Optum Physician EMR v 8.1 Release Notes

Transcription

1 Optum Physician EMR v 8.1 Release Notes OptumInsight 70 Royal Little Drive Providence, RI Copyright OptumInsight. All rights reserved.

2 Document Information Author(s) Release Date G.Caldera TBD Date Last Updated 06/11/14 Version 1.01 Document Control Version Date Changed Completed By Description of Changes /04/14 G.Caldera Initial Release /11/14 G.Caldera Updated: 2.3 Transition of Care Summary Meaningful use requirement description for summary of care records New Orders Application Help topic reference location New Progress Note Template Added information about the transition plan for implementing IMO Favorites in global templates. The Other section in the Diagnosis list is renamed to Problem List. The Favorite Diagnosis tab in the A&P tab is renamed to Visit tab (third tab in the A&P window). 3.3 Full EHR Export Changed CCD reference in Full EHR Export (CDA) to C-CDA. 4.2 Meaningful Use Key Performance Indicator (KPI) Reports Added the list of 2014 KPI reports. Optum Physician EMR v8.1 Release Notes_1.01 ii of 43

3 Contents About this Document... iv Purpose... iv Before You Begin... iv Document Conventions... iv 1 Release Overview Medical Record Module Consolidated Clinical Document Architecture (C-CDA) Clinical Information Reconciliation Problem List Reconciliation Medication Reconciliation Medication Allergies Reconciliation Transition of Care Summary Clinical Summary Visit Summary Specialty Reports Progress Note Templates Drop-Down Lists Copying Values Family History Transmitting Syndromic Surveillance Data Outgoing Referrals Consultation Documents Diagnosis Updates Diagnosis Search Provider Favorite Diagnoses Problem List Application New Orders Application Order Sets Application New Progress Note Template Immunization Reporting VIS Dates Immunization Refusal Reasons Immunization Information Source Sending Immunization Data to Immunization Information System (IIS) Result Report Patient Education References Physician Education Resources (InfoButton) Patient Care Management Administration Module Clinical Audit Log Clinical Letter Editor Full EHR Export Reports Module Meaningful Use 2014 Clinical Quality Measure (CQM) Reports Meaningful Use Key Performance Indicator (KPI) Reports Patient Clinical Log Report Optum Physician EMR v8.1 Release Notes_1.01 iii of 43

4 About this Document Purpose This document outlines new and updated features for the 8.1 release of Optum Physician Electronic Medical Record (EMR). Before You Begin Clear the Cache Before you log in to a new release of Optum PM and Physician EMR, clear your computer (or ipad) memory cache to ensure proper performance. For instructions on clearing your cache, see Optum PM and Physician EMR > Support > Support Knowledge Base > How to Clear Cache. Document Conventions This document uses the following formatting conventions: Formatting Convention Description Indicates a note about online help or training or support. Support note is indicated as Support and online help is indicated as Online Help. Indicates an important message or warning. Italics Bold [Placeholder] Italics are used to denote paths and cross references. Denotes the names of field names. Indicates information that is not yet available or a feature that is under development. Optum Physician EMR v8.1 Release Notes_1.01 iv of 43

5 1 Release Overview This section highlights some of the key enhancements included in this release: Updated document standards for CCD (CDA format) see Consolidated Clinical Document Architecture (C-CDA) on page 6 Clinical information reconciliation (import CDA data) see Clinical Information Reconciliation on page 8 Free type entries in single and multi-select dropdown lists see Drop-Down Lists on page 18 Copy capabilities in templates see Copying Values on page 19 Structured data recording for family history see Family History on page 20 Submission of syndromic surveillance data see Transmitting Syndromic Surveillance Data on page 22 Diagnosis search upgrade with Intelligent Medical Objects (IMO ) integration see Diagnosis Updates on page 24 Electronic data submission updates to immunization registries see Immunization Reporting on page 30 Meaningful Use compliant laboratory results for reporting see Result Report on page 33 Access to physician education resources on the Medline Plus website (Infobutton) see Physician Education Resources (InfoButton) on page 35 Meaningful Use complaint updates to the clinical audit log see Clinical Audit Log on page 37 CMS recommended CQMs (PDF and QRDA formats) see Meaningful Use 2014 Clinical Quality Measure (CQM) Reports on page 41 Optum Physician EMR v8.1 Release Notes_ of 43

6 2 Medical Record Module 2.1 Consolidated Clinical Document Architecture (C-CDA) Optum PM and Physician EMR now supports the Consolidated Clinical Document Architecture (C-CDA) technology to help satisfy Meaningful Use requirements. The C-CDA is an XML file that complies with the new standards for exchanging clinical data between care providers. To generate a C-CDA with relevant administrative, demographic, and clinical information about a patient's healthcare, click View on the Clinical toolbar and then click CCD. You can then click Current CDA to generate an up to date C-CDA. You can use C-CDA to do any of the following: Save C-CDAs to your computer or other electronic devices. Send C-CDAs to a Health Information Exchange (HIE). View historical and current C-CDAs in the CDA viewer. the C-CDA to a secure account (via Direct Mail). For more information on Direct Mail, see the Practice Management Release Notes. Attach C-CDAs to a ToDo, mail or fax Import C-CDA data to reconcile clinical information with the patient s medical record. For more information, see section 2.2 Clinical Information Reconciliation. Provide patient s access to their own C-CDA to transmit the health information to a third party (via Optum Patient Portal). For more information, see the Practice Management Release Notes. Figure 1 Generating and Viewing a C-CDA Optum Physician EMR v8.1 Release Notes_ of 43

