Vitera Intergy EHR New System Features, Version 9.00

Transcription

1 Vitera Intergy EHR New System Features, Version 9.00

2 Vitera Intergy EHR 9.00 New System Features Confidential This document and the information it contains are the confidential information of Vitera Healthcare Solutions. Neither this document nor the information it contains may be disclosed to any third party or reproduced, in whole or in part, without the express prior written consent of Vitera. Vitera reserves the right to change, without notice, product offerings, product specifications and the information in this document. This document supersedes any prior document containing similar subject matter with regard to the descriptions of features and functionality of product offerings. You may receive supplements to this document based on changes that may occur in the product. This document may not be reproduced in any form without prior written permission from Vitera Vitera Healthcare Solutions, LLC. All rights reserved. Vitera, the Vitera logo, Intergy, and Intergy EHR are registered trademarks or trademarks of Vitera Healthcare Solutions, LLC., or its affiliated entities. All other trademarks are the property of their respective owners. MSO# /22/2013 For more information about Vitera, please contact us on the Web at If you have any feedback on this document, or would like to request changes, please send an to In your message, please include the title and date of the document (listed above) as well as any other information you feel will help with your suggestion West Boy Scout Blvd., Suite 800 Tampa, FL

3 Table of Contents Version 9.00 New System Features Intergy EHR Basics Selecting Patients Closing the Current Patient New Select Diagnosis Dialog Box Prescription Information Added to Chart List Pop-Up Care Team Provider Roles Renamed Care Team Chart Displaying Specimens for Lab Test Results Including Images when Printing the Patient s Chart Patient Education and Provider Reference Information Renaming Zip Files When Exporting a Patient s Full Chart Patient Internet Access Status Patient Care Program Preferred Communication Method Encounter Note E&M Calculator Enhancement SNOMED Code Compatibility Voiding Vital Signs in an Encounter Note Health Information Exchange Document List Views for the Exchange Tab Enhanced CCD Import Functionality Generating an Exchange Document Exchange Documents as Secure Message Attachments Exporting an Exchange Document to an HIE Printing an Exchange Document Health Reminders Selecting an ICD-10 Code for a Diagnosis on the Add to Orders Tab Selecting an ICD-10 Code for a Diagnosis on the Health Reminders Window Vitera Intergy EHR 9.00 New System Features i

4 ICD ICD Code Overview ICD-10 Readiness Setup Setting Up Intergy EHR for ICD Using ICD-9 and ICD-10 Diagnosis Codes Converting Diagnoses to Findings ICD-10 to ICD-9 Mapping Rx Summary Immunizations Immunity Flag on Immunizations Page New Immunization Fields Recording Immunization History Information Source Selecting ICD-10 Codes When Administering Immunizations VFC Eligibility Vaccine Information Statements Labs Test Groups Orders/Charges Selecting an ICD-10 Code for a Diagnosis in Orders/Charges Using Macros with ICD-10 Codes Practice Portal Activity on Patient Health Information Recorded and Provided Customize Practice Portal Exchange Documents Direct Messaging Now Supported Patient Cell Phone Support for New Patient Registration Secure Messages Predictive Order Management Selecting an ICD-10 Code for an Order or Diagnosis on the POM Tab Prescriptions Medication Reconciliation Recording Formulary Checks Problems Care Plan Copying Assessments to the Problems List Copying Diagnoses to the Problems List Converting Problems to Findings Including Voided Problems in the Problem List ii Vitera Intergy EHR 9.00 New System Features

5 Quick Text Personal Quick Text Added Tasks Changes to Cardiology Result Tasks Sending Secure Messages When Working a Lab Results Review Task Visit Note User Preferences Default Procedure/Diagnosis Favorites List Vitals Vital Signs Now Displayed in Your Preferred Units of Measure Vitera Intergy EHR 9.00 New System Features iii

6 Vitera Intergy EHR Version 9.00 New System Features The Vitera Intergy EHR 9.00 New System Features document summarizes the new features and enhancements of Vitera Intergy EHR, version The purpose of this document is to guide you through a high-level set of the most meaningful changes, including the primary purpose of each new feature and enhancement, and how each can be used. Pro Tip How To Search the NSF Effectively When searching this document for information about a feature, you can first scan the Table of Contents. Topics are grouped into sections based on the area of the system they affect, and the sections are listed alphabetically. Also, when viewing this document online, be sure to make use of the handy Search tool in Adobe enter your search term here Tools Comment Share Reader. For example, if you are looking for topics related to Chart, enter chart in the search field. Adobe Reader will find all instances of your search term in the document, which allows you to quickly browse the sections that interest you. Vitera Intergy EHR Version 9.00 New System chart use the forward and back arrows to find other instances of your search term The Vitera Intergy EHR 9.00 New System Features document summarizes the new features You can access the Search tool either by pressing CTRL F, or from the Adobe Reader menu by selecting Edit, then Find. Vitera Intergy EHR 9.00 New System Features 1

