Familiarizing Yourself with Primum® CCS Software

There is a set of options you will have while dealing with your patient. You need to exercise these options in administering appropriate healthcare. Following is the list of options you will have. These options make CCS interactive and this is like talking to the patient and providing your patient with healthcare. We strongly urge you to take Primum® CCS tutorial to get better oriented to CCS. It is important to understand the concept of “Real Time” and “Simulated Time” while dealing with your patient.

Real Time: This is the time that has elapsed between your initiating patient management and the present. For a given case, there will be a maximum amount of time allowed. After that time limit, the case will come to an end whether or not you have managed the patient appropriately. At times, the case may come to an end before the maximum real time assigned is over. This may happen if you have demonstrated optimal care or even when your management is deemed detrimental to the patient.

Simulated Time: This is the time you would have had taken in real life to manage the patient. You primarily control simulated time by advancing the clock and so going forwards in time. This may vary from a couple of minutes to many months.

1. Interval History or Physical Examination

This allows you to perform

• Complete physical examination or
• Pertinent physical examination and/or
• Interval Examination at any time to periodically assess the patient’s condition.

After you make your choice of examination/ assessment, you will be shown how much time it is going to take to do what you have ordered. Before it does so, you will need to confirm your move. You will have to decide about the acuity of the condition because once you decide to order what you have chosen, the clock will advance by that amount of “simulated time”. This would mean that you have done nothing therapeutic in this time. For instance if the clinical presentation and vitals strongly suggest that the patient has unstable angina, it would not be prudent to perform a complete physical examination (totaling fifteen minutes) before you start therapeutic intervention. Likewise for a patient with mild fever or joint pains you do not want to start right away with high doses of analgesics without performing an adequate physical examination.  Choosing complete physical examination should be appropriate in ambulatory setting, when you have ample time and patient does not present acutely. At times, you may want to skip the entire physical examination and go directly to order entry to ‘stabilize’ the patient first, before examining the patient (e.g. A patient who is actively seizing). It is your judgment call. Interval examinations should be done periodically. It is like asking your patient: “How do you feel?” It is important to assess your patient periodically, so as to know whether or not your treatment is working. If the patient is admitted to the wards, remember to do physical examination either complete or at least pertinent organ systems everyday. It is like ‘rounding’ on your patient everyday. We recommend limiting yourself to relevant organ systems only. If any other developments occur, the system will alert you.

2. Write Orders or Review Chart

This is the option you will be using most often and it is essential to become familiar with this. This helps you perform most things. Below is the list of features available with this option.

• Order Sheet
• Progress Notes
• Vital Signs
• Lab reports
• Imaging
• Other Tests
• Treatment Record

This is like your secretary who will take your orders, lab technician who will perform tests, phlebotomist, your nursing aide, your record keeper, your medico legal section and hence forms the most important of all options. It is here that you play the role of being a doctor. While ordering you will use the “Order Sheet” and type your orders. CCS software is designed in a remarkable way and recognizes a wide range of commands. When you fail to type the correct spelling it offers you close matches and you can go and select that. You must provide at least the first three letters of your instructions/ orders for the software to understand. Generally it will not take any instructions that are less than three characters. For vital signs, you can type “vs”. You can write as many orders as you want at any given time with certain exceptions as detailed below.

For all the orders you have placed, the Primum® software will ask you to choose from other resembling choices, if any and will ask you about the route of administration and frequency. You DO NOT have to worry about their DOSAGES as the software assumes that you have chosen the appropriate dosage to be given. After you have made your choices and confirmed your orders, you will be shown the list of your orders along with route, frequency, the time you ordered it and in the case of a test, the time the results will be made available. This helps you to schedule the patient’s appointments accordingly (you probably want to see the patient again when you have got the results).

While it is time-effective to write most tests at the same time, some combinations have to be ordered separately. Any test or instruction that will require advancing the clock can only be ordered one at a time. For instance you need to separately order for “ smoking cessation”, “ alcohol abstinence”, “arthrocentesis”, “lumbar puncture”, “ laryngoscopy” etc. These cannot all be ordered at the same time, as these interventions require advancing time. You will have a fairly good idea about this once you start using the “order sheet”. However even if you do choose these instructions at the same time, software will prompt you to make these choices separately and one at a time. Medications and labs can be ordered together.

