My Neuropsychological Report Writing Workflow: TextExpander, MultiMarkdown Composer 2, et al.

In the past six months I have super-revised my neuropsychological report-writing workflow. I went from using Microsoft Word to the following applications and services. What a difference.

The Tools

MultiMarkdown Composer 2

MultiMarkdown Composer 2 has been my primary text editor for non-code writing for the past few months. I was lucky enough to be a beta-tester and was super impressed with its pedigree right from the start. It’s not like I can’t write a patient report using any other text editor or word processor out there; any one will do the trick. It’s just that I’ve used probably most of them, and I really believe that for me and my personal needs/wants/style, MultiMarkdown Composer 2 gets the job done with all the tools I need just a keystroke away. [1] There’s a lot to love about this application if you use Markdown syntax and find yourself needing the additional features offered by the MultiMarkdown fork. More than almost anything, I just want to write into a plaintext file, but still have a syntax that affords plenty of power for when I need to convert foo.txt to foo.docx, foo.html, or whatever. That’s what MultiMarkdown brings to the table, and MultiMarkdown Composer 2 is the ideal and natural substrate (both syntax and application were produced by the excellent Fletcher Penney).

TextExpander

Having only started using it about six months ago, it is hard to be a relative newcomer to TextExpander and try to say something about it that hasn’t already been said. But here goes, anyway.

I use TextExpander for every single report I write, but it goes a little deeper than that. When I create a blank text file, the first thing I type is either ,skelout or ,skelin, which represent sort of semantic classes for “Report Skeleton: Outpatient” and “Report Skeleton: Inpatient,” respectively. Firing off that snippet gives me all the basic headings of the report, including fields for patient name, date of birth, presenting problems, medical history, and so forth. It also includes a separate snippet, which, depending on whether it’s an out- or inpatient, will give me an appropriate mental status exam paragraph. This is included as a separate expansion since I can use the same mental status template for different patient cohorts. Mental status reporting is something that, while ultimately tailored to each patient, is a highly standard report section across most or all mental health care disciplines.

Dictation

I dictate using any one of three methods, depending on my physical location: (1) my desk at home, (2) my desk at work, or (3) other. “Other” means I’m away from my laptop or that I can’t access it (e.g., while driving). The methods are:

  1. Here, I’m using the built-in dictation that ships with Mac OS 10.8 Mountain Lion.
  2. For this scenario, I’m pairing up Better Touch Tool and BTT Remote. There is no wifi at my office; it’s all Ethernet. To get around this problem I advertise my MacBook Pro as its own network, and connect to it using BTT Remote on my iPhone. All I have to do then is swipe right to expose the BTT keyboard, hit the mic icon, and start dictating.
  3. Here, I am using the iOS application “Drafts.” Drafts is a great application that allows you to capture text quickly, and then export it to any number of apps and/or places. For my reports, I export the note to a file in Dropbox. So, if I’m out on a walk or in my car, I can dictate as much as I can pull from memory about the evaluation, and the text will be ready for me to cut and paste into the patient’s report when I am back in front of my laptop.

Anyone familiar with HIPAA and/or HITECH law will probably balk at these dictation methods. These laws, which outline the how, when, and what of Protected Health Information disclosure, would be seriously violated if I were dictating information that could reasonably identify any of my patients. This is because the dictation solutions I use send whatever I say out to servers, which then pipe back down to the text file. That’s the very short version of what happens, but it’s enough to know that I could be in big trouble if I included too much information. To work around this, I simply alter or exclude all information that could possibly identify a patient. Names and dates are changed, circumstances are rendered vague, and then all of this gets fixed when I finally transfer the report to my university workstation (a Dell PC that’s under the university’s network and control).

Pandoc

At this point, I could use MultiMarkdown Composer’s “Copy Document As -> Rich Text” feature to copy the nearly-completed draft into Microsoft Word (my reports are ultimately required to be in the .docx file type); however, I prefer to use Pandoc from the command line by cd-ing into the report’s directory and running pandoc -o "destination_file.docx" "source_file.txt". This gives me a perfectly formatted Word document right in the directory of the source file.

Finalizing the Report

I transfer the still-de-identified .docx file to my PC workstation via either SFTP or by putting it inside an encrypted disk image on a flash drive. My drives, by the way, are encrypted using the excellent TrueCrypt. Either solution offers an encrypted file transfer, which keeps me all HIPAA-compliant like. Once it’s there, it takes about five minutes to replace the placeholder information with the patient’s actual information. Done.

The End Result of Changing My Workflow

In simplest terms, the end result is that my reports now take about an hour-and-a-half to write, versus the previous timeframe of three to four hours. I find the biggest difference came from dictating instead of typing. Not only does it keep me from editing sentences on-the-fly, which I’m given to if typing, but it also yields a more natural sounding, human narrative, which I feel is a critical element often missing from such reports. We are dealing with real people, after all, and not some anonymous case.

As with all workflows, this is a solution that works for me. Your mileage may vary, especially since this is something that I devised precisely for writing patient reports. That being said, it would not at all be hard to adapt it to other writing tasks, and could be worth it if you find yourself wanting to always work everywhere you are because you’re a complete maniac like I am utterly dedicated to your craft.


  1. I kind of cheated here, since I put keyboard shortcuts wherever they don’t already exist. Thank you Quicksilver and Better Touch Tool.  ↩

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