7 Intergy EHR Basics Intergy EHR Basics This section describes the enhancements made to Chart. Selecting Patients Closing the Current Patient New Select Diagnosis Dialog Box Prescription Information Added to Chart List Pop-Up 2 Vitera Intergy EHR 9.00 New System Features

8 Intergy EHR Basics Selecting Patients Selecting Patients In Chart, the Patient Search (magnifying glass) button has been moved beside the Patient tab for consistency and ease of access. Previously, the Patient Search button was on the right side of the window. With this change, you now have the following options for switching from the currently-selected patient to another patient: Click the Patient Search button to open the Select Patient dialog box; Click the drop-down menu under the patient s name in the patient header, which allows you to select a recent patient or open the Select Patient dialog box; or Click the patient s chart tab in the Patient Queue. The following illustration shows the location of each method of switching from one patient to another in Chart. Intergy EHR Madison Medical Center P.A. Appointments for: David Ford My Day Patient Murphy, Sham... 9:10A Asthma Abner, Darlene E 1:10P Allergy Carlson, Sharo... 3:30P Follow-up Visit Aaron, Alice B 4:50P Chest Pain Allergies Info Reminders Carlson, Sh.... select the magnifying glass 03/12/1934 button... 79y F Clin Hx JUNE Appts Chg Hx Diag Hx Select Patient... Abner, Darlene E. Medications GlipiZIDE-MetFORMIN... 07/07/ y 10m F twice a day for 30 days. 1 refill Ford, David E. MD Abner, Carla D. Coumadin 2.5 MG TABS 11/22/ y 10m F 07/31/ /30/2007 League, Claire E. Actos TABS 09/30/ y F 07/31/ /30/2007 Aaron, Alice B.. Actos TABS 07/31/ /30/ /11/ y F Chest Pain at 4:50 PM Actos TABS Murphy, Eileen W. 07Murphy - Eileen007 06/03/ y F Well Baby Check Ford, David E. MD All...or the drop-down arrow to search for another patient 01/08/ days left 01/08/ /17/2012 Scheduled 10/17/ /17/2012 Scheduled 11/08/2012 select a patient s chart tab Chart Flowsheets Note Orders/Charges to switch to that OB patient Chart SPLIT Problems Carlson, Sharon A. 03/12/ y F SSN: xxx-xx-5639 Allergies Ragweed COMN MIGRNE WO NTRC MGRN Note: You can still use the Select Patient option in the Intergy EHR menu on the title bar as well. You have reached the end of the Selecting Patients topic. Vitera Intergy EHR 9.00 New System Features 3

9 Intergy EHR Basics Closing the Current Patient Closing the Current Patient When you finish working with the records for a patient in Intergy EHR, you can close that patient s chart and return to the My Day page. The workflow below describes how to close the current patient. Workflow: Closing the Current Patient 1. Hover the mouse pointer over the patient s name in the patient header. The Close Patient button displays to the right of the patient s name. 2. Select the Close Patient button. The patient s records are closed, and Intergy EHR returns you to the My Day page. Intergy EHR Madison Medical Center P.A. Aiken, Isabella Dr. Close Patient button My Day Patient Carlson, Steven W. 08/16/ y M Info Chart SSN: xxx-xx-3434 Patient: Close Patient 10 Phone: (916) Chart: 10 Tasks Send Secure Message More You have reached the end of the Closing the Current Patient topic. 4 Vitera Intergy EHR 9.00 New System Features

10 Intergy EHR Basics New Select Diagnosis Dialog Box New Select Diagnosis Dialog Box The new Select Diagnosis dialog box has been added in the Intergy and Intergy EHR systems. This dialog box provides you with enhanced diagnosis search and selection options. Additionally, the new dialog box provides you with the ability to work with ICD-9 and ICD-10 diagnosis codes. The new dialog box replaces the existing Select Diagnosis dialog box in the Intergy and Intergy EHR systems. Previously, the Intergy and Intergy EHR systems had different Select Diagnosis dialog boxes. Now, both the Intergy and Intergy EHR systems have the same dialog box. Note: Some Select Diagnosis dialog boxes also allow you to select the Findings or ICD tab. Whether the Findings and ICD tabs display depends upon the area of the system in which you are working, and whether the tabs are relevant to the diagnosis search. For more information, see Selecting ICD-9 and ICD-10 Codes for Problems and Findings on page 62. The workflow below describes how to use the new Select Diagnosis dialog box. Vitera Intergy EHR 9.00 New System Features 5