If you want to discontinue or cancel any order you just need to click on that option on the order sheet and accept the cancel-order.

If you want to give a drug, first as a bolus and then continuously, like Insulin in DKA, you will first need to order “one time/ bolus” followed by a repeat order and this time as “continuous”.

You can also seek specialist consultation if you deem it appropriate. Normally such help is of little use. Specialists usually will not be of great help as the exam is designed to assess “Your” capability. However, if surgery is required, you can seek surgical consultation and surgery will be scheduled as it appears okay to the Primum. However you will need to keep treating the patient until surgery takes place or the case comes to an end.   

You can follow your patient’s progress by going back to “Progress Notes” . This feature allows you to have a snapshot of initial presentation, interval examinations, physical examinations and various consults done previously. Generally, you do not need to use this feature often. At times, you may want to go back and look at the progress notes.

The software keeps a record of all the previous “Vital Signs”. These are available for your review by clicking on this option. Various test results “Lab Results”, “Imaging” and “Other tests” may be obtained and reviewed by clicking on these tabs. “Treatment Record” is your medex and has a record of all the orders that you discontinued, gave as one time bolus or cancelled.

3.Obtain results or See patient later

This feature allows you to advance the clock by a given length of time. This facilitates you to view the results of previously ordered tests. Remember, once you have advanced the clock by either requesting a lab result or by scheduling the patient, you have gone ahead in the simulated time and CANNOT go back in time again. If you think any intervention needs to be done prior to advancing, do it now. This feature also allows you to give an appointment to your patient. Be especially careful while using this feature.

4.Change Location

This feature allows you to change location of the patient. Available options include

• Emergency Department
• Office
• Ward
• Intensive Care Unit
• Home

As you advance in a case, based on patient’s progress, you may want to change the location.

A clinical encounter may abruptly come to an end at any time and in any situation. Before you exit the case, time permitting, you will be asked to put in your final orders (you may put some orders or cancel existing orders) and primary diagnosis. You will reach “End of Case” screen once maximum allowed time for that case is over and in some situations, you may reach “End of Case” screen before maximum time is reached. If you have offered optimal care or your care is detrimental to patient, the case is likely to come to an end. Coming to an end does not mean that you have adequately managed the case or you have sub optimally managed the case. If you are comfortable with your management, you may reassure yourself. Just as in real life, the patient may not improve in spite of adequate and appropriate care. As long as you are managing the case well, that is all that matters. Likewise, a patient may improve even after sub optimal or no care. Improvement on interval examination generally reflects good care. Whatever you do, the software will be courteous enough to ‘Thank You’ for taking care of the patient. Performance on one case in no way affects your next case. Do not get discouraged if the case suddenly comes to an end! Regardless of how you managed the previous case, start the next case afresh.

Test Taking Strategies and Tips:

The CCS software is exceptionally designed. The patients in case simulations behave in a certain way. It is worth knowing about some salient features

1. Patients in CCS are very compliant with their medications, follow-ups and lifestyle and dietary modifications.
2. CCS has already taken consents for you. If for any procedure or intervention, the patient declines to consent, the software will let you know. For minors, consent has been taken from parents or legal guardians.
3. CCS dispenses optimal dosage of any medications you order. You need not worry about the dosages of various medicines
4. If you want to taper any medications, CCS will do this by itself. You just need to cancel the order and CCS will appropriately taper the medication. If you want to restart, make an entry in order sheet.
5. When starting a patient on a medication with a known and common side effect, watch out for it. If you started a patient on amiodarone, obtain thyroid function tests; if you started Dilantin, monitor LFTs; if starting on vancomycin, gentamicin, ifosfamide, keep an eye for renal function. Monitor CBC, if using heparin, look at PT/INR if using coumadin.
6. On a separate sheet, write down the age, sex, and social habits, presenting complaints of the patient. This will give you a snapshot and help you to counsel appropriately. Age, sex and co morbidities will help you with vaccinations and screening tests. You are also judged on how efficiently and effectively you use your resources (time and money).
7. Healthcare maintenance is a must. Vaccinations are important. Screening tests include Pap smear, lipid profile, colonoscopy, fecal occult blood testing, mammography, breast examination, rectal examination and others should be offered to appropriate patients.
8. Counseling is essential. Alcohol abstinence, smoking cessation, safe sex, partner education, medical compliance, weight loss, seat belt safety, suicide contract, breast self examination, home glucose monitoring, dietary compliance are some examples. You need not necessarily counsel every patient about everything. As long as you have counseled more important aspects, it is fine. Counseling is important but not at the expense of more important acute or appropriate management. Remember counseling is quick and easy to do and earns you little albeit valuable points in the scoring system.
9. Order only relevant labs. Order entry should be appropriate, chronological and relevant. More important tests should be ordered first. Cost is an important concern. While you need to be selective when requesting labs, do not order blood work unnecessarily. Try to avoid pricking the patient repeatedly. (I am not sure if CCS adds on to already available specimen or pricks the patient every time you request a lab!).
10. Scoring system of CCS is confidential and not known to us. Based on what we understand, you are given high scores, low scores or no scores based on your interventions. You may even be penalized for detrimental orders. As a model of our understanding, let us take an example.

