Optum Physician EMR v 8.0 Release Notes

Transcription

1 Optum Physician EMR v 8.0 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 01/31/14 Version 1.02 Document Control Version Date Changed Completed By Description of Changes /13/14 G.Caldera Initial Release (Beta) /23/14 G.Caldera Updated: /31/14 G.Caldera Updated: Medication History- Added a note about displaying SIG instructions New Progress Note Templates Changed the specialty from Internal Medicine to Cardiology for the Non-invasive Venous Eval v3 template. Removed Obstetrics and Gynecology templates. Optum Physician EMR v8.0 Release Notes_1.02 ii of 22

3 Contents About this Document... iv Purpose... iv Before You Begin... iv Document Conventions... iv 1 Release Overview Clinical Today Module Print Scheduled Charts Medical Record Module Clinical Alerts Chart Summary: Review Medications Formal Health Record and Chart Summary Printouts Progress Note Templates New Progress Note Templates Immunization Details Visit Capture Progress Notes Application Medications and Prescriptions Add Medications Medication Order Details Medication History Medication Administration Immunizations: Search Historical Immunizations Recalls New Recall Status Filter Updates Column and Grid Updates ToDo, Mail and Fax Resource Information Administration Module Care Management Activation Print Scheduled Chart Settings Operator Audit Log Extract Optum Physician EMR v8.0 Release Notes_1.02 iii of 22

4 About this Document Purpose This document outlines new and updated features for the 8.0 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. Online Help For instructions on clearing your cache, see Optum PM and Physician EMR Online Help > 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 v8.0 Release Notes_1.02 iv of 22

5 1 Release Overview This section highlights some of the enhancements included in this release: The Print Scheduled Charts application now allows you to customize the items to include in the appointment charts report. Additionally, you can use the Print Scheduled Charts application in the Administration module to pre-define the default items to include in the report and set up recurring reports to run nightly. See section 2.1 Print Scheduled Charts on page 6 and section 4.2 Print Scheduled Chart Settings on page 21. Per HIPAA Omnibus ruling, you can include or hide the information associated with a private pay visit from the formal health record and chart summary printouts. See section 3.3 Formal Health Record and Chart Summary Printouts on page 8. The Medication History dialog box now comply with the Optum user interface standards and is in accordance with regulatory and industry guidelines. Additionally, you can set the status, and enter start and end dates for administered medications. See section Medication Administration on page 14. The immunization search now includes the option to show obsolete immunizations. See section 3.7 Immunizations: Search Historical Immunizations on page 15. The Recalls application in the Medical Record module is now consistent with the Recall application in the Scheduling module. See section 3.8 Recalls on page 15. The Link Patient Data feature in the ToDo, Mail and Fax applications now displays additional information to help select the correct item to attach. See section 3.9 ToDo, Mail and Fax on page 17. The Care Management application now displays additional information about the source of each measure, allows you to activate and deactivate measures and registries by user, and displays a log to view activity on a measure. See section 4.1 Care Management Activation on page 20. Optum Physician EMR v8.0 Release Notes_ of 22

6 2 Clinical Today Module 2.1 Print Scheduled Charts The Print Scheduled Charts Dialog Box is updated with the items listed below. The Include VIP Patients' Chart in the Print check box is added to print charts for VIP patients. The Charts Sections to Include section is added to help filter the information included in the printed charts. The details to include in all charts can now be pre-defined from the Print Schedule Charts application in the Administration module. For more information on defining print scheduled chart defaults, see section 4.2 Print Scheduled Chart Settings. Note: If Progress Notes is selected, the printed reports only include the most recent progress note that pertains to the patient. The Generate button is renamed to Publish Reports. To print scheduled charts, click the Print Scheduled Charts link in the Appointments application of the Clinical Today module. Figure 1 Appointments Application: Print Scheduled Charts Dialog Box Additionally, the scheduled chart reports are now sent to a queue when printed and saved in the Group folder of the Published Reports application. The reports are saved in the following format: Daily Scheduled Charts yyyymmddhhmiss Locations, Resources To access the Published Reports application, click the Reports module and then click the Published Reports tab. Online Help For information on printing appointment charts, see the following topic in Optum PM and Physician EMR Online Help: Clinical Today Module > Appointments > Printing Appointment Charts. Optum Physician EMR v8.0 Release Notes_ of 22