7 Described in the table below is the information included in each section of the C-CDA. Table 1 C-CDA Section Information Section Items Date Encounters Diagnosis Code Diagnosis Description Provider Location Name Allergies Functional Status History of Immunizations Reaction Severity Status Date Description Name Date Status Name Medications Treatment plan SIG Start Date Stop Date Status Date Plan Onset Date Problems list Procedures Diagnosis Code Diagnosis Description Status Date CPT Code Description Result Date Results Social History Name Results Description Status Smoking Status Optum Physician EMR v8.1 Release Notes_ of 43

8 Section Items Encounter Date Vital Signs Weight Height Blood Pressure BMI For more information on the Consolidated Continuity of Care Document (C-CDA), see the following chapter in Optum PM and Physician EMR : Medical Record Module > CCD & C-CDA. 2.2 Clinical Information Reconciliation You can now review and reconcile problems, medications and medication allergies imported from a C- CDA with the patient s medical record to help satisfy Meaningful Use requirements. You can import clinical data in a C-CDA from the following locations: Incoming Direct Mail message (with a C-CDA attachment) - A message prompts allowing you to save the C-CDA and import the clinical data in the C-CDA to the patient s medical record. Figure 2 Direct Mail: Import C-CDA Data Documents application- You can click the CCD folder in the application, and then click the Import icon next to the C-CDA to import and reconcile with the items in the patient s medical record. Note: To save C-CDAs to the CCD folder, you must generate a C-CDA or upload a C-CDA to the patient s medical record via the Document Upload or the Historical Document Import applications. Optum Physician EMR v8.1 Release Notes_ of 43

9 Figure 3: C-CDA Reconciliation Problem List Reconciliation You can review the following information for each problem in the patient s active problem list and the C- CDA before selecting the item to include in the reconciled list. Optum Physician EMR v8.1 Release Notes_ of 43

10 Problem description Status Date the problem was recorded, updated or deactivated (last modification date) You can use the check box associated with a problem or use the Select All check box to select and remove all problems from the lists. You can also change the status of the problems in the active problem and reconciled lists. After you verify the reconciled list, click Import to save the problems to the patient s medical record. Figure 4: Problem List Reconciliation Medication Reconciliation You can review the following information for each medication in the patient s active medication list and the C-CDA before selecting the item to include in the reconciled list. Medication description SIG Status Date the medication was recorded, ordered, prescribed, refilled, dispensed or edited (last modification date) Note You must have an encounter in context to reconcile the list of medications. You can use the check box associated with a medication or use the Select All check box to select and remove all medications from the lists. You can also change the status of the medications in the active medications and reconciled lists. After you verify the reconciled list, click Import to save the medications to the patient s medical record. Optum Physician EMR v8.1 Release Notes_ of 43

11 Figure 5: Medications Reconciliation Medication Allergies Reconciliation You can review the following information for each medication allergy in the patient s active allergy list and the C-CDA before selecting the item to include in the reconciled list. Allergy description Reaction Note: An allergy must have a reaction selected to save to the patient s medical record. Status Date the medication allergy was recorded, updated or deactivated (last modification date) You can use the check box associated with an allergy or use the Select All check box to select and remove all allergies from the lists. You can change the status of the allergy in the active allergy list and reconciled lists. After you verify the reconciled list, click Import to save the allergies to the patient s medical record. Optum Physician EMR v8.1 Release Notes_ of 43

12 Figure 6: Medication Allergies Reconciliation For information on clinical information reconciliation, see the following topics in Optum PM and Physician EMR : Medical Record Module > CCD & C-CDA > Clinical Information Reconciliation. 2.3 Transition of Care Summary You can now create and transmit a summary of care record in C-CDA format when transitioning a patient to a different setting of care. To meet Meaningful Use requirements, you must send the summary of care record in a secure mail message via Direct Mail. For more information on Direct Mail, see the Practice Management Release Notes. To create and transmit a summary of care record, click the Mail or Direct tab of the Message application and then click the Link Patient Data link. You can then access the Transition of Care/Referral Summary section to attach and send electronically. Optum Physician EMR v8.1 Release Notes_ of 43

13 Figure 7 Transmitting Transition of Care/Referral Summary (C-CDA format) When the summary of care record is attached to the mail or Direct Mail message, you can click the file to open in the C-CDA viewer. You can also click the Upload icon to view or save the document via the Document Management application or click the Delete icon to remove the document from the mail or Direct Mail message. When the summary of care record is transmitted, the Transition of Care Summary Generated entry is recorded in the clinical log for tracking purposes. You can access the Mail or Direct Mail applications from the following locations: Name Bar > ToDo > Mail tab or Direct tab Medical Record Module > ToDo on the Clinical toolbar > Mail tab or Direct tab For information on transmitting a summary of care record, see the following topic in Optum PM and Physician EMR : Medical Record Module > Transition of Care > Transmitting Summary of Care Records. Optum Physician EMR v8.1 Release Notes_ of 43

