How Praxis Works

How Praxis Works
  • Introduction: Dr. Bob Comeau on Praxis EMR
"Your mind does not think in a template system. Before templates, before words, your mind has a concept. This concept is related to the diagnosis and then expressed in words. The heart of Praxis is a Concept Processor that links your mind to Praxis. Physicians are not all trained the same way; therefore, they have different concepts of the same diagnosis. In Praxis, this concept continues to evolve as medicine changes."
Dr. Robert Comeau OB / GYN - Praxis EMR user since 2001
Listen to Dr. Comeau discuss his experience with Praxis during a public webinar announcing the release of Praxis EMR v5.
Praxis Electronic Medical Records (EMR) - OB / GYN Case Study
  • The Praxis Concept Processor Solution

Your Practice of Medicine is Unique.

As a physician, you practice an art form. You have developed your philosophy and technique with years of training, experience and learning. Of course, you think and express yourself in your own way. No two physicians practice medicine exactly the same way.

However, as a practitioner you also experience a bell-shaped frequency distribution of cases. Some cases are so rare that you may never see them in a lifetime. Others you could see five times a day. Still others you see five times a week, or five times a month.

The bell shaped curve best describes how the Concept Processor creates a medical knowledge database for each physician.

Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
Bell-Shaped Curve

A Concept Processor is a neural network that automatically generates the documentation of new patient encounter by instantly retrieving text from the most similar previous encounter you have seen in the past using the software.

From this simple concept, a different EMR technology emerges that is not simply about documentation, but about automating your practice your way, and allowing you to work smarter. Unlike other systems based on templates, Praxis gets progressively faster and more powerful the more you use it, becoming a unique personal assistant.

With each new case, you encounter one of three possible outcomes:

  1. The new patient encounter may be identical to one previously "learned" by the program. Medical schools may argue that there are no two identical patients, and therefore no two identical cases. But in the reality of daily practice, you often find yourself writing exactly the same way many times. This is true because repetition exists within your mind as a physician. In other words, you tend to develop a particular set of words that you use to express the same concepts, and you use the same methods to handle identical situations.

  2. The new patient encounter may be different, but similar to one previously learned by the program from another patient.

  3. The new patient encounter may be unique and different from any you have seen before.

No other possibilities exist; an encounter must fall within the bell-shaped curve describing types of cases versus frequency for any given provider.

  • Identical Encounters

If the encounter today is identical to one you treated in the past, the text will be generated for you instantly. Not only are you charting at once in your own words, but your encounter note is also accompanied by the countless additional documentation you need at the same time: prescriptions printed, faxed, or eprescribed; instructions and patient handouts; procedures and operative reports; letters to referring providers; admitting orders to the hospital; laboratory orders; return visits and scheduling; even the routing slip for billing purposes. All of these documents are generated and printed or faxed along with the progress note as fast as a laser printer can print... instantly!

And the text produced must be to your liking, because it was you who wrote it, albeit for a different patient with the same condition. Generating an entire note with all its corresponding documents in this manner is certainly faster than dictation or speech recognition, and much faster than writing longhand!

  • Similar Encounters

Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
The new encounter (in red) is created by editing a similar previous encounter (in green).

If the new encounter is not identical to a previously charted encounter, then you simply edit from the text of the most similar one that fits your current needs. Making small changes is obviously faster and easier than typing an entirely new case from scratch, and less fraught with errors. After you make the few changes, the entire set of documents is produced instantly as before, but all the new changes are saved separately for re-use with a similar case in the future.

Therefore, when a future case falls in between these two closest encounters, the editing takes half the time as the one before it, and then a quarter of the time for the next such case, and so on...

The more you use Praxis, the faster and smarter it performs. In fact, the Concept Processor becomes your "second brain", continuously helping you document faster, better, and easier.

Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
Note that the distance between the new encounter in red and the two previous encounters in green is half as much as in the previous case. The more one charts, the less editing one does!


Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
With each new case entered, the editing time is further reduced. As you can see, Praxis EMR gets faster and smarter the more you use it. No other EMR does this!


Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
You will be surprised by how quickly your bell curve fills up. Before you know it, you'll be charting at the speed of your mind!

The effectiveness of documentation improves exponentially with each new case until you are charting at the speed of your mind. Keep in mind that reading your own writing is easier and faster than reading someone else's. One can say that this unique approach uses the computer as your brain's helper in the complex process of clinical documentation and automation.

Concept processing provides an opportunity for continual self-teaching and self-learning. Each new encounter improves the quality of your writing and of the Medicine you practice. Random errors are reduced and medical quality continues to evolve long after you reach your optimum charting speed. In fact, the quality improvement is never ending.  Not only can make sure that all your t's are crossed and all your i's are dotted, but the chart itself may also be used the way a pilot uses a checklist - to make sure that nothing is forgotten or overlooked. You can prompt yourself to ask the right questions, check for the right physical findings, and order the correct studies or treatments with ease - even at 3 o'clock in the morning. It is all self-designed and self-taught. And, any additional symptoms or signs you elicit from your patient will be automatically added to your knowledge base, to consider with your future patients. This software never forgets, and it always gets better.

  • Rare Cases

Even rare cases are no problem for the Concept Processor.

Most often, what makes a case rare is the particular way the set of encounter elements comes together. Patient encounter elements that make up a rare case - such as physical findings, X-Ray reports, procedures, instructions to the patient, and others - may be easily retrofitted to meet the case's documentation needs with minor changes, or none at all. Indeed, most elements making up a rare case have probably been recorded in the past with many other patients presenting with more common problems. Because elements that make up any encounter follow independent bell-shaped curves of their own, they are instantly recalled by the Concept Processor for use with a rare or unique case.

For example, the precise fever instructions for a case of the common cold may be used for a case of Mediterranean Hemorrhagic Fever with few if any changes (and those changes are then saved for the future). As a result, even a rare case need not be entered from scratch, and recycling your elements from previous cases is still infinitely faster and easier using the Concept Processor than starting from scratch.

  • Charting "Bass-Ackward"

Although this method of charting may seem unusual or contrary to traditional medical teachings, you should realize that this form of documentation is a natural part of the human thought process. In fact, our brain functions much like a biological "Concept Processor" by searching its subconscious for the right phrases, sentences and even entire paragraphs to articulate spontaneous ideas that come to our mind. None of us think about every word being uttered. The process of verbalization - oral or written - is always semi-automatic. Certainly, any experienced physician has felt this while dictating or writing at 3 o'clock in the morning!

Therefore, rather than charting what you do, doesn't it make far more sense to do what you chart? Certainly, doing what you wrote is not only faster and easier, but also better medicine. (See "Charting Bass Ackward", by Clayton Reynold's MD) .

  • Speech Recognition

Some people ask whether Praxis includes "speech recognition" technology. The answer is yes, all Electronic Medical Record programs include speech recognition technology, because speech recognition technology, like your keyboard or mouse, is external to the EMR application. The only purpose of speech recognition technology is to convert your human voice into typewritten text or hotkey directions for your EMR. Praxis certainly has that ability, and so do many other EMRs, but that is not the issue.

At issue is what takes place between your fast mind and your all too human mouth. You know exactly what to say; how to say it is the problem, and it makes no difference whether you are typing, writing long hand, using dictation/transcription, or speech recognition software. In a way, speech recognition has a built-in handicap in that it will "write" exactly what it hears, and not necessarily what you really meant to say. As an adjunct to the Concept Processor, however, speech recognition technology is excellent. Here, all you need to do is verbally correct the already present text to fit your actual case.

Keep in mind that only three viable speech recognition programs exist, and all of them are compatible with Praxis. You should not have to pay more for a glorified speech recognition program simply because it is found within your EMR.