11 Intergy EHR Basics New Select Diagnosis Dialog Box Workflow: Using the New Select Diagnosis Dialog Box 1. Specify the set of diagnoses that you want to include in the diagnosis list. You can select whether to list all diagnoses, patient diagnoses, or favorite diagnoses by using the All, Patient, and Favorite buttons located in the upper portion of the dialog above the list of diagnoses. To list All diagnoses Diagnoses that have been used for the current patient Favorite diagnoses for the user who is currently logged in Do this Select the All button. All diagnosis codes in the Intergy system are displayed. Select the Patient button. The diagnoses that have been used previously for the patient are displayed. Select the Favorites button. You can select whether to list all favorites or the favorite diagnoses in a specific category, such as blood diseases or circulatory system. You can list a category if favorites diagnoses by clicking the down arrow on the right side of the button for all or a category diagnoses. The list that is displayed is based on the setting of the Default Procedure/Diagnosis Favorites List user preference. Favorite diagnoses lists are maintained under Favorite Procedure/Diagnosis List Maintenance in Intergy Practice Administration. The list displays the description and ICD diagnosis code for each diagnosis. Either ICD-9 or ICD-10 codes will be displayed, based on the ICD-10 Diagnosis Code Effective Date System Parameter and the date of service or encounter date in context when the dialog is called. For example, if the current date is 06/01/2013 and the ICD-10-Diagnosis Code Effective Date parameter value is 10/01/2014, the Select Diagnosis dialog diagnosis list will display ICD-9 diagnosis descriptions and codes because the current date is prior to the ICD-10 effective date. 2. Sort the diagnoses in the Select Diagnosis dialog box. To sort by diagnosis description, click the Description column heading. To sort by ICD diagnosis code, click the ICD column heading (ICD-9 or ICD-10). 3. Search for a diagnosis in the Select Diagnosis dialog box. After you have set up a list of diagnoses, you can shorten or limit the list of diagnoses and search for a diagnosis. You can shorten the list by typing numbers, letters, or words from a diagnosis code or description in the Search diagnoses text box located in the upper left portion of the dialog box. The more characters you type, the shorter the list becomes. The matching characters of the diagnoses listed for the search are highlighted. If no diagnoses match the search, the message No matches found for is displayed in the list area. To see the full list, clear the search field. 6 Vitera Intergy EHR 9.00 New System Features

12 Intergy EHR Basics New Select Diagnosis Dialog Box If the window is in ICD-10 mode, you can search matching ICD-9 codes by entering 9- before the code you are searching for. For example, entering will search for ICD-9 code Additionally, if the window is in ICD-10 mode and your search returns no matches, an option to search the entire ICD-10 master list is displayed below the message. You can click the Search the entire ICD-10 master list link to perform the search. Note that the ICD-10 Master List search filter is displayed above the list only after search of the ICD-10 master list was performed for the current work session in the window. If a matching diagnosis is found, the diagnosis is displayed. If the diagnosis is selected, the diagnosis is added to the list for the Select Diagnosis dialog box. 4. Select the diagnosis you want by clicking the row of the diagnosis. The Select Diagnosis dialog box closes and the diagnosis code is displayed in the field displays in the field of the window for which you were selecting a diagnosis. You have reached the end of the New Select Diagnosis Dialog Box topic. Vitera Intergy EHR 9.00 New System Features 7

13 Intergy EHR Basics Prescription Information Added to Chart List Pop-Up Prescription Information Added to Chart List Pop-Up When viewing prescription information in the Chart List, you now can see how a prescription was issued in the informational pop-up window that appears when you hover the mouse pointer over the prescription. For example, you can see whether the prescription was handwritten, printed, or issued electronically. The following illustration shows where the information about how the prescription was issued displays in the pop-up: Problems Admin Rx Meds Vitals Docs Labs Immun. Imaging Darvocet-N MG TABS 04/02/ /12/2012 Lapsed Lipitor 20 MG TABS 04/02/ /22/2012 Lipitor 20 MG TABS Amoxicillin 500 MG TABS 03/25/ /04/2011 Lapsed Crestor 10 MG TABS 03/25/ /02/2012 Darvocet-N MG TABS 03/25/ /02/2012 Naprosyn 500 MG TABS 03/25/ /24/2011 Lipitor 20 MG TABS 03/21/ /02/2012 Amoxicillin 500 MG TABS 02/17/ /18/2011 Vioxx 25 MG TABS 04/08/ /25/2011 Patient Encounter - Ford, David E. MD General Check-up - Ford, David E. MD mouse pointer hovering over this prescription No images since last appointment Reported Amoxicillin 500 MG TABS Recent e Images Clinical History Discontinued Dx: ROTATOR CUFF SYND NOS Qty: 40 days: 10 refills: 0 sig: 1 every 6 hours Discontinued Issued Via: Hand Written Provider: Ford, David E. MD Discontinued Pharmacy: Sunshine Drugs Information about how the Discontinued Take 1 tablet every 6 hours with a full glass of water prescription was issued Discontinued Discontinued Lapsed s Section You have reached the end of the Prescription Information Added to Chart List Pop-Up topic. 8 Vitera Intergy EHR 9.00 New System Features

14 Care Team Prescription Information Added to Chart List Pop-Up Care Team This section describes the enhancements made to Care Teams, which were formerly referred to as Provider Roles. Provider Roles Renamed Care Team Vitera Intergy EHR 9.00 New System Features 9