14 2.4 Clinical Summary You can create and send a clinical summary that follows the C-CDA standards to a patient after each office visit. To meet Meaningful Use requirements, you must send the Clinical Summary via a mail to the Patient Portal or send a secure mail message via Direct Mail. For more information on Direct Mail, see the Practice Management Release Notes. To create and send a clinical summary, click the Mail or Direct tab of the Message application and then click the Link Patient Data link. You can then access the Clinical Summary section to select the items you want to include and click Save to attach to the mail or Direct Mail message. Figure 8 Creating and Sending a Clinical Summary (C-CDA Format) When the clinical summary is attached to the mail or Direct Mail message, you can click the file to open in the C-CDA viewer. You can also click the Upload icon to view or save the document via the Document Management application or click the Delete icon to remove the document from the mail or Direct Mail message. Optum Physician EMR v8.1 Release Notes_ of 43

15 You can access the Mail or Direct Mail applications from the following locations: Name Bar > ToDo > Mail tab or Direct tab Medical Record Module > ToDo on the Clinical toolbar > Mail tab or Direct tab For information sending a clinical summary, see the following topic in Optum PM and Physician EMR : Medical Record Module > Visit Summary/Clinical Summary > Transmitting an After Visit Summary. 2.5 Visit Summary The following sections in the Visit Summary are updated with new information to help satisfy Meaningful Use requirements. By default, the new information is included in the printout. However, you can customize the printout via the Visit Summary application in the Administration module, if necessary. Table 2 Visit Summary Section Updates Section New Items Gender Race Ethnicity Patient Information Primary Language Group Provider PCP Referred By Note: The information is based on the entries made in the Demographics application of the Patient module. Visit Summary Information Chart Information Reason for Visit Note: Displays the reason for visit recorded in the Other Complaint text box of the progress note template. Administered Medications Note: Displays administered medications recorded in the Medications application. Administered Immunizations Note: Displays immunizations recorded via the New Vaccination application accessed from the Clinical toolbar. Social History Note: Displays smoking status information recorded in the Smoking Status field in the Tobacco Assessment section of the History application or progress note template. Open orders Note: Displays open order information in the Open Activities section in the patient s medical record. Pending appointments Optum Physician EMR v8.1 Release Notes_ of 43

16 Figure 9 Visit Summary Print Sample To print a visit summary, access the patient s medical record, click the Arrow icon next to Print in the Clinical toolbar and then click Print Visit Summary. Optum Physician EMR v8.1 Release Notes_ of 43

17 Additionally, you can also attach and send the visit summary directly to a secure address. To send the visit summary, click the Arrow icon next to Print in the Clinical toolbar and then click Send Visit Summary to Direct. For information on printing and sending the visit summary, see the following chapter in Optum PM and Physician EMR : Medical Record Module > Visit Summary/Clinical Summary. 2.6 Specialty Reports You can now generate and attach a specialty report to the Message application by clicking the new Msg Center button in the Filter dialog box. Note: You must select a case to generate the specialty report. Figure 10 Chart Summary: Transmitting a Specialty Report For information on sending a specialty report, see the following topic in Optum PM and Physician EMR : Medical Record Module > Chart Summary > Transmitting a Specialty Report. Optum Physician EMR v8.1 Release Notes_ of 43

18 2.7 Progress Note Templates The progress note templates are now supported with the features described in the sections below Drop-Down Lists You can now type an entry in single and multi-select drop-down lists to find a matching option from the lists. If a match is not found when you press ENTER, the entry is saved in the list for the current encounter. When an entry is saved to a multi-select drop-down list, the check box in front of the entry is automatically selected. If you misspell an entry, you can deselect the check box next to the wrong entry and type the term again to save the new entry to the list. Figure 11 Progress Note Template: Single Select Drop-Down List Figure 12 Progress Note Template: Multi-Select Drop-Down List Optum Physician EMR v8.1 Release Notes_ of 43

19 2.7.2 Copying Values You can now save time required for recording data in a progress note template by activating the following copy features. Copy sequence values - To copy values between sequences, enter and save values in the current sequence and then click the new Copy link. You can then select the required options from the Copy From and the Copy To fields, and click Copy From Previous to copy the values. Figure 13 Progress Note Template: Copy Sequence Values Copy section values- To copy values between sections, click the Copy buttons available on the template. Figure 14 Progress Note Template: Copy Section Values Optum Physician EMR v8.1 Release Notes_ of 43