  • The Learning Curve

Please see the new Knowledge Exchanger to dramatically speed up your learning process:

The greatest surprise to most of our clients is the speed at which a Concept Processor becomes useful. To understand why, you must first appreciate how we humans learn to express ourselves.

While the Oxford English Dictionary defines more than four hundred thousand words, most of us use less than fifteen hundred of them. Yet no two of us use the same set of words! Over time, each of us develops our own set of words that we rely upon for generating our unique discourse.

A similar process occurs at the level of phrases, sentences and text fragments. Our mind seems to store a set of comfortable strings of text that we instantly access subconsciously with extraordinary speed when needed.

With the Concept Processor, these naturally occurring principles are simply transferred to the computer. For example, if you commonly describe a normal abdominal exam as follows: "Abdomen soft, non-tender, liver/spleen not enlarged, bowel sounds normoactive, no masses palpable," then you need not re-enter this text ever again! It is ready to be accessed instantly in the future. The same is true for medications, instructions to patients, laboratory orders, and so on.

And, the Bell-Shaped curve effect guarantees that this learning is geometrical, growing faster and faster the more you use Praxis. Within a few hours of practice, Praxis is ready to be useful in your clinic.

To learn the program, you will be linked via the Internet to a trained Medical Transcriptionist and Praxis expert. Your trainer's task is two-fold: to teach you how to use Praxis, and to "prime the pump" by having you dictate hypothetical cases, starting from the most common in your practice. What you will quickly find is that with each new "sample" case entered, Praxis increasingly assists with the right text ready at hand. Each case is therefore entered faster and easier until Praxis is ready for use in your real world practice.

Praxis Electronic Medical Records (EMR) - The Praxis Concept Processor Solution
Once in the clinic, the physician starts by entering the simplest cases, then the more complicated ones, and finally the rest. The process is that simple.

Praxis Electronic Medical Records (EMR) - The Learning Curve
Time that the average case takes to enter versus number of cases entered. Obviously, the learning process gets faster and faster the more cases that are seen.

But even when the charting speed reaches its plateau, the quality of charting will continue to improve indefinitely. You will always be building on your own past documentation to make the next case that much better.

Praxis Electronic Medical Records (EMR) - The Learning Curve
Average speed of cases that may be charted per hour

  • Habit Change

Medicine is always evolving: different payers demand different requirements for the same type of case; a wealth of articles are published in medical journals each month; rules are constantly changing. It can become nearly impossible for anyone to keep all of this information straight for future reference. The beauty of the Concept Processor is that it learns everything on the fly - anytime, anywhere - and any addition or change made once is ensured to be there the next time for a different patient. If you learn of a new treatment approach in a journal or at a seminar, you can easily enter it into your knowledge base. When the right case presents in the future, your learned approach will appear instantly to be of help. You can then enter new information, such as journal references, with such ease that patients and colleagues will begin to wonder how you could possibly remember it all. The habit change becomes automatic. Given that medical practice is based on habit, the Concept Processor is probably one of the most powerful aids devised to practice better medicine.

  • Clinical Practice Guidelines and Your Personal Freedom

As previously discussed, the Concept Processor and free text does not contradict the use of Clinical Practice Guidelines (CPGs); quite the contrary. Praxis comes with a uniquely powerful CPG engine that is meant to provide you information at the point of care with minimum noise or interference.

The moment you agree that a CPG is worth incorporating into your practice, the change is made instantly for you. Most of the time, it is your habit that needs be changed, and nothing can do it better or faster than the Concept Processor. (see Paper on Practice Guidelines and Queries)

  • The critical difference between a Concept Processor and a Template
At first glance, the Concept Processor's rapid text generation may lead you to the conclusion that it is some sort of template system. Nothing could be further from the truth...
  • Comparison of Concept Processing With the Other Ways of Entering Information

Praxis Electronic Medical Records (EMR) - Comparison of the Concept Processor and other types of EMRs
Comparison of the Concept Processor and other types of EMRs

Indeed, an inverse relationship exists between the speed and the flexibility of data-entry in all template systems. At one extreme, expert-system type EMRs may generate text instantly, but the text does not accurately represent what you wish to express at the point of care. At the other extreme are those systems that allow for total manual changes (such as a word processor) at the expense of speed and accessibility. You would be typing or dictating forever. In the middle range you have the templates; you are then forced to select from endless pick-lists, only to find that none of the pick-list options are adequate for your case.

