EMERALD EMR. Arun B. Rajan, M.D.

Transcription

1 EMERALD EMR Arun B. Rajan, M.D. Introduction: I have been using an EMR since Back then, there were not too many EMRs. I chose an EMR that was cost-effective and something that I would be able to use in my neurology practice. 2 weeks after purchasing the software, I called the software vendor asking if they would take the software back and return my money. Obviously, they refused. That was actually a blessing. The software was sitting unused in my office. One day, unable to find an MRI report in my paper chart, I decided that there has to be a better way to be able to find reports and better documentation. I then took the brave step of learning to use the software. After struggling for several weeks, I was able to use the software on a daily basis. Needless to say, every physician practices medicine in his/her own way. A single software will not fit and be acceptable to all physicians. It is with this concept that Emerald EMR was developed. We have tried to make it as user friendly as possible and as flexible as possible. We invite any suggestions to improve the software and also we are willing to provide customization to the end user as much as possible. We welcome your comments, suggestions, and criticisms. We will gladly accept any praise. As I had alluded to above, any and all software requires some effort and time on your part to learn the software. Rome was not built in a day and you did not learn to ride the bicycle without falling off at least once! Once you have mastered the basics, you will be able to understand the functionalities that the software can provide and use the software to your own specific needs. In choosing a software ask yourself, what are you paying for? Are you sure you need that expensive software? Expensive does not always mean high quality. Be sure of your needs. 1

2 EMR pros 1. Better, accurate documentation 2. Legible documentation 3. Completion of documentation in a timely manner 4. Ease of location of information 5. Access to patient information anytime, anywhere 6. Decrease staff labor, time 7. Increased efficiency of staff 8. Easy tracking of discrete data over time 9. Integration of laboratory data, radiology etc. 10. Elimination of bulky paper chart racks 11. Decrease or eliminate prescription refill request telephone calls 12. Eliminate calling pharmacies 13. Prescribe from your computer or Smartphone 14. Eliminate or minimize transcription cost EMR cons 1. Cost? 2. Learning curve 3. More time required for (but better) documentation 2

3 VENDOR FUNCTIONS The practice will need to provide information about the master user/users. Typically this function is done by the provider/s in the practice. The physicians will need to be master users. The practice can designate a second master user for the practice like the office manager who can designate user access levels based on the role of each user in the practice. Vendor will create the master users and subsequently other users can be assigned access levels by the physician or practice manager. 3

4 PRACTICE SET UP Once the master users have been set up and the user name and login is provided, the first step is to set up other users and assign rights to each user. Log in to EMERALD. ADD USER The first screen has a set of functions with icons at the top of the screen. Locate the USER icon and click on it. This will take you to the List of users of EMERALD AND Assign Rights page. You can add users here. Click on the add button at the bottom of the page. This takes you to the Add User area: Select the role, fill in the details, submit and the user is ready to be assigned rights. Once you click on the submit button, the pages reverts back to the List of Users and Assign Rights page. 4

5 Click on Assign Rights ASSIGNING RIGHTS Select your user (red arrow) and for each item on the left assign specific rights. Click on save and you have completed the task of setting up one user for EMERALD. The master user can modify or delete a user at anytime. 5

6 Using the software: OFFICE STAFF (Medical Assistant) FUNCTIONS: 1. Create a chart for a new patient 2. Enter Demographics 3. Create encounter 4. Launch E-Prescription Module to enter patient s clinical information-current medication, allergies, medical diagnosis and prior surgeries. Exit out of module when done. 5. Record Vital Signs in chart 6. Review of Symptoms 7. List reason for office visit and insert templates etc. (This is practice specific function as designated by the provider) Login Procedure: Go to and enter your user name and password You will be taken to the main menu screen: 6

7 Near the top right side of the chart Click on the ADD PATIENT shown above. This will take you to the patient s demographic screen. Complete the demographics. Note that some fields are required for saving the entered information. Certain fields require that the entry be done according to specifications. Eg. Telephone numbers should not contain parenthesis, dashes etc. Chart Contents is the area that enables you to store and locate patient information including physician orders. The top of the screen contains the menu of functions of the EMR (shown below). 7