20 Support To activate the copy feature in a template, log a ToDo to your Support entity. When logging the ToDo, set the Category to Content, Type to EHR and Reason to Templates. The requests will be reviewed by the Clinical Content team. For information on working with lists and sequence entries, see the following topic in Optum PM and Physician EMR : Medical Record Module > Progress Note Templates > Documenting a Patient Encounter > Default Progress Note Template Features Family History Recording family history information now includes the following updates to help satisfy Meaningful Use requirements Add Family Member You can now select the relationship and enter the name when recording history information about a family member. If a family member name is entered, the name displays in the sequence. If a family member name is not entered, the relationship displays in the sequence. Figure 15 History: Adding a Family Member Optum Physician EMR v8.1 Release Notes_ of 43

21 You can add family members from the Add Family Member dialog box accessed from any of the following locations: Medical Record Module > Progress Notes (Clinical toolbar) > Hx Tab > Family History by Member section > click the New link Medical Record Module > History (Patient Health History pane) > Family History tab > click the + icon For information on recording family history details, see the following topic in Optum PM and Physician EMR : Medical Record Module > History > Recording Family History Progress Note Activity Log The following updates are made to the Details tab of the Progress Note Activity Log to capture family history information recorded via the Progress Note and History applications: The new Relationship column displays the option selected in the Relationship field. Additionally, the column displays the SNOMED code associated with the first degree family member selected in the Relationship field. First degree relatives include parents, offspring, and siblings. The Sequence column displays the entry in the Name field. The Medcin column displays all SNOMED codes associated with the Medcin ID. The Medcin ID is linked to the item used for recording history information. Figure 16 Progress Note: Activity Log To access the activity log, access the Progress Note application in the Medical Record module, click the Arrow icon next to the progress note and then click Log. For information on viewing the progress note activity log, see the following topic in Optum PM and Physician EMR : Medical Record Module > Progress Note Templates > Viewing the Progress Note Audit Log. Optum Physician EMR v8.1 Release Notes_ of 43

22 2.7.4 Transmitting Syndromic Surveillance Data You can now submit syndromic surveillance data recorded during a patient encounter to public health agencies to help satisfy Meaningful Use requirements. This also helps public health agencies to immediately analyze and follow-up on potential outbreaks. To send syndromic surveillance data, click the new Transmission icon on the narrative after completing the progress note for the visit. Support The Transmission icon displays only if the interface required to submit health data to the state is activated for the group. To activate the state health agency interface, log a ToDo to the Support entity. Figure 17 Progress Note Template Narrative: Sending Syndromic Surveillance Data You can access progress note template narratives from any of the following locations: Medical Record Module > Progress Notes (Clinical toolbar) Medical Record Module > Progress Notes (Patient Health History pane) For information on sending syndromic surveillance data, see the following topic in Optum PM and Physician EMR : Medical Record Module > Progress Notes > Transmitting Syndromic Surveillance Data. 2.8 Outgoing Referrals The Specialty field for outgoing referrals is now linked to SNOMED codes. Therefore, when creating an outgoing referral from the Referral application, you must select a specialty to help satisfy Meaningful Use requirements. Optum Physician EMR v8.1 Release Notes_ of 43

23 Figure 18 Referrals and Authorizations Application: Specialty Field You can access the Referrals and Authorizations application from one of the following locations: Name Bar > Refer Medical Record Module > Referrals in the Clinical toolbar For information on creating an outgoing referral, see the following topic in Optum PM and Physician EMR : Medical Record Module > Referrals and Authorizations > Creating Referrals. 2.9 Consultation Documents The global Consult subtype is now linked to a SNOMED code. Therefore, when uploading consultation documents, you must select Consult under the Global section in the Sub Type list to meet 2014 Clinical Quality Measure requirements. Figure 19 Document Management Application: Uploading Consult Documents Optum Physician EMR v8.1 Release Notes_ of 43

24 You can upload consult documents from any of the following locations: Name Bar > DocMgt > + Add Document link Messages Center > ToDo tab, Mail tab, Fax tab, Direct Mail tab > + Add Document link Patient Module > Add Attachment link and Add Picture link Doc Management Module > + Add Document Clinical Today Module > Document Management link in the Quick Tasks menu> + Add Document link Medical Record Module > Attachments in the Clinical toolbar Medical Record Module > Documents in the Patient Health History pane > + Add Document link For information on uploading documents, see the following topic in Optum PM and Physician EMR : Medical Record Module > Document Upload and Batch Scanning > Uploading Documents Diagnosis Updates The IMO system integrated within Optum PM and Physician EMR provides an engine that supports ICD- 10 content required for billing and Meaningful Use terminology required for clinical quality measures. The sections below describe the updates made to support IMO integration and maintain consistency in the applications that allow you to search and manage diagnoses Diagnosis Search The diagnosis search is now consistent in the Problem List, New Orders (Clinical toolbar), Order Set (Clinical toolbar) and New Progress Notes (Clinical toolbar) applications. The Diagnosis Search dialog box is accessed by clicking the Search icon next to the Diagnosis list. The Diagnosis Search dialog box allows you to view provider favorite diagnoses before searching for a diagnosis. The Search For and Search Terms fields are replaced with a text box. You can use the text box to enter a full or partial keyword, ICD code, or a SNOMED code to search for a diagnosis. If searching by SNOMED code, you must enter SCT as the prefix. The search results display the diagnosis description, ICD9 and ICD10 codes for each diagnosis. The provider's favorite diagnoses in the search results are indicated with the On Favorites icon. You can add additional diagnoses to the favorite list by clicking the Add As Favorite icon next to each diagnosis. Diagnoses with additional modifiers are indicated with a Plus icon. You can click the Plus icon to select a more specific diagnosis. Optum Physician EMR v8.1 Release Notes_ of 43