7 3 Medical Record Module 3.1 Clinical Alerts The clinical alerts for patients age 13 and older now display the smoking status in addition to the date the status was set. Figure 2 Clinical Alerts Dialog Box Note The smoking status is set in the Tobacco Assessment section of the History tab or the Quality tab of the progress note template. 3.2 Chart Summary: Review Medications When reviewing a patient s list of medications during a transition of care visit, you must verify that the medication list for the patient is current and accurate by comparing it with all orders. With this release, the Chart Summary is updated to match the Medication application, and displays a message to confirm that the medication list was reconciled. The message displays when you click Mark Reviewed during transition of care type encounters. Note To mark an encounter as a transition of care, access the encounter by clicking the Encounters link on the Patient Detail bar, and set the Transition of Care list to Yes. Optum Physician EMR v8.0 Release Notes_ of 22

8 Figure 3 Medication Reconciliation for Transition of Care Visits 3.3 Formal Health Record and Chart Summary Printouts HIPPA requires you to provide patients with the option to exclude information recorded during private pay visits from the formal health record and chart summary printouts. To comply with the new requirements, you can select the new Exclude Private Pay Information check box to remove the information associated with an encounter. The information includes: Vitals Encounters Procedures Correspondence Patient History Progress Notes Orders Documents Note To exclude the information recorded during private pay visits from the printouts, the Insurance field must be set to Private Pay in the Visit application (Visit Summary tab). Figure 4 Formal Health Record Dialog Box: Exclude Private Pay Information Field To print the formal health record or chart summary, click the arrow next to Print on the Clinical toolbar, and then click Print Chart Summary or Print Formal Health Record. Optum Physician EMR v8.0 Release Notes_ of 22

9 Online Help For information on printing the chart summary and the formal health record, see the following topics in Optum PM and Physician EMR Online Help: Medical Record Module > Chart Summary > Printing the Chart Summary and Medical Record Module > Chart Summary > Printing the Formal Health Record. 3.4 Progress Note Templates The Progress Note Templates application now includes new templates to use when documenting a patient encounter and is supported with the features described in the sections below New Progress Note Templates Listed below are progress notes that are available with this release. Table 1 New Templates Specialty Template Cardiology Physical Therapy Non-invasive Venous Eval v3 PT (30-day and DC) (v5) Note: The new template displays both the previous and current values you enter for easy comparison. The narrative associated with the template also displays the previous and current values in table format. To access the new templates, click Progress Notes on the Clinical toolbar Immunization Details Immunization information recorded during a patient encounter is now displayed in the narrative as a paragraph or table. The table format displays each immunization detail in a new line. Support If you want to display specific immunization details in the narrative, 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. Optum Physician EMR v8.0 Release Notes_ of 22

10 Figure 5 Progress Note Template Narrative: Viewing Immunization Details (Table Format) Visit Capture You can now send CPT, HCPCS or V code (ICD-9) associated with the items selected in a progress note template to the Visit application during a patient encounter. Support To activate the setting to send all or specific codes from a progress note template to the Visit application, log a ToDo to the Support entity. When logging the ToDo, set the Category to Content, Type to EHR and Reason to Templates. Figure 6 Progress Note Template: Sending Codes from the Template to the Visit Application Optum Physician EMR v8.0 Release Notes_ of 22

11 3.5 Progress Notes Application The Progress Note application currently maintains deleted progress notes in inactive status. With this release, you can view and restore the deleted notes. To view deleted progress notes, select the new Show inactive check box. The deleted notes appear dimmed. To restore a deleted progress note, click Restore Note at the bottom of the window. When the note is restored, the Note Reactivated entry is recorded in the clinical log. Figure 7 Progress Note Application: Viewing and Restoring Inactive Notes You can access the Progress Notes application from the following location: Medical Record module > Progress Notes Patient Health History pane Online Help For information on deleting and restoring a progress note, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > Progress Note Templates > Deleting and Restoring a Progress Note. 3.6 Medications and Prescriptions The Medications and Prescriptions applications include the following updates: Add Medications When adding multiple medications at a time to a patient s medical record, the Provider field auto populates with the provider from the previous medication you entered. Optum Physician EMR v8.0 Release Notes_ of 22

12 Figure 8 Medications Application: Adding Medications To add medications, click +Patient Med in the Medications application. You can enter information for the first medication and then click Save and New to enter another medication. Online Help For information on adding a medication, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > Medications/Prescriptions > Adding Medications Medication Order Details The Rx Tasks dialog box displays detailed information about a medication order and is accessible from the locations listed below. Home module > Dashboard tab > Prescriptions New link (Clinical section) > click on the medication name From the Clinical Today module using one of the following methods: Clinical Today module > Tasks tab > Rx New (from the Tasks menu) > click on the medication name Clinical Today module > Rx New (from the Quick Tasks menu) > click on the medication name Medical Record module > Medications > click on the medication SIG The Rx Tasks dialog box accessed from the Medical Record module is now consistent with the Rx Tasks dialog box accessed from the other locations. Optum Physician EMR v8.0 Release Notes_ of 22