15 Care Team Provider Roles Renamed Care Team Provider Roles Renamed Care Team In version 9.00 of Intergy EHR, Provider Roles have been renamed Care Team. Following is a review of Care Teams in Intergy EHR. The Care Team page displays a list of providers associated with the patient s care and specifies each provider s role as associated with the care of the patient. For example, in addition to a primary care provider, patients may have providers assigned to their care for specific conditions or procedures, such as surgery and gastroenterology. My Day Clin Hx Allergies Info Reminders JUNE Appts Chg Hx Patient Abner, Carl... 05/08/ y F SSN: xxx-xx-0206 Phone: (916) abnerc@e4health.com PROBLEMS Asthma URIN TRACT INFECTION NOS ALLERGIES Latex MEDICATIONS None Patient: 1 Chart: 1 More No appointments for the selected doctor and date Chart Flowsheets Note Orders/Charges OB Chart SPLIT Provider Bennett, Joel W. CRNA Johnson, Katrina L. MD Morris, Thomas J. Specialty Anesthesiology Family Practice General Surgery Office # (916) (916) (916) Care Team: Carla D. Abner Mobile # Care Team for patient Carla Abner Comments Diag Hx JUNE Recalls Tasks APPOINTMENTS NO UPCOMING APPOINTMENTS RECENT Asthma Allergy Allergy Discuss Results Abdominal Pain 10/25/ /19/ /05/ /03/ /16/2011 Problems Admin Rx INSURANCE Anaheim Managed Health PHARMACY No Default Pharmacy Vitals Docs Meds OTHER INFO Account & Guarantor Info Advance Directives Patient Alerts and Notes Patient on Account Care Team Rx Benefit Plans Sliding Fee Labs The Care Team List displays the following information: the name of the provider, the specialty of each provider who is caring for the patient, the office phone number and the mobile phone number of the provider, any comments regarding the provider and his or her role in the patient's care (for example, noting that the provider is a referring or consulting physician), the practice user who last updated the care team information (automatically updated by the system based on the current user logon), and 10 Vitera Intergy EHR 9.00 New System Features

16 Care Team Provider Roles Renamed Care Team the date the care team information was last updated (automatically updated by the system based on the system date). You have reached the end of the Provider Roles Renamed Care Team topic. Vitera Intergy EHR 9.00 New System Features 11

17 Chart Provider Roles Renamed Care Team Chart This section describes the enhancements made to Chart. Displaying Specimens for Lab Test Results Patient Education and Provider Reference Information Renaming Zip Files When Exporting a Patient s Full Chart Patient Internet Access Status Patient Care Program Preferred Communication Method Including Images when Printing the Patient s Chart 12 Vitera Intergy EHR 9.00 New System Features

18 Chart Displaying Specimens for Lab Test Results Displaying Specimens for Lab Test Results In the Labs list in Chart, if specimen information is available for a lab result, the specimen information will now be included in the lab result information in the hover. Additionally, when you display a lab test in the Details view, if specimen information is available for a lab test result, the indicator Comments is now displayed as a blue hypertext link on the right side of the lab test name that is located above the Component list. You can view the specimen information in the lab test in the Lab Test Comments dialog box by clicking the Comments hypertext link. You have reached the end of the Displaying Specimens for Lab Test Results topic. Vitera Intergy EHR 9.00 New System Features 13

19 Chart Including Images when Printing the Patient s Chart Including Images when Printing the Patient s Chart All documents and images are now included when you print a patient s chart. In addition, all the chart images are printed in a single PDF file, rather than individually, which makes printing charts with many images easier and more efficient. Previously, images were not included as part of the print job, and each document was a separate print job. The only thing necessary to combine chart images into a single PDF file is to have the Microsoft XPS Document Writer installed as a printer on your system. Once you have done this, then the images are automatically combined into one PDF and printed on whichever printer you select. You do not need to perform any special steps while printing the chart. If the Microsoft XPS Document Writer is not installed on your system, the chart images will continue to be printed individually on the printer you select. The workflow below describes how to print a patient s chart images as a single PDF file. Workflow: Printing a Patient s Chart Images as a Single PDF File 1. Verify that the Microsoft XPS Document Writer is installed as a printer on your system. 2. Open the Chart window and select the patient for whom you want to print chart data. 3. From the Intergy EHR menu, select Print Patient Chart. The Print Patient Chart dialog box opens, through which you can specify which patient chart data should be included in the printout. 14 Vitera Intergy EHR 9.00 New System Features

20 Chart Including Images when Printing the Patient s Chart Note: When you select a printer, you do not need to select the Microsoft XPS Document Writer in order to print the images in a single PDF file. The Microsoft XPS Document Writer only needs to be installed. The images will automatically be combined into a single PDF file, regardless of which printer you select. 4. Continue making selections and printing the patient s chart as you normally would. You have reached the end of the Including Images when Printing the Patient s Chart topic. Vitera Intergy EHR 9.00 New System Features 15