25 Figure 20 Diagnosis Search Dialog Box Updates Provider Favorite Diagnoses The new Favorites icon next to the Diagnosis list allows you to access the Manage Provider Favorites dialog box to manage the provider s favorite diagnoses. You can do any of the following to manage diagnoses: Add and remove favorite diagnoses Re-order favorite diagnoses manually Sort the favorite diagnoses alphabetically Note: If diagnoses are added, you must click the A-Z icon alphabetically. again to resort the diagnoses Optum Physician EMR v8.1 Release Notes_ of 43

26 Figure 21 Manage Provider Favorites Dialog Box Problem List Application The Diagnosis column and the ICD Code columns in Problem List window displays the diagnosis description, ICD9 code and ICD10 code for diagnoses recorded after this release. When adding a diagnosis from the Problem List application, you can now view provider favorite diagnoses in the Diagnosis list. The Diagnosis list displays the diagnosis description, ICD9 code and ICD10 code for each diagnosis. For example, Headache around the eyes (784.0, R51). The new Favorites icon next to the Diagnosis list allows you to access the Manage Provider Favorites dialog box to manage favorite diagnoses. For more information on managing favorite diagnoses, see section Provider Favorite Diagnoses. Figure 22 Problem List Application: Diagnosis List and Managing Favorites Optum Physician EMR v8.1 Release Notes_ of 43

27 To access the Problem List application, click the Problem List Patient Health History pane in the Medical Record module. For information on adding a diagnosis, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > Problem List > Adding Diagnoses New Orders Application The Diagnosis list now displays provider favorite diagnoses in addition to the current encounter diagnoses and the patient s problem list. The Current Encounter section displays diagnoses you selected from the progress note or the search results. The Problem List section displays active diagnoses recorded in the patient s problem list. The Diagnosis list displays the diagnosis description, ICD9 code and ICD10 code for each diagnosis. For example, Throat clearing (784.99, R19.8). The new Favorites icon next to the Diagnosis list allows you to access the Manage Provider Favorites dialog box to manage favorite diagnoses. For more information on managing favorite diagnoses, see section Provider Favorite Diagnoses. Figure 23 New Orders Application: Diagnosis List Optum Physician EMR v8.1 Release Notes_ of 43

28 To access the New Orders application, click Orders module. on the Clinical toolbar in the Medical Record For information on adding a diagnosis to a new order, see the following topics in Optum PM and Physician EMR : Medical Record Module > Orders > Entering New Orders Order Sets Application You can now view the following updates when adding a diagnosis to an order set via the Order Set-Add Diagnosis dialog box. The new Favorite column displays diagnoses added as provider favorites. The Diagnosis list displays the diagnosis description, ICD9 code and ICD10 code for each diagnosis. For example, Headache around the eyes (784.0, R51). The new Favorites icon next to the Diagnosis list allows you to access the Manage Provider Favorites dialog box to manage favorite diagnoses. For more information on managing favorite diagnoses, see section Provider Favorite Diagnoses. To access the Order Set-Add Diagnosis dialog box, click the Add Diagnosis link in the Order Set application (Clinical toolbar). Note You can also add a diagnosis to an order set from the Order Set application in the Administration module. For information on order sets, see the following chapter in Optum PM and Physician EMR : Medical Record Module > Order Sets New Progress Note Template The tooltip on the Chart icon tab is renamed to Template. The tab allows you to select diagnoses from the template in use. Important Optum PM and Physician EMR is transitioning towards using the IMO favorite functionality released in 8.1 in all global templates. The IMO favorites will replace the point and click diagnosis section in the Template tab of all global templates. There will be 12 weeks after the 8.1 release to use the new diagnosis search feature and build your new favorite diagnosis list. During the transition period, Optum will continue to display diagnoses selected from the point and click diagnosis section in the progress note narrative. However, the diagnosis will not be saved in the Today s selected diagnosis section or will not be saved to the Visit application to capture visits. A news item will be posted at the end of the transition period to remind you of this change. The Diagnosis Search box in the Template, Problem List and Visit tabs is now replaced with a list that includes three diagnosis sections. The sections include Current Encounter, Favorites and Problem List. Optum Physician EMR v8.1 Release Notes_ of 43

