Advanced EHR Customization: Templates, PC, Encounter Builders

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Allyson Mosley
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1 Advanced EHR Customization: Templates, PC, Encounter Builders User Conference 2014 Presented by: BJ Bloom EHR Training Specialist

2 Objectives Encounter Builder: Purpose and Benefits Phrase Construction: How and Where Templates: Advanced Needs Surveys: How to Create

3 Encounter Builder: Purpose and Benefits Where in OP - Utilities Manage Forms Encounter Builder

5 Global Building Blocks If you want items available in more than one template, then build here first. Content available for templates and visits Customize History Groups and Questions Special Needs sections available Sex Specific

6 Components: Section: Exam: multi-system or single system ROS: All Visit Types or Well Visits Only History Groups: represent the groups under the Section and Exam type Questions: click to report items under each Group should be listed as a statement Sort Order: how listed Scope: Global - applies to all templates Bulleted - counted toward cpt level of service Sex: is the statement sex specific

7 log in: ADVCUSTOM password: UC2014 Let s Try It!

8 Exercise 1. Under ROS: All Visit Types > Respiratory a. Add: nighttime cough with sort order 2 and Global, NOT Bullet 1. Under ROS: Well Visit Only > Oral Health a. Add: Child has a dental home with sort order 6 and Global, Bullet 1. Under ROS: All Visit Types a. Add in a new Group: Special Need b. Add in a question: feeding appliance ; Global, NOT Bullet c. Add in a question: in school assistant ; Global, NOT Bullet

9 Phrase Construction: How and Where Where in OP - Utilities Manage Forms Phrase Construction

11 The Phrase Construction Library is organized into four levels: 1. Volume - Each volume is organized into topics, or "notebooks". 2. Notebooks - The complete list found on Index. Click on any topic to view the organized view of the different notebooks as tabs. 3. Pages- Each notebook is organized into sub-topics or "pages". 4. Phrases - Each page contains a number of phrases or labels that describe a specific item for that sub-topic.

12 Making New and Editing WHY? Procedure Notes Patient Instructions Plans so no duplication in notes Counseling Provider specific needs Can build on the fly

13 Let s Try It!

14 Exercise 1. Create a New Notebook: Counseling a. Create a new Page: Weight management b. Create new Phrase Label with Advised to limit eating out to once per week and eliminate sodas and juices from diet. 1. In our Procedure Notebook a. Create a new Page: Wart Destruction b. Create new Phrase Label with your procedure for wart destruction.

15 Templates: Advanced Needs Saving Templates on the Fly - Unique visits Copying Templates for New Use Custom Questions vs Encounter Builder Understand stacking of templates Understand fields which drive CPT coding

16 Copying a Template for a New Use Great for a template series obesity: initial dx, obesity: f/u doing well, obesity: f/u not doing well, obesity: symptom template ADD/ADHD: initial eval, ADHD f/u, ADD f/u, ADD: symptom template Write the first one with appropriate custom questions Repurpose and rename for additional use Use top sections (CC, HPI, ROS) to create a symptom template

17 Template Series

18 Custom Questions

19 Copy From Template

20 Let s Try It!

21 Exercise Open the template FAILURE TO THRIVE 1. Create a Custom Question to replace question a. remove: Cardiovascular: change in exercise tolerance b. create: Cardiovascular: tires with feedings 1. Create a Series template for FAILURE TO THRIVE a. FAILURE TO THRIVE: doing well b. FAILURE TO THRIVE: lack of progress

22 Templates & CPT Coding Can set up templates to have shell that supports appropriate E/M coding levels Headache, fatigue, abdominal pain have components to support as long as appropriate CC/HPI and history review added Many are 99213/14 "bubble" and knowing what to add/subtract easily makes them fall to one or the other Many templates only have one skin exam bullet, and adding skin turgor can be enough to move PE section from to 99214

28 Surveys: How to Create Where in OP - Utilities Manage Forms Survey Administrator

Survey Toolbar Click Create to Open survey window Complete the fields - Survey Name - Source: Local - Description: for internal use - Instruction: visible if a parent takes the survey on the portal -

29 Survey Toolbar Click Create to Open survey window Complete the fields - Survey Name - Source: Local - Description: for internal use - Instruction: visible if a parent takes the survey on the portal - Alert type/value: alert you if any scores fall above or below or certain value - Equiv LOINC: if correspond to a lab with an identical LOINC code - Default Dx: for billing - Default CPT/Mod: sent to SB when the survey is marked as complete

can assign scores - Permit a typed in answer, select Enable custom answer checkbox Integers: Answer used to set a numeric answer - can be scored - can set default value Chars: Answer used to set

30 Survey Questions Score Alert for Survey: score above/below Is the question Required? Fill in Question Text: Create a text field that can be used for comments or entry to explain List: Create a list of choices that can be selected for the questions - Single or multiple choice - can assign scores - Permit a typed in answer, select Enable custom answer checkbox Integers: Answer used to set a numeric answer - can be scored - can set default value Chars: Answer used to set an alpha character - can set default value Boolean: used to set a value to an assumed yes/no response - can be scored - can set default value Date/Time: Answer will be entered as a date Masked Edit: Set the answer to a preset value (Custom = date, Phone, Extension, Social security, Short or Long Zip code

31 Exercise Open the template Survey Administrator 1. Create a Survey: UC Workshop 2. Mark all questions as required 3. Question 1: What time zone do you live in? a. List answers: EST = 4, CST = 3, MTN = 2, PST = 1 4. Question 2: Do you like ice cream? a. Boolean answers: Yes = 1, No = 0 5. Question 3: What is your favorite sport? a. Text answer: maximum = 25; Normal

Exploring OP14: EHR Features

Exploring OP14: EHR Features User Conference 2014 Presented by: BJ Bloom EHR Training Specialist Hands ON introduction to OP14 the new features: Re-organization of Menus Search Text Function in Summary