21 Chart Patient Education and Provider Reference Information Patient Education and Provider Reference Information From Chart you can now access and display patient education and patient-specific provider referential information from specific medications, problems, and lab results that have been recorded for a patient. You can access the information by using the new right-click options and buttons that have been added in Chart. For example, in Chart you can access patient education resources for a medication from the following locations: Location Chart Tab Info chart list Meds chart list A selected medication Description In the Patient Summary, locate the Medications section, right-click on the medication for which you want to access information, and select Patient Education from the pop-up menu that displays. In the chart lists on the left side, select the Info chart tab to display the Info chart list, locate the Medications section, right-click on the medication for which you want access information, and select Patient Education from the pop-up menu that displays. In the chart list on the left side, select the Meds chart tab to display the Meds chart list, locate the medication for which you want access information, right-click on the medication, and select Patient Education from the pop-up menu that displays. Select a medication in the Patient Summary, the Info chart list, or the Meds chart list. The medication details display and the Patient Education button is available. Select the Patient Education button. Patient education When you access patient education resources for a lab component result, a web page of information about the lab component result is displayed. The information that is displayed is based on the current patient s demographic information, such as age, gender, and language.the web page can be viewed, printed, and provided to the patient. Provider reference information When you access provider education resources, a web page of diagnostic or therapeutic information is displayed. The web page can be viewed and printed. The provider referential options are available to users who have been permitted security access for Health Management in Users and Security in the Intergy system. Patient Education/Provider Reference information website The website that displays the provider reference information and patient education information is based on the URL that is specified as the value of the new Patient Education/ Reference Information Website Address system/practice parameter. The URL value for the 16 Vitera Intergy EHR 9.00 New System Features

22 Chart Patient Education and Provider Reference Information parameter can be set in System Configuration in System Administration and Practice Configuration in Practice Administration. You have reached the end of the Patient Education and Provider Reference Information topic. Vitera Intergy EHR 9.00 New System Features 17

23 Chart Renaming Zip Files When Exporting a Patient s Full Chart Renaming Zip Files When Exporting a Patient s Full Chart When you export a patient s full chart to a file archive (.zip file), the default naming convention of zip archive file is Last_First_FullChart.zip, where Last is the patient s last name and First is the patient s first name. For example: Carlson_Steven_FullChart.zip. With this enhancement, you now can change the default name of the zip file during the export process. For example, if you prefer to include the current date in the file name, you could rename it Carlson_Steven_FullChart zip. Note: Images and voided documents in the patient chart are not included in the zip archive file. The workflow below describes how to export a patient s full chart, and how to change the name of the zip file in the process. You can find the enhancement described above in the Zip File field in step 3 of the workflow. Workflow: Exporting a Patient s Full Chart to an Archive File 1. Select the patient whose chart you want to export. 2. From the Intergy EHR menu, select Tools and then select Export Full Chart. The Export Full Chart dialog box displays. 3. Make entries in the following fields: Field Zip File Description Specify the folder and file name where you want to save the exported archive file. The location can be the path to a directory on your computer or network (such as c:\exportedcharts), or it can be external storage media (such as a flash drive or DVD). The default file name is created as described above. However, you can rename the file if you want. The default file path is the one from the last successful chart export. For example, if the last successful chart export was to the c:\chartexport directory, that same file path is used as the default the next time you perform a chart export on the same workstation. 18 Vitera Intergy EHR 9.00 New System Features

24 Chart Renaming Zip Files When Exporting a Patient s Full Chart Field Zip File Password Protection Password Description Specify whether you want the exported archive file to be protected with a password. If you password-protect the archive file, anyone who wants to open the file will have to enter the password. To password-protect the archive file, check this box, then type the password in the Password field. If you do not want to password-protect the archive file, leave this box unchecked. Type the password to be used for opening the exported archive file containing the full patient chart. Note: This field is only available if the Zip File Password Protection box is checked. 4. Select the Export button to start the export process. A progress bar is displayed on the Export Full Chart dialog box. The exported files are then archived and the zip archive file is placed in the specified folder. When processing is completed, an information window opens, indicating the full path name of the zip file and confirming the password, if one was entered. 5. Select the OK button to close the message box and the Export Full Chart dialog box. You have reached the end of the Renaming Zip Files When Exporting a Patient s Full Chart topic. Vitera Intergy EHR 9.00 New System Features 19

25 Chart Patient Internet Access Status Patient Internet Access Status You can now view the status of whether a patient has access to use the internet. The status provides information about whether the patient has access to the internet for the ability to view, download, or transmit his or her health information online. The new Patient Internet Access field has been added to Chart (Patient Demographics section). (Y)es Indicates that the patient has internet access. (N)o Indicates that the patient does not have internet access. Additionally, the new Internet Access field has been added in the Intergy system in Patient Registration (Contact Information page), Patient Information (Personal page, Contacts tab) and Person Maintenance. You can set the patient internet access status when you are registering a patient, editing patient information, and adding or editing person information in the Intergy system. You can select one of the following options: (Y)es Indicates that the patient does have internet access. (N)o Indicates that the patient does not have internet access. The field is shipped with a default value of (Y)es. You have reached the end of the Patient Internet Access Status topic. 20 Vitera Intergy EHR 9.00 New System Features