13 Figure 9 Rx Tasks Dialog Box Online Help For information on viewing medication order details, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > Medications/Prescriptions > Viewing Medication Details Medication History The Drug History dialog box is renamed to Medication History, and is updated to comply with Optum standards to streamline the workflow. The updates are listed below. The patient banner is added to display patient and appointment information. You can verify and add vitals, medications, diagnoses and allergies from the patient banner. The new Diag column is added to display diagnoses treated with the medication. The columns are renamed to match the Medications application. Table 2 Medication History Column Updates Old Column Name New Column Name Drug Provider Quantity Received Fill Date Medication Fill Provider Qty Renewal Optum Physician EMR v8.0 Release Notes_ of 22

14 The imported SIG instructions are added below the medication name. Note: The SIG instructions display only if the information is provided by the Pharmacy Benefit Manager (PBM). The Medication and Fill Provider columns are now updated with the ability to sort. The Update Last Fill Dates Only button is renamed to Update Last Renewal Dates Only. Figure 10 Medications Application: Medication History Dialog Box You can access the Medication History dialog box from the following location: Medical Record module > Medications (Patient Health History pane) > Request Med History link Online Help For information on viewing the medication history, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > Medications/Prescriptions > Viewing Medication History Medication Administration You can now enter the following details on medications administered to the patient. Start and End date Status Statuses include Active, Inactive, Discontinued, Erroneous, Completed, Medication Refused or Failed. This ensures all administered medications are captured in the patient s medical record and the Continuity of Care Document (CCD) until an end date is recorded or the status is changed from Active to a different status. Optum Physician EMR v8.0 Release Notes_ of 22

15 Figure 11 Administered Medications Dialog Box: Start Date, End Date and Status Fields To enter information about medications administered, click Med Administration in the Medications application. Online Help For information about medication administration, see the following chapter in Optum PM and Physician EMR Online Help: Medical Record Module > Medications/Prescriptions > Medication Administration. 3.7 Immunizations: Search Historical Immunizations The Immunization Search dialog box now includes a Show Obsolete check box allowing you to view historical immunizations. This allows you to add historical immunizations that were administered or refused to the patient s immunization list. Figure 12 Immunization Application: Immunization Search Dialog Box 3.8 Recalls The Recalls application in the Medical Record module is updated to match the Recalls application in the Scheduling module. The application now displays all recalls including inactive and completed recalls for the patient. Additionally, the application includes the updates described in the sections below. Optum Physician EMR v8.0 Release Notes_ of 22

16 Figure 13 Recalls Application New Recall Status Recalls linked to an appointment now display with the new Completed status. You cannot edit a completed recall Filter Updates The Show Inactive check box is now replaced with the two new check boxes listed below. Show Active Only- Select the check box to display active recalls for the patient in context. Show All- Select the check box to display active, inactive and completed recalls for the patient in context Column and Grid Updates The column and grid updates are listed below. The Due Date column is renamed to Recall Date. The new Status column displays the status of the recall. The statuses include active, inactive and completed. The InAct/Act. column is removed. The new Edit column allows you to click the Edit icon to edit recalls in the active and inactive statuses. You cannot edit recalls in the completed status. The new Audit Log column allows you to click the Log icon to view all activity related to the recall. You can access the Recalls application from the following location: Medical Record module > Recall on the clinical toolbar Online Help For information on recalls, see the following chapter in Optum PM and Physician EMR Online Help: Medical Record Module > Recalls. Optum Physician EMR v8.0 Release Notes_ of 22

17 3.9 ToDo, Mail and Fax You can now view detailed information when linking patient data to a ToDo, mail or fax. This helps to quickly identify the sections and items in the chart you want to attach. Figure 14 ToDo: Linking Patient Data (Results) The table below lists the updates made to each section. Table 3 ToDo Attachments/Links Dialog Box Section Updates Section Change Description New Columns Reported Results Collected Description Provider Optum Physician EMR v8.0 Release Notes_ of 22