In contrast, your Concept Processor "migrates" from the initial 0,0 point on the graph above, into the top right quadrant within a few days of use, and then slowly continues to evolve further to the right as it improves its knowledge and flexibility.

  • Templates that "Save" (so-called "Intelligent Templates")

You must be careful in recognizing and distinguishing the various ways EMRs save data. During a presentation, a demonstrator might appear to quickly generate a case, and there are some templates that may even save a given diagnosis for future use. With these templates, however, a case can only be saved under a given diagnosis name, later to be recalled for future use as an entire block of boilerplate text. However, you do not evaluate and treat a given diagnosis in a monolithic way, but in fact in a myriad of different manners. So, even this kind of savable or "intelligent" template does not come close to approaching the flexibility, accuracy, and speed of a Concept Processor based on neural network technology, which is constantly learning and improving while you work.

Your "Second Medical Brain"
  • Far more than just a documenter

Praxis Electronic Medical Records (EMR) - Venn diagram representing the elements of the Encounter Note
Venn diagram representing the elements of the Encounter Note. These elements interact with each other in real time to create the note and help you manage your practice.

As we have outlined, the Concept Processor utilizes a neural-network approach to find the right words precisely when they are needed, by learning from your past. Therefore, it is not limited to the standard SOAP-type elements such as history of present illness, objective findings, procedures, or prescriptions. It goes much farther!

Based on critical feedback from hundreds of Praxis users, over many years, it was discovered that the documentation features - as vital as they are - make up only a small part of what the Concept Processor could accomplish within an EMR. In fact, the most exciting element of the Concept Processor is the unique way in which it becomes your helper in automating the many tasks you face every day. By virtue of the Concept Processor, Praxis EMR offers eleven features unavailable in any other application:

  1. Intelligent messaging (agents) that "complete tasks" automatically on your behalf. These messages are generated within your case automatically (based on similar cases you have handled in the past). They are sent to the right people in your clinic either now, or at a preset time in the future. The agents also prompt for feedback after completion, and they know how to file themselves properly in your patients' records for medico-legal protection. As an example, if you want a patient to return for an endoscopy in 6 months, the message will "wake-up" six months from now and alert the right people in your office to contact your patient. Agents can also trigger when certain conditions take place, such as the return of a given patient, or when a chart is reviewed by a certain kind of user (i.e. the dietitian). If the agents are sent to you, they become self-reminders!
    (See technical paper on the Concept Processor for more information of the Praxis agents. Concept Processing Technical Paper)

    Of critical importance is the learning capability of the agent via the Concept Processor. The next time you see the same clinical problem in a different patient, the agent will be there to remind you once again to send it in the same way. In essence you are creating a customized health maintenance engine based on your personal criteria and the needs of your patients. These agents can also be used as clinical practice guidelines (see Clinical Practice Guidelines and Queries) .

  2. An automatic scheduler based on the scheduling of previous patients presenting similar conditions. As soon as you are done with your patient, your scheduler opens up on the exact date needed and for the exact time required - all learned again from your past actions. You or your assistant approve with a click of the mouse and you are done: Your patient has been scheduled instantly!

  3. A separate automatic Health Maintenance Engine linking any of your Procedures and Plan elements including medications, so that they can prompt you to repeat them in the future automatically. When the patient returns to see you, the order is right there on your chart, ready to be activated with a click of the mouse. As in the other cases, this engine learns from previous similar cases.