29 A new Search icon is added next to the Diagnosis list in all three tabs allowing you to use the new diagnosis search. For more information on the diagnosis search updates, see section Diagnosis Search. The Problem List tab is updated with the following items: The Select All and None links are now replaced with a check box to help select all diagnoses or clear the selection with one click. The ICD9 Code and Original Date columns are renamed to ICD Code and Onset Date. The Deactivate icon is removed. You can click the diagnosis name to make additional changes in the Diagnosis dialog box. This helps manage diagnoses recorded in the patient s problem list directly from the progress note template. The Visit tab is updated with the following items: The Visit tab icon is replaced with a new icon. The Medcin term (third column) of the diagnosis is replaced with the diagnosis description, ICD9 code and ICD10 code. The Today s Selected Diagnosis section at the bottom of all three tabs is updated with the following items: The new check box on the column header allows you to select all diagnoses or clear the selection with one click. The Description column is renamed to Diagnosis and displays the IMO diagnosis description. The ICD9 column is renamed to ICD Code and displays both the ICD9 and ICD10 codes. The Status column is removed. The new PL column allows you to select the diagnosis to save to the patient s problem list (Problem List application). You can deselect the check box to remove the diagnosis from the patient s problem list by setting the status to Inactive, Erroneous, Resolved and Treatment Ended in the Diagnosis dialog box. Optum Physician EMR v8.1 Release Notes_ of 43

30 Figure 24 New Progress Note Template Application: Diagnosis Tab Updates The dialog box accessed by clicking the Finding Details icon is updated with the following items: The header displays the diagnosis description, ICD9 code and ICD10 code. The Insert Quick Text and Save Quick Text Notation options are removed. For information on selecting and managing diagnoses, see the following topic in Optum PM and Physician EMR : Medical Record Module > Progress Note Templates > Documenting a Patient Encounter > Selecting and Managing Diagnoses Immunization Reporting The Immunizations application now includes the following updates to help satisfy Meaningful Use requirements for submitting electronic data to immunization registries VIS Dates You can now save the publish dates of all Vaccination Information Sheets (VIS) provided to the patient when recording information about a combination vaccination (single injection). By default, all injections included in the combination vaccination display the latest VIS dates provided by the Centers for Disease Control and Prevention (CDC). You can change the dates if different to dates on the VIS provided to the patient. This helps to transmit the VIS published dates of combination vaccinations to the immunization registry. For example, when recording the DTaP-HepB-IPV vaccine, the following VIS published dates are saved and transmitted to the immunization registry. Optum Physician EMR v8.1 Release Notes_ of 43

31 Figure 25 New Immunizations Application: Recording VIS Dates Immunization Refusal Reasons The Refusal Reason list in the Immunization Refused dialog box now includes the options displayed in Figure 26 Immunization Refusal Reasons List. You can select these options if the patient shows evidence of immunity to a particular disease when an immunization is refused. Figure 26 Immunization Refusal Reasons List Optum Physician EMR v8.1 Release Notes_ of 43

32 Immunization Information Source The Information Source field now includes the Historical from school record option. You can select the option when recording immunizations that came from school records. The information source is included when transmitting immunization information to the Immunization Information System (IIS). Figure 27 Immunization Application: Information Source List Sending Immunization Data to Immunization Information System (IIS) You can now send historical, refused, and immunizations recorded during a visit in a single message to an immunization registry. By default the new IIS check box in front of the immunizations are automatically selected when an immunization is recorded during an encounter. You can also select the IIS check box associated with other immunizations and then click the new Send to Registry button to send all selected immunizations to the IIS. When an immunization is send to the registry, the IIS check box pertaining to the immunization sent appears dimmed. The check box also appears dimmed if you click Save and Send Electronically after recording an immunization. Note The Send to Registry button is only available if the company is set to transmit messages. Optum Physician EMR v8.1 Release Notes_ of 43

33 Figure 28 Immunizations Application: Sending an Immunization to Registry You can add past and refused immunizations, and record new immunizations from the following two locations: Medical Record module > Immunizations > Add Past/Refused Immunizations Medical Record module > Immunizations (Clinical toolbar) For information on sending immunization information to the IIS, see the following topics in Optum PM and Physician EMR : Medical Record Module > Immunizations > Submitting Data to Immunization Registries Result Report The results report now displays the following information required to meet Meaningful Use and other quality measure requirements. Specimen information Specimen Type Specimen Condition Specimen Rejection Reason Note: If a result is linked to multiple tests, the report displays the specimen information for each test. County/Parish code of the organization where the test is performed. Parent and all child results associated with the order. Optum Physician EMR v8.1 Release Notes_ of 43

34 Figure 29 Results Report To view the result report, click the result in the Result application. To print the report, click Print the Lab Result Report dialog box. in For information on printing a result report, see the following topics in Optum PM and Physician EMR : Medical Record Module > Results > Printing Patient Results Patient Education References The Patient Education titles, references, and operator roles are renamed to Patient Education/Clinical Reference to maintain consistency throughout Optum PM and Physician EMR. Figure 30 Example: Patient Education/Clinical Reference Title Optum Physician EMR v8.1 Release Notes_ of 43

35 2.14 Physician Education Resources (InfoButton) You can now access the Medline Plus website to view associated education resources for the following items: Diagnoses- To access information associated with a diagnosis, access the Problem List application, click the Arrow icon next to the diagnosis and click Diagnosis Info. Medications- To access information associated with a medication, access the Medications application, click the Arrow icon next to the medication and click Medication Info. Laboratory results- To access information associated with a lab result access the Results application and click the result you want to view. Click the Info icon next to each result to view associated information. Most documents are available in both English and Spanish and are for reference only. You can also and print the information, and search for other information if necessary. For more information about MedlinePlus, go to Note You must have the Patient Education/Clinical Reference role to access reference information via the Info icon. Figure 31 Patient Diagnoses: Accessing Health Information (MedlinePlus) Optum Physician EMR v8.1 Release Notes_ of 43