8 By default, the opening screen will consist of the patient charts that require attention from the provider. These charts have information that requires a provider to sign off before it can be refiled. Patient charts that have not been signed off by the provider will continue to remain in the Pulled Charts list. You will not be able to refile these charts. If a patient is not seen in the Pulled Charts list, click on the All Charts tab. This will open up tab from A-Z. You can search by last name and first name or date of birth. When a patient chart is opened, the following dialogue appears: Next: Click on Enables the user to add an encounter. Requires that a physician or provider be chosen for that encounter. Using the drop dowm menu, choose the provider and also the type of office visit. Enables the user to delete an unsigned encounter only. Signed off encounters cannot be deleted. 8

9 You are now ready to start entering data about the patient. Step 1. Click on the e-rx radio button. This will launch the electronic prescription function. You will see the patient demographic information. The first step will be to select the pharmacy for the patient. 9

10 Choose the pharmacy for the patient by adding some basic information in the patient pharmacy information area. This will provide you with the list of different pharmacies in that particular ZIP code or area as designated by you. Choose the correct pharmacy by clicking on it. Save the local pharmacies in the practice list so that you can easily find the pharmacy for each subsequent patient. You can do this by searching for the pharmacies by ZIP codes. Step 2: Allergy Click on Manage Allergies. Enter allergy information by searching for the medication and the type of allergy. There is a default list of common medication allergies as a drop down menu with type of allergic reaction (red arrow). Additionally, you can search for each medication by entering the drug information incomplete or even partially. E.g.: Topa for Topamax. It may be easier to search with a partial name as incorrect spelling will result in errors. Once completed click on done with allergies and you go back to the main erx screen. 10

11 Step 3: Manage Medications Click on Manage Medications Next enter the list of medications that the patient is currently taking including the dosage, times etc. You can search for each medication by entering the drug information incomplete or even partially. Again, it may be easier to search with a partial name (unless you are confident of your spelling) as incorrect spelling will result in errors. Return to the main screen to continue. Step 4: Manage Problems Click on Manage Problems. Takes you to another screen to enter all past medical diagnosis and past surgeries. 11

12 Enter the list of diagnosis that the patient already has one by one using the search function. This is linked to the current ICD-9 comprehensive list of codes. Again, it may be easier to search with a partial diagnosis (unless you are confident of your spelling) as incorrect spelling will result in errors. Each time that you enter a diagnosis click on use favorite button. This will store that particular diagnosis in the Favorite Diagnosis list. Next time you need to add that particular diagnosis for a different patient, all you need to do is pull it up from your favorite list. You can also search for the diagnosis using the ICD-9 code. This would complete the electronic prescription module functions and you can log out of the module. You will be returned to the main screen and the information that was entered into the electronic prescription module will be automatically downloaded into the respective area of the EMR. PMH, PSH, Meds, Allergies into the respective areas at the top of the screen. Information about Family History, Social History can then be entered. The MAs can then complete the ROS field. Macros can be utilized in any field. Finally the vitals can be entered. BMI is calculated and automatically filled when the height and weight are entered in the respective fields. 12

13 Additional MA functions: Step 5. Entering data in the DOS (date of service) encounter screen: 13

14 Using Macros and Template function: Macros: The macro function button is located at the top of the encounter screen. Click on it. This will open the macro creation module This shows the list of Macros that is available. Click on the Add button at the bottom of the screen. This will open the add macro screen. 14

15 Give a 3-4 letter name for the macro for eg: ROS for review of systems macro. Click on the save button and return to the previous screen. You can add as many Macros as you want, but create a system so that you can easily recall the macro. E.g.: For inserting side effects of medicines that you commonly prescribe and want to insert in your narrative or plan you could use topse for side effects of Topamax, Fiose for Fioricet side effects and so on. You can use this function to suit your own needs. To insert the Macro; type the macro code e.g.: topse in the field that you want it in, say the plan field. Then hold down the control, shift keys with your ring and middle fingers respectively and then hit the z key with your index or pointing finger. (This has worked well for us, but choose your own method of working). This will enter the macro into the selected area. You can insert macros into any field of the encounter screen. 15

16 Templates: Similar to creating Macros. Clicking on the above icon will take you to the View Templates screen. Click on the add button at the bottom of the screen. This screen appears: Give the template a name and you can then start filling the available fields with the information that you would want in that template. 16

17 Once you save this template, you can insert it into the encounter that has been created by clicking on the Insert Template icon. Other Functions: Medical Record: Click on the Encounter Report icon. Select the Full Chart and click on Print Preview. The entire medical record will be collated. This can then be printed or saved and then ed or faxed. 17