Special Topics in Vendor- Specific Systems. Outline. Results Review. Unit 4 EHR Functionality. EHR functionality. Results Review

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1 Special Topics in Vendor- Specific Systems Unit 4 EHR Functionality EHR functionality Results Review Outline Computerized Provider Order Entry (CPOE) Documentation Billing Messaging 2 Results Review Laboratory results Laboratory results Linked to laboratory information system Linked to laboratory information system e.g., bacterial cultures, complete blood count, therapeutic drug levels e.g., bacterial cultures, complete blood count, therapeutic drug levels Imaging results Imaging results Linked to radiology (imaging) information system Linked Used to radiology with Picture (imaging) Archiving information Communications system Systems (PACS) Used which with manage Picture Archiving digital radiography Communications Systems (PACS) which manage digital radiography e.g., radiology reports, X-rays, CAT scans, MRI images e.g., radiology reports, X-rays, CAT scans, MRI images Vendor system differences Vendor Critical system results differences notification Critical Viewing results formats notification Viewing Table/flowsheet formats format Table/flowsheet Graph for display format of trends Graph for display of trends 3 1

2 Computerized Provider Order Entry (CPOE) System used for direct entry of 1 or more types of orders by a by a provider into a system that transmits those orders provider into a system that transmits those orders electronically to the appropriate System used for direct entry of 1 or more types of orders electronically to the appropriate department (Armstrong, 2000) department (Armstrong, 2000) Medications, Nursing, Laboratory, Radiology/imaging, Provider referrals, Medications, Nursing, Laboratory, Radiology/imaging, Provider referrals, Blood bank, Physical therapy, Occupational therapy, Respiratory therapy, Rehabilitation therapy, Dialysis, Provider consults, Discharge and transfer Blood bank, Physical therapy, 4 CPOE (cont.) Potential Potential to alleviate to alleviate patient patient safety safety problems problems by limiting by limiting Illegible handwriting Use of dangerous abbreviations Illegible Verbal orders Use of dangerous Transcription Verbal orders handwriting abbreviations errors Transcription errors Unintended Consequences Wrong patient selected from list Wrong drug selected from list Changes workflow, may decrease interdisciplinary communication Unintended Consequences Wrong patient selected from list Wrong drug selected from list Changes workflow, may decrease interdisciplinary communication 5 CPOE: Vendor System Differences Online formularies e-prescribing Online formularies Medication prescriptions in ambulatory setting Health plan formulary Transmission of the prescription directly to pharmacy e-prescribing Medication prescriptions in ambulatory setting Health plan formulary Transmission of the prescription directly to pharmacy 6 2

3 CPOE: Vendor System Differences (cont.) Decision Support Functionalities Decision Support Functionalities Dosing recommendations and calculations Dosing Customized recommendations order sets and calculations Customized Bar coding order scanning sets technology Bar coding Medication scanning administration technology process (pharmacy administration) Medication Right administration patient gets the process right drug (pharmacy at the right administration) time Right Alerts patient gets the right drug at the right time Alerts Allergy alert Allergy alert Drug-interaction checking Drug-interaction checking Laboratory Laboratory alerts alerts Medication reconciliation process Medication Outpatient reconciliation Emergency process Department Hospital Admission Inpatient Outpatient Course Emergency Hospital Discharge Department Hospital Admission Inpatient Course Hospital Discharge 7 CPOE Meaningful use criteria: Non-hospital setting: CPOE Non-hospital used for at least 80% setting: of all orders e-prescribing CPOE used for at for least at 75% least 80% of all orders of all prescriptions Hospital setting: CPOE used for at least 10% of all orders e-prescribing used for at least 75% of all prescriptions Hospital setting: transitions of care CPOE used for at least 10% of all orders Component Medication 14/Unit 4 reconciliation performed for at least 80% of relevant encounters & Medication reconciliation performed for at least 80% of relevant encounters & 8 Multiple disciplines Physician Nurse Physician Social worker Nurse Physical Therapist Respiratory Therapist Other Physical clinicians Respiratory Therapist Therapist Social worker Other clinicians 9 3

4 Visit Note, Discharge Summary, Peri- Electronic capture of clinical information Clinical notes Clinical Visit notes Note, Discharge operative Summary, Note Perioperative Note Patient Patient assessments Vital Sign Flowsheet assessments Vital Sign Flowsheet Clinical reports Clinical reports (MAR) Medication Administration Record (MAR) Advance Directives For procedures Advance and Consents Directives and Consents For procedures Medication Administration Record 10 Methods of information capture Unstructured: Unstructured: Narrative free-text notes Narrative free-text notes Semi-structured: Structured Semistructuredtext entry headings Structured with headings some free-text with some free- entry Structured: Check boxes in MAR Check boxes in MAR Structured: Flow sheet vital signs and patient assessment Flow sheet vital signs and patient assessment 11 Potential Barriers to Implementation Workflow implications Increased documentation time Overuse of checkboxes Increased may documentation impact cognitive time Workflow processes Overuse of checkboxes may implications impact cognitive processes 12 4

5 Vendor System Differences Note creation options: Templates Templates Macros Clinical discipline Clinical discipline Combination of keys Specialty generate a user Or type of note predefined text set Or type of note Structured Macros documentation Copy and paste Combination of keys generate Tailored a user assessments predefined text set Component Voice 14/Unit 4 Recognition Version Software/Embedded 1.0/Fall 2010 dictation Voice Recognition Software/ Embedded dictation 13 Legal Issues Discovery of electronic records for legal purposes Discovery of electronic records for legal purposes Centers for Medicare and Medicaid and Joint Commission Centers for Medicare and Medicaid and Joint Commission Accepted standards for Legal Health Record HIPAA privacy Accepted rule standards for Legal Health Record Organizations HIPAA privacy identify rule designated record set Organizations identify designated record set How the information is used (e.g., was it used to provide patient care?), not where is resides, determines if it is part of the legal record How the information is used (e.g., was it used to provide patient care?), not where is resides, determines if it is part of the legal record 14 Billing All vendor systems support these All ICD-9-CM vendor systems codes (The support International these Classification of Diseases, 9th Revision, ICD-9-CM codes (The International Clinical Classification Modifications) of Diseases, 9th Revision, Clinical ICD-10-CM Modifications) in October 2013 CPT ICD-10-CM codes (Current in October Procedural 2013 Terminology) CPT codes (Current Procedural Terminology) 15 5

6 Billing Professional billing (Physicians and Nurse Professional billing (Physicians and Nurse Practitioners services) Practitioners services) ICD-9-CM codes ICD-9-CM Hospital codes discharge summary or Outpatient visit note Hospital discharge CPT codes summary or Outpatient visit note CPT codes Procedure (e.g., surgery) CPT Procedure codes E/M (e.g., (Evaluation surgery) and Management) CPT Level codes of evaluation E/M (Evaluation & management and Management) service performed at patient visit Hospital Level billing of evaluation & management service performed at patient visit ICD-10-PCS Inpatients billing by hospitals Hospital billing ICD-10-PCS Inpatients billing by hospitals 16 Messaging Internal Secure for patients EHR linked automatic text page Intraoffice group communications 17 Messaging (cont.) Copy chart or lab results to another provider with a note Telephone message documentation Patient scheduling Referral letter or consultation report Patient follow-up deficiency alerts 18 6

7 References Armstrong, C. W. (2000). American Hospital Association guide to computerized physician order-entry systems. Chicago, IL: American Hospital Association 19 7

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