36 For information on accessing physician education resources, see the following topics in Optum PM and Physician EMR : Medical Record Module > Problem List > Viewing Diagnosis Health Information, Medical Record Module > Medications/Prescriptions > Viewing Medication Health Information and Clinical Today Module > Results > Viewing Result Health Information Patient Care Management The Patient Care Management application now allows you to point to a measure to view a description of the measure. Figure 32 Patient Care Management Application: Measure Description You can access the Patient Care Management application from the following location: Medical Record Module > Patient Care Management Patient Health History pane For information on patient care management, see the following chapter in Optum PM and Physician EMR : Medical Record Module > Patient Care Management. Optum Physician EMR v8.1 Release Notes_ of 43

37 3 Administration Module 3.1 Clinical Audit Log The clinical audit log now includes the following updates to help satisfy Meaningful Use requirements. The clinical log displays the Clinical Note Searched entry when you search for a keyword in a progress note template. The clinical log displays the Clinical Note Copied entry when you copy information from a note associated with a previous encounter. You can point to the Note icon to view the encounter date and the sections that were copied from the previous note. Figure 33 Clinical Audit Log: Progress Note Activities The clinical log allows you to access the progress note audit log associated with the following entries. Clinical note printed Clinical note unsigned Clinical note removed/inactivated Patient vital signs added Clinical note signed You can access the progress note audit log in the Progress Note application by clicking the View icon. This helps to view more detailed information about the log entry in the clinical log. The clinical log allows you to access the order audit log associated with the following entries: Order Accessed Order Added Order Marked Complete Order Modified Order Printed Order Removed/Inactivated You can access the order audit log in the Orders application by clicking the View icon to view more detailed information about the log entry in the clinical log.. This helps Optum Physician EMR v8.1 Release Notes_ of 43

38 Figure 34 Clinical Audit Log: Order Activities You can access the clinical audit log from the following location: Administration module > Clinical tab > Clinical Audit Log link (Daily Administration section) For information on the clinical audit log, see the following topic in Optum PM and Physician EMR Online Help: Administration Module > Clinical > Daily Administration > Viewing the Clinical Audit Log. 3.2 Clinical Letter Editor You can now create clinical letters to display the ICD10 code and associated descriptions by using the two new letter fields listed below. Note: The ICD10 diagnosis formatting fields only display diagnoses recorded via the new IMO search in the Problem List application. To display the ICD9 and ICD10 codes of any diagnoses recorded in the patient s medical record, use the ICD9 formatting fields. The ICD9 formatting fields are independent of the search method used to record the diagnosis. Diagnosis ICD10 Code (Single) - Displays the ICD10 description and code of the last diagnosis recorded in the patient s problem list. For example, Abdominal Pain, Unspecified Site (R10.0). Diagnosis ICD10 Code (All) - Displays the ICD10 description and code for all diagnoses recorded in the patient s problem list. For example, Abdominal Pain, Unspecified Site (R10.0), Unspecified Congenital Anomaly of Heart (Q24.9). To add the new fields, click the Add Letter Field icon in the Clinical Letter Editor application. In the Select Letter Field dialog box, click the Patient Fields category, and then click the Patient Diagnosis sub category. Optum Physician EMR v8.1 Release Notes_ of 43

39 Figure 35 Clinical Letter Editor: Select Letter Field You can access the Clinical Letter Editor application from the following location: Administration module > Clinical tab > Clinical Letter Editor link (Daily Administration section) For information on creating clinical letter templates, see the following chapter in Optum PM and Physician EMR : Administration Module > Clinical > Daily Administration > Clinical Letter Editor > Creating a Clinical Letter Template. 3.3 Full EHR Export The Full EHR Export application facilitates batch export of patient data. The feature is further enhanced with the updates listed below. The existing Full EHR Export application is renamed to Full EHR Export (PDF). This application facilitates batch export of patient data in PDF format. Optum Physician EMR v8.1 Release Notes_ of 43

40 You can access the Full EHR Export (CDA) application from the following location: Administration module > Clinical tab > Full EHR Export(PDF) link ( Import/Export section) The new Full EHR Export (CDA) application facilitates exporting C-CDAs pertaining to patients. This helps to electronically export current C-CDA summaries for all patients and meet Meaningful Use requirements on data portability. Support: To export a batch of patient C-CDAs using the application, you must have the Full EHR Export (CDA) override added to your user profile and log a ToDo to the Support entity. When a ToDo is logged, OptumInsight will provide you a user name and password to access a folder in the Secure File Transfer Protocol (SFTP) site. You can then use the Full EHR Export (CDA) application to export patient C-CDAs to the assigned folder. Figure 36 Full EHR Export (CDA) Application You can access the Full EHR Export (CDA) application from the following location: Administration module > Clinical tab > Full EHR Export(CDA) link (Import/Export section) For information on the Full EHR Export application, see the following topic in Optum PM and Physician EMR : Administration Module > Clinical > Import/Export > Full EHR Export (CDA). Optum Physician EMR v8.1 Release Notes_ of 43