26 Chart Patient Care Program Patient Care Program Using the Care Program section of Chart, you can now assign a risk level to selected patients, which allows you to use Practice Analytics to report on patients by risk level and care program, such as ACO. The Care Program section has been moved higher up on the Patient Info List. In addition, a similar Care Program section now is located in the patient banner. Both Care Program sections list the codes of the care programs in which the patient is included, as well as the risk level assigned to the patient. Risk levels range from 1 (lowest), indicated by a green icon, to 6 (highest), indicated by a red icon. If no care program has been assigned to the patient, the message Not included in a care program displays. Vitera Intergy EHR 9.00 New System Features 21

27 Chart Patient Care Program Pro Tip Care Program and Risk Level Setup Care programs are set up in System-Defined Lookup Maintenance in Intergy, and their use is governed by the practice parameter This Practice Participates in a PCMH/ACO Program. While the Risk level lookups are defined as levels 1 through 6, the definitions of these risk levels are based on criteria set up by each individual practice. For example, one practice s criteria for assigning a risk level 3 to a patient might be different from another practice s criteria. The name of the Patient Care Program particular lookup is PatientCareProgram in System- Defined Lookup Maintenance in Intergy. Many care programs are shipped with Intergy EHR, but are inactive until you activate them. For more information about setting up a Care Program, refer to the topic Patient Care Program Setup in the Intergy System in the Intergy New System Features document. The workflow below describes how to assign a care program and risk level to a patient. Workflow: Assigning a Care Program and Risk Level to a Patient 1. On the patient s chart, click on Care Program and select Edit from the pop-up menu that displays. Alternately, if you want to edit an existing care program or risk level, you can click on the care program codes or the risk indicator in the Care Program section. 22 Vitera Intergy EHR 9.00 New System Features

28 Chart Patient Care Program The Edit Patient Care Programs dialog box displays. 2. Make entries in the following sections: Section Care Program(s) Patient Risk Level Description Check the box by each care program that the patient is in. Select the patient s risk level. Definitions of risk levels are based on criteria set up by each individual practice. 3. Click the OK button. The code for each selected care program and the patient s risk level display in the Care Program section of the patient s chart. You have reached the end of the Patient Care Program topic. Vitera Intergy EHR 9.00 New System Features 23

29 Chart Preferred Communication Method Preferred Communication Method The preferred communication method can now be selected and displayed for a patient. This allows you to indicate, display, and identify the method of communication preferred by a patient. The following enhancements have been implemented: The updated Comm. Method field is now included in Chart (Patient Demographics section. Previously, the field was labeled Recall Method. Now, the field is labeled Comm. Method. The updated Set Comm. Method button is now included in the lower portion of the Chart window. Previously, the button was labeled Set Recall Method. The updated Patient Comm. Method dialog box displays when you click the Set Comm. Method button. Previously, the Patient Recall Method dialog box displayed. Note: The patient communication method is only available for setting if your practice is using the optional Practice Portal feature, and if the patient is set up to use secure messaging. Otherwise, the preferred communication method is automatically set to Paper and the method cannot be edited. In the Intergy system, the updated Preferred Communication Method field is included in the Patient Information (Personal page, Contacts tab) window and the Edit Patient Contacts window. Additionally, the updated Select Preferred Communication dialog box is now available. You have reached the end of the Preferred Communication Method topic. 24 Vitera Intergy EHR 9.00 New System Features

30 Encounter Note Preferred Communication Method Encounter Note This section describes the enhancements made to Encounter Note. E&M Calculator Enhancement SNOMED Code Compatibility Voiding Vital Signs in an Encounter Note Vitera Intergy EHR 9.00 New System Features 25

31 Encounter Note E&M Calculator Enhancement E&M Calculator Enhancement Encounter Note includes a tool for estimating the evaluation and management (E&M) code for a patient visit. The E&M Calculator provides this automated estimate based on the current encounter findings and other information for the visit. In version 9.00 of Intergy EHR, the E&M Calculator has been enhanced to show any previously selected codes for a note, as well as newly calculated ones. That is, if you chose an E&M code but then made changes to the note that resulted in a different E&M code being calculated, the E&M Calculator now displays both the code you selected previously and the newly calculated ones. The workflow below describes how to estimate the E&M code using the E&M Calculator. You can find the enhancement described above in step 7 of the workflow. Workflow: Estimating the Evaluation and Management Code 1. From the Encounter Note toolbar, select the E&M button. The Evaluation and Management Form dialog box opens, containing the default E&M code calculated from the findings selected in the encounter note for the patient visit. 2. In the Step 1 section at the top of the dialog box, verify the visit information and enter or edit any further details about the patient visit. The values entered in these fields are 26 Vitera Intergy EHR 9.00 New System Features