18 Section Change Description New Columns Date Orders Test Description Provider Renamed Columns Test Description (previously named as LabOrder) New Columns Referrals Referral to Referral from Deleted Columns Referral New Columns Documents Doc Date Renamed Columns Name (previously named as Document) New Columns Prescriptions Renewal Fill Provider Renamed Columns Medication (previously named as Rx) New Columns Due Date Recalls Appointment Provider Notes Deleted Columns Recall To link patient data from the above sections, click the Link Patient Data link in the ToDo, Mail or Fax applications. You can access the above applications from the following locations: Name Bar > ToDo Medical Record module > ToDo on the Clinical toolbar Online Help For information on creating a ToDo, see the following topic in Optum PM and Physician EMR Online Help: Medical Record Module > ToDo(s) > Creating ToDo(s). Optum Physician EMR v8.0 Release Notes_ of 22

19 3.10 Resource Information The resource name is added next to the last and next appointment information in the following format: Date - Appointment Name, Resource Name, Location The resource information is available in the following locations: Medical Record module > Rx application (clinical toolbar) Medical Record module > New Order application (clinical toolbar) Medical Record module > Medications patient health history pane > click on a medication Figure 15 Rx Application: Last Appointment Details Optum Physician EMR v8.0 Release Notes_ of 22

20 4 Administration Module 4.1 Care Management Activation The Care Management application is now updated with the items listed below. Figure 16 Care Management Activation Application The new Type column indicates if the measure is for preventive maintenance or disease management. The column displays Health Maintenance or Disease Management based on the type of care. The new Measures/Registries column displays the measure or registry name, description and the source of information. Additionally, you can click the name to view the supporting documentation provided by Optum. The new Operators column allows you to activate the measure for operators in your group and view the operators that have the measure activated. To activate a measure for an operator in your group, click the Operator icon and then select one or more operators from the Care Management-Operator Alerts dialog box. You can also click Select All to select all operators, or click None to clear your selection. Note: If a measure is activated for one or more operators, the check box in front of the Type column displays a check mark. To view operators that have the measure activated, point to the Operator icon. Note: The care management alerts in the Clinical Alerts dialog box and the measures available in the Patient Care Management application are based on the measures activated for the operator. The new Log column allows you to view activity related to the measure. Click the Log icon to access the View Care Management Admin Logs dialog box. Figure 17 Care Management Activation Application: Activity Log You can access the Care Management Activation application from the following location: Administration module > Clinical tab > Care Management Activation (System Administration) Optum Physician EMR v8.0 Release Notes_ of 22

21 Online Help For information on the Care Management Activation application, see the following topic in Optum PM and Physician EMR Online Help: Administration Module > Clinical > System Administration > Activating Care Management Items. 4.2 Print Scheduled Chart Settings The new Print Scheduled Charts application allows you to define the following default information to include in the charts printed through the Appointments application in the Clinical Today module. For information on printing charts in the Appointment application, see section 2.1 Print Scheduled Charts. Chart sections Note: The progress notes only include the most recent progress note that pertains to the patient. Time period Additionally, the application allows defining and adding reports to run nightly. In addition to setting the chart sections and the time period, you must set the following for recurring reports: Resource- You can select one or more resources that have scheduled appointments from the Resource list. You can also click All to select all resources, or click None to clear your selection. Location- You can select one or more locations from the Location list. You can also click All to select all locations with appointments, or click None to clear your selection. You can click Save and New to define multiple reports to run nightly without exiting the Recurrence dialog box. The recurring reports are saved under the Saved Recurring Reports section. Figure 18 Print Scheduled Charts: Defining Recurring Reports Optum Physician EMR v8.0 Release Notes_ of 22

22 Additionally, you can do the following to manage the recurring reports. Click Edit to update the resource and location set on the reports. Click Delete to delete reports that are not in use. Figure 19 Print Scheduled Chart Settings: Editing Recurring Reports You can access the Print Scheduled Charts application from the following location: Administration module > Clinical tab > Print Scheduled Charts (System Administration) Online Help For information on the Print Scheduled Charts application, see the following topic in Optum PM and Physician EMR Online Help: Administration Module > Clinical > System Administration > Setting Scheduled Chart Defaults. 4.3 Operator Audit Log Extract The new Operator Audit Log Extract application allows you to extract Practice Management and EMR operator logs pertaining to a group as two separate exportable CSV files. For more information on the Operator Audit Log Extract application, see the Optum Practice Management Release Notes. Figure 20 Operator Audit Log Extract Application You can access the Operator Audit Log Extract application from the following location: Administration module > Practice tab > Operator Audit Log Extract link (Security Logs section) Optum Physician EMR v8.0 Release Notes_ of 22