on faith that these are the answers the ABPN wants. There are also some questions that don't seem to belong there, like the one about the most effective form of contraception. I would feel remiss if I didn't encourage my patient to have that discussion with her gynecologist.

2. The videos are of varying quality. The ones given by Jack Krasuski, who runs the company, are decent. He doesn't simply repeat what's in the written material, and he has a good way of organizing what he's trying to convey. He does have, well, it's not quite risus sardonicus, but an unnervingly permanent smile glued to his face, that's a little off-putting. Besides his videos, I've only watched those by one other guy, and he is soporific. It's that poor use of power point, where if you're just going to repeat the written material I have in my hand, why should I bother listening to you babble on.
   The presentations are done in such a way that they start off with a multiple choice question, and use that as a jumping off point for the discussion. There's nothing earth-shattering about this approach, but it isn't bad, either.

3. The Med-Quick guide is a pdf in 4 parts. Part 1 is a list of FDA-approved medications 2009-2013. Part 2 is a list of psychiatric disorders with their respective FDA-approved meds. Part 3 is a review of individual medications. And part 4 includes additional board-pertinent information, like drugs to use during pregnancy.
   I sort of remember the site offering the Med-Quick guide for free, when I was first checking it out , but when I tried to access it, the link didn't work. I can understand why. I think if I can memorize this guide, I'm pretty much set. the non-med questions in the question bank are easy and intuitive, except for the statistical ones (what percentage of pedophiles self-identify as heterosexual? 20-40%, 40-60%, 60-80%, 80-100%?) I tend to err on the side of moderation if I don't know the specific number, but that's clearly the wrong approach. But there aren't that many of those, so if I have the meds down, I think I'll pass.

(It just occurred to me that, having documented this process publicly, it'll be really embarrassing if I fail).

Overall, on a scale of 1 to 10, I give Beat the Boards an average thumbs up. Since it's effectively the only game in town, though, I can't complain.