41 4 Reports Module 4.1 Meaningful Use 2014 Clinical Quality Measure (CQM) Reports You can now generate the following Clinical Quality Measure (CQM) reports to submit data required for Meaningful Use incentives. For more information on Centers for Medicare and Medicaid Services (CMS) Meaningful Use reporting requirements, go to: Guidance/Legislation/EHRIncentivePrograms/2014_ClinicalQualityMeasures.html Adult Recommended Core Measures (CMS165) NQF0018-Controlling High Blood Pressure (CMS156) NQF0022-Use of High-Risk Medications in the Elderly (CMS138) NQF0028-Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (CMS166) NQF0052-Use of Imaging Studies for Low Back Pain (CMS2) NQF 0418-Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS68) NQF 0419-Documentation of Current Medications in the Medical Record (CMS69) NQF Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (CMS50) Closing the referral loop: receipt of specialist report (CMS90) Functional status assessment for complex chronic conditions Pediatric Recommended Core Measures (CMS146) NQF0002-Appropriate Testing for Children with Pharyngitis (CMS155) NQF0024-Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents (CMS153) NQF0033-Chlamydia Screening for Women (CMS126) NQF0036-Use of Appropriate Medications for Asthma (CMS117) NQF0038-Childhood Immunization Status (CMS154) NQF0069-Appropriate Treatment for Children with Upper Respiratory Infection (URI) (CMS136) NQF0108-ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (CMS2) NQF0418-Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan (CMS75) Children who have dental decay or cavities You can generate the Meaningful Use reports listed above from the following location: Reports module > Reports tab > Stage 2 Meaningful Use 2014 CQM Reports link (Medical Reports section) Optum Physician EMR v8.1 Release Notes_ of 43

42 For information on generating Meaningful Use reports, see the following chapter in the Optum PM and Physician EMR Help: Reports Module > Reports > Meaningful Use. 4.2 Meaningful Use Key Performance Indicator (KPI) Reports The Report list options in the Meaningful Use KPI Reports application are renamed as listed below option - Meaningful Use Stage option Meaningful Use Stage 2 The 2014 KPI reports include the following: Meaningful Use Core Objective 1 - CPOE for Medication, Laboratory and Radiology Orders Meaningful Use - Core Objective 2 eprescribing Meaningful Use - Core Objective 3 - Record Demographics Meaningful Use - Core Objective 4 - Record Vital Signs Meaningful Use - Core Objective 4 - Record Vital Signs BP Out of Scope Meaningful Use - Core Objective 4 - Record Vital Signs HT LG WT Out of Scope Meaningful Use - Core Objective 5 - Record Smoking Status Meaningful Use - Core Objective 7 - Patient Electronic Access - Measure 1 Meaningful Use - Core Objective 7 - Patient Electronic Access - Measure 2 Meaningful Use - Core Objective 8 - Clinical Summaries Meaningful Use Core Objective 10 - Clinical Lab Test Results Meaningful Use - Core Objective 12 - Patient Reminders Meaningful Use - Core Objective 13 - Patient Specific Education Resources Meaningful Use - Core Objective 14 - Medication Reconciliation Meaningful Use - Core Objective 15 - Summary of Care - Measure 1 Meaningful Use - Core Objective 17 - Secure Messaging Meaningful Use - Menu Objective 2 - Record Electronic Notes in Patient Records Meaningful Use - Menu Objective 3 - Imaging Result Meaningful Use - Menu Objective 4 - Record Patient Family History You can access the Meaningful Use KPI reports application from the following location: Reports module > Reports tab > Meaningful Use KPI Reports link (Medical Reports section) For information on generating Meaningful Use KPI reports, see the following topic in the Optum PM and Physician EMR Help: Reports Module > Reports > Meaningful Use > Meaningful Use KPI Reports. Optum Physician EMR v8.1 Release Notes_ of 43

43 4.3 Patient Clinical Log Report The following order and progress note entries recorded in the clinical audit log are now included in the Patient Clinical Log report to help satisfy Meaningful Use reporting requirements. Table 3 Clinical Log Report Entries Category Entries Order Accessed Order Added Order Order Marked Complete Order Modified Order Removed/Inactivated Order Printed Progress Note Clinical Note Printed Clinical Note Signed Clinical Note Searched Clinical Note Copied Patient Vital Signs Added Clinical Note Unsigned Clinical Note Removed/Inactivated You can access the Patient Clinical Log report from the following location: Reports module > Reports tab > Other Reports link (Medical Reports section) > select Global-Patient Clinical Log in the Report list. For information on the Patient Clinical Log report, see the following topic in the Optum PM and Physician EMR Help: Reports Module > Reports > Medical Reports > Medical - Other Reports. Optum Physician EMR v8.1 Release Notes_ of 43