“ A 50 year old Dutch woman comes in to your office with chief complaints of feeling hot, loosing weight and palpitations”. Diagnosis: Hyperthyroidism.

High positive credit: Complete physical examination, EKG, TSH,

Low positive credit: CBC, ESR, smoking cessation, alcohol abstinence, breast self-examination, colonoscopy

No credit, no penalty: Lifestyle modification, safe sex practice.

Low penalty: prednisone, amiodarone, cyproheptadine, and limited physical examination.

High penalty: Lumbar puncture, brain biopsy, and thoracentesis

Any intervention may be inappropriate at one time and may make you loose points. The same intervention in a different situation may earn you good score. If you ordered radioactive iodine on the first interaction with this patient, without fully assessing the case, you will loose points. If you order it after diagnosing the patient as being hyperthyroid and ensuring that there are no contraindications to RAI, you will gain valuable points. Hence, one must not be too hasty in ordering tests unnecessarily. Ordering a vast array of unnecessary tests may even cost you points (and costs you real time in the exam). It is a good thought to advise your patient about safe driving. However, this should not be the first order you place, as it is unlikely to be the most important management to institute for your patient.

The scoring may range from a high positive credit to a high penalty. Any given order may be viewed as being scored by the CCS in the following manner:

• High positive credit: You must make this order entry.

Excellent! That’s what is expected! . This case requires this intervention. Such an order should be done in timely manner and is critical in management.

• Low positive credit: You should make this order entry.

Good! That is required. This will help you manage this case. This intervention is appropriate and most physicians would do this. Nevertheless, this test is not as important as some other tests, which need to be ordered earlier.

• No credit, no penalty: You may or may not make this order entry.

Well! That’s fine. Even if you did not order this, it would not significantly change things. Anyways, it does not harm the patient. But remember, in doing this you are wasting precious time, and you don’t have that luxury in this exam.

• Low penalty: You should have avoided this order entry.

Nay! You did not need this. You should have preferably avoided this. This inappropriately costs time and money. May also harm the patient.

• High penalty: You must not make this order entry.

Boy! You’re busted! Now, you are harming the patient. At least don’t kill your patient. This is considered highly inappropriate care. In real life, you would need to see your lawyer!

Here is another example:

“A 67 year old Caucasian man is brought in to the Emergency Room complaining of sudden onset of shortness of breath and chest pain.”

High positive credit: Limited physical examination, EKG, ABG, oxygen, CXR, thoracentesis (after diagnosing pneumothorax).

Low positive credit: CBC, ESR, CT scan,

No credit, no penalty: CBC, type and cross

Low penalty: TSH, ESR, weight loss counseling, medical alert bracelet prednisone, amiodarone, cyproheptadine

High penalty: Complete physical examination, stress testing, x-ray of extremities,

We have attempted to provide as much important details as we could. For any updates about the examination and any changes in pattern, format and contents of the examination, we urge you to visit the official website of USMLE TM and FSMB TM. We hope we have been able to help you in preparing for Primum® Computer based Clinical Simulations section of the examination.