32 Encounter Note E&M Calculator Enhancement factored into the E&M code calculation, so changes to these field may cause the estimated E&M Code to change: Use the radio buttons to specify whether the patient is a new patient or an existing patient. In the Setting field, you can specify the type of facility at which treatment is provided. Further information about the service provided can be entered in the Service Type field. The Exam Type field allows you to select the specific system designated for medical examination, which results in greater accuracy in code calculation. The >50% time spent counseling check box is used to determine the accurate percentage of time a caregiver has devoted to face-to-face communication with the patient. You can specify the amount of time spent with the patient in the Total face to face or Floor time field. 3. If assessment findings exist for the encounter, they will display in the Assessment table. You can further modify the assessment by selecting the appropriate check boxes for each finding. Selecting these modifiers may affect how the data is assessed for the E&M code. For example, indicating that a problem is New with planned Additional Workup may be assessed differently than an existing problem which is indicated solely as Active. 4. To include your changes into the E&M code calculation, select the Recalculate E&M button. Your changes are then applied to the E&M code. 5. The table in the Step 2 section of the dialog box shows the level of service calculated for the various components of the examination, based on the encounter note. You can override the estimated level of service value for an examination component, if you decide that it should be different than the calculated value. Vitera Intergy EHR 9.00 New System Features 27

33 Encounter Note E&M Calculator Enhancement You can review the details of those sections which feature a blue linked title in the table. Selecting the link opens a details panel below the table which displays the details from the encounter note used to calculate the E&M code. 6. To override a level of service value, select the level of service field for the corresponding examination component. The letter 'U' (for User) will display in each field that you enter 28 Vitera Intergy EHR 9.00 New System Features

34 Encounter Note E&M Calculator Enhancement an override. Level of service override values may only be selected in the table fields with a white background. Table fields with a gray background cannot be changed. 7. When completed, select the Calculate Override button. The system will recalculate the E&M code using the override values. If the E&M code calculated using the override values is different than the code calculated from the documentation, both the Documented E&M code and the Override E&M code will display. In addition, if an E&M code was selected for the current note, and then you made more changes to the note which resulted in a different E&M code being calculated, the Vitera Intergy EHR 9.00 New System Features 29

35 Encounter Note E&M Calculator Enhancement Previously Selected code displays along with the newly-calculated one. You can select which of these E&M codes you want to charge for the visit. 8. When you are satisfied with the E&M code selection, choose the Accept button. The selected E&M code will display on the Charges tab on the Intergy EHR Orders/Charges window. You have reached the end of the E&M Calculator Enhancement topic. 30 Vitera Intergy EHR 9.00 New System Features

36 Encounter Note SNOMED Code Compatibility SNOMED Code Compatibility You can search for a MEDCIN finding based on a SNOMED (Systemized Nomenclature of Medicine) code, and problems are now mapped to SNOMED codes in Intergy EHR. SNOMED codes are displayed in the Problems Details screen. Intergy EHR now also uses them in addition to ICD-9 codes and MEDCIN findings to determine if a problem listed in the Continuity of Care Document (CCD) is already present in the Patient Chart. You have reached the end of the SNOMED Code Compatibility topic. Vitera Intergy EHR 9.00 New System Features 31

37 Encounter Note Voiding Vital Signs in an Encounter Note Voiding Vital Signs in an Encounter Note In Encounter Note, the Delete button has been replaced by the Void button. However, the functionality of the button itself did not change. You still cannot view a patient s vital sign records after they have been voided. Note: You can also void a set of vitals by right-clicking the link of the vital set you want to void and selecting Void from the pop-up menu that displays. You have reached the end of the Voiding Vital Signs in an Encounter Note topic. 32 Vitera Intergy EHR 9.00 New System Features

38 Health Information Exchange Voiding Vital Signs in an Encounter Note Health Information Exchange This section describes enhancements to Health Information Exchange functionality. Document List Views for the Exchange Tab Enhanced CCD Import Functionality Generating an Exchange Document Exchange Documents as Secure Message Attachments Exporting an Exchange Document to an HIE Printing an Exchange Document Vitera Intergy EHR 9.00 New System Features 33

39 Health Information Exchange Document List Views for the Exchange Tab Document List Views for the Exchange Tab You can set the document list view for the Exchange tab to show all documents, only documents that you generated, or only documents you retrieved from outside sources. In addition, you can include voided documents in any of those views. In Intergy EHR, the drop-down menu for selecting Exchange document views has changed slightly, with the Include Voided option now available as a separate check box that you can use with any of the views. For example, you could display only generated Exchange documents, and also include any voided documents in the list. The workflow below describes how to set the document list view for the Exchange tab. Workflow: Setting the Document List View for the Exchange Tab 1. From the drop-down menu above the Exchange documents directory, select one of the following views: All Display all Exchange documents in the view. Generated Display only previously-generated Exchange documents in the view. Retrieved Display only retrieved Exchange documents in the view. 2. If you want to include voided documents in any of the views you select, check the Include Voided box. To exclude voided documents, leave the box unchecked. Intergy EHR displays the Exchange documents that match the display settings you selected. You have reached the end of the Document List Views for the Exchange Tab topic. 34 Vitera Intergy EHR 9.00 New System Features