  4. A unique method for handling recurring patients with multiple chronic complaints. Unlike acute medical problems, when you see chronic follow-up cases, you usually know exactly what's wrong with your patient. Here the Concept Processor simply excels. You are reminded of medications to refill, diagnostic procedures to order, and other tasks which must/should be done for the patient presenting with multiple complaints during this follow up visit. All of this is handled instantly and perfectly by Praxis, always following your personal approach as learned from previous similar cases.

  5. Intelligent flow-charting of labs, medications, vital signs and other clinical parameters, instantly created and customized for each patient and condition. When you see a new patient with a similar condition, the flow charts are instantly created. They take the information from your labs, vital signs, clinical parameters and medications. For example, if you see a patient with Iron Deficient anemia, the flow chart is instantly created and populated with the Hemoglobin levels, the Hematocrits, the Iron levels, the pulses, etc... exactly as you have taught it to do with other similar patients. Each flow chart is learned from a similar one, becoming progressively more powerful.

  6. Pre-SOAP protocols that help your clinic assistants properly prepare your patient prior to the encounter with you, depending on the kind of encounter it is. These protocols also allow the generation of the most appropriate questionnaires, vital signs, medication statuses, and other clinical parameters required for any type of case right before the visit.

  7. Graphic Overlays that learn from the past to show graphic images at the point of care, allowing you to draw on top of them. This is excellent for clinical descriptions, procedure reports, and patient handouts.

  8. External documentation, such as journal articles, instantly appearing linked to your note as you have taught it from similar cases. If you read an interesting article and save it in your computer (as a scanned image or a direct digital save), the next time you see another patient with the same condition, the article link is there, ready to be reviewed!

  9. Integrated Dictation/Transcription that progressively reduces the cost of, and ultimately the need for, this service.

  10. Automatic printing and/or faxing of any form required during the encounter, from the hospital admitting forms, to prescriptions, to department of motor vehicles forms - anything. The recipient of the form will think you had nothing better to do than get an old-fashioned typewriter and fill out all of their forms. But you never had to: Praxis did it all for you instantly!

  11. The most powerful prospective and retrospective query engine in medicine, with a revolutionary approach to Clinical Practice Guidelines and queries that simply cannot be equaled by templates. (See Paper on Practice Guidelines and Queries)

  12. Instant intelligent charging for services based on similar charges in the past for the same type of case and insurance.

In addition to these unique features, many other improvements have been made, such as drug contraindication detection, rapid and automatic classification of incoming scanned documents, HIPAA protection and HIPAA logging.

Most of the above features unique to concept processing are currently a reality in hundreds of clinics and can be seen in our full demo : VIEW FULL PRAXIS DEMO

  • Conclusion: Medicine is an Art as well as a Science

The Concept Processor began as a unique way to help any physician chart extraordinarily quickly using his or her own words. However, over the years, as countless physicians have taken advantage of this unique technology, it was soon discovered that the Concept Processor is far more than just an intelligent charter. It is a "second medical brain" to a provider and can not only do what is required in documentation - accurately, on the fly, and extraordinarily quickly - but also learn from it, therefore speeding it up in the future.

Unfortunately, the industry has taken a more primitive approach based on what appears to be an erroneous premise - that there is one correct way to practice medicine, and that the EMR should basically tell the provider what that one way is, and how to practice it. In this scenario, the EMR would essentially straightjacket the physician user, turning you into a technician.

The computer is meant to liberate, not to oppress. It should advise and not coerce your practice of medicine. It is only with a free text approach, learned from you, that good medicine will continue to evolve. You are your own best teacher and student.

At the same time, we understand that you wish to be kept informed of the current best available practice methods. Concept processing was designed to do this.

Finally, we will always respect your medical expertise. Praxis software development is based on the expertise of all of its users. Thus far, hundreds of physicians in every specialty of medicine have shared their experiences with this amazing technology, and in doing so have directed our way to the future.

Whereas template programming has reached its peak and come up short, Concept Processing technology continues to evolve naturally, empowering physicians and nurses to provide an indispensable value added to medicine. After all, empowering you, the provider, should be the ultimate goal of any Electronic Medical Record.

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