40 Health Information Exchange Enhanced CCD Import Functionality Enhanced CCD Import Functionality From the updated Exchange List in Chart, you can import clinical data from Continuity of Care Documents (CCDs) into patients medical records in your practice s Intergy EHR system. Now, when you import a patient s medications, including lapsed and discontinued medications, Intergy EHR now uses the RxNorm code in addition to the Medi-Span drug code and prescription issue date to determine if a medication listed in the CCD is already present in the Patient Chart. Intergy EHR now uses SNOMED codes in addition to ICD-9 codes and MEDCIN findings to determine if a problem listed in the CCD is already present in the Patient Chart. When you import a patient s drug-specific allergies, Intergy EHR now uses the RxNorm code in addition to the Medi-Span drug code to determine if drug-specific allergies listed in the CCD are already present in the Patient Chart. You can now preview your import selections and the clinical items that are already in the Patient Chart by using the updated Preview button located at the bottom of the window. To preview the Patient Chart items, change the preview setting from Off to On by selecting the blue button on the left side of the Off indicator. In the Chart column, the items that are already in the Patient Chart have a check inside a circle. The items that have been selected for import have a check inside a circle. To close the preview of the Patient Chart items, change the preview setting from On to Off by selecting the blue button on the right side of the On indicator. You can also right-click items from the patient s Intergy EHR chart and select Deactivate/ Discontinue. You have reached the end of the Enhanced CCD Import Functionality topic. Vitera Intergy EHR 9.00 New System Features 35

41 Health Information Exchange Generating an Exchange Document Generating an Exchange Document The process of generating an Exchange document has been enhanced with more intuitive dialog boxes that help provide a smoother workflow. The old Generate Document dialog box has been replaced with the new Generate Exchange Document dialog box: The following changes were made in the new Generate Exchange Document dialog box: No. Description The new TO section replaces the Send To section from the previous dialog box. The new WHAT section allows you to choose the type of Exchange document you want to send: Clinical Summary, Referral Summary, or Full Chart. The new INCLUDE section replaces the area of the previous dialog box where you selected the information to include in the Exchange document. In addition, the following changes were also made: The type of information to include in the Exchange document is now selected through the new Included Sections - Patient dialog box, as explained in the workflow below. The De-identify Patient check box has been moved to the new Included Sections - Patient dialog box. After you have generated a Clinical Summary Exchange document, a check mark displays beside the Print Summary button on the Today panel of the Patient Summary page. A similar check mark displays beside the Exchange Document check box on the Sign Encounter Note dialog box if a Clinical Summary has already been generated. 36 Vitera Intergy EHR 9.00 New System Features

42 Health Information Exchange Generating an Exchange Document The workflow below describes how to generate an Exchange document using the improved, redesigned dialog boxes. Workflow: Generating an Exchange Document with Encryption 1. Open the Chart window and select the patient for whom you want to generate an Exchange document. 2. Select the Exchange button to display the Exchange tab. 3. Select the Generate button. The Generate Exchange Document dialog box opens, containing options for specifying what patient clinical data should be included in the Exchange document. Vitera Intergy EHR 9.00 New System Features 37

43 Health Information Exchange Generating an Exchange Document 4. Complete the following sections of the dialog box to specify information about the Exchange document: Section TO Description Select one of the following to choose the recipient to whom the Exchange document will be sent: Patient Generate the Exchange document for the patient. Referring Provider Generate the Exchange document for the referring provider that you select from the drop-down list. Person/Organization Select either the Person or the Organization radio button, then type their name in the Name field. Intergy EHR will generate the Exchange document for the recipient you specify. WHAT Select what type of information you want to include in the Exchange document. 1. From the drop-down menu, select Clinical Summary, Referral Summary, or Full Chart. 2. If you selected Clinical Summary or Referral Summary, click Choose Encounter to select the encounter from the Select Encounter dialog box that displays. The Exchange document will include information from that encounter. Note: If you selected Full Chart, you do not need to select an encounter, because the patient s entire chart will be included. 38 Vitera Intergy EHR 9.00 New System Features

44 Health Information Exchange Generating an Exchange Document Section INCLUDE Description Select the information you want to include in the Exchange document, such as allergies, medications, problems, social history, and so forth. The information to be included is listed on the dialog box. If you want to change it: 1. Click the Change link at the end of the list. The Included Sections - Patient dialog box displays, through which you can select the information to include in the Exchange document. 2. Check the box by each section of information you want to include. Uncheck any boxes you do not want to include. 3. To keep the patient s information from displaying in the Patient Detail section of the Exchange document, check the De-identify Patient box. The patient s name will display as Anonymous in the Exchange document, and the Date of Birth and Gender fields will display as empty. 4. When you are finished making selections, click the Save button. Vitera Intergy EHR 9.00 New System Features 39

45 Health Information Exchange Generating an Exchange Document TIP If you want to save your selections as the default for the next time you generate an Exchange document, check the Save as Default box in the Included Sections - Patient dialog box. 5. When you save the generated Exchange document to a file directory of external storage (such as a flash drive or CD ROM), you can save the Exchange document as a chart copy, or you can save the document to a file. Saving the Exchange document as a chart copy is useful if you want to view or print an Exchange document that represents a patient s clinical history for a given point in time. Saving the Exchange document as a file is useful when you want the patient s complete history. Both options are described below. To save the Exchange document as a chart copy Select the Save button, then select Save To Chart from the drop-down menu. The Exchange document is saved as a chart copy. 40 Vitera Intergy EHR 9.00 New System Features