Exploring OP14: EHR Features

Transcription

1 Exploring OP14: EHR Features User Conference 2014 Presented by: BJ Bloom EHR Training Specialist

2 Hands ON introduction to OP14 the new features: Re-organization of Menus Search Text Function in Summary Notes Well Visit ROS change Problem List Allergy List Rx Interaction Checks Coding Tab History Changes/Family History Diagnostic Tests Procedure Tab in Templates Clinical Recalls Care Plans

3 Re-organization of Menus Activities = Import Diag Tests, Vaccine Inventory, Correspondence, Bulk Payments, Capitation Reports = DAR, Grid of Vaccines, Financial Utilities = Manage Codes, Manage Practice, Manage Clinical Features, System Admin

4 Search Text Function in Summary Notes Summary section of an open or finalized encounter Any letter, number, word or phrase can be found by typing it into the search field.

5 Well Visit ROS terms change Reporting Wellness: Reports is now Confirms GREEN Denies is now Concerns PINK BJB

6 Problem List The Problem List must now be coded with SNOMED. Therefore, by entering a key search word, the HLI engine will present associated SNOMED codes. The SNOMED code will appear next to the text entry field AND in the Problem List

7 Allergy List The Allergies must now be coded with SNOMED. The MU indicator will be on the Medication allergy only. By entering a key search word, the HLI engine will present associated SNOMED codes.

8 Rx Interaction Checks Drug-drug/Drug-allergy interaction checks Interactions default to Med/Allergy and Med/Med Administrative user has ability to turn on/off Med/Med and Med/disease. Med/Allergy cannot be turned off The Admin user can still change all warning levels.

9 Coding a Visit Diagnosis will be applied to the visit in the Asses/Plan tab CPT coding will be done in the Coding tab you will be able to apply up to 4 diagnoses to each CPT code this can also be done on the Add/Edit charges screen BJB

10 History Changes New Look Past Medical History: Summary Tab removed; only PMH NEW Family Hx: OP 11 and OP 14 practice will do a one time conversion from OP 11 -> OP 14 based on contacts defined as family After Conversion completed, OP 11 Fam Hx may be archived. *Important: Conversion can not be undone. NEW Social History: now is separate; can still copy to siblings that are linked as social family NEW Perinatal History: now is separate; Newborn Carriage is removed; All Newborn Hx buttons have separate tabs; Neonatal course tab removed; text field in Maternal/Pregnancy Hx removed

11 Family History OP 14 New Tab 4 discrete fields: Family Member - selected by role, paternal gm Problem - (from Encounter Builder) linked to the HLI engine and the SNOMED code is automatically populated DX Age - age ranges Notes Field

12 Diagnostic Tests The diagnostic test screen has been reorganized. Categories: This is defined in Diagnostic Test Set Up; filtered by buttons on left hand side Labs: Count towards MU Screens: Hearing and Visions (will not count towards MU) Imaging: Count towards MU Procedures (ex: Nebulizers) will not count towards MU Function buttons: the top right In-House Send-Out Legacy buttons Print, Send and Report The requisitions listed in each category will have orders contained within them which are categorized as such (if the original req contains a combination it will be sorted)

13 Diagnostic Tests requisition orders results Orders are presented below based on the requisition highlighted above Each order will have a Plus (+) sign to expand the grid for results to be viewed Results entered as alpha. All other fields can be entered as well. If results are interfaced, each field will be populated based on what is returned from the 3rd party (e.g. lab, imaging center, etc )

14 Diagnostic Tests F7/Practice Workflow the ability to Review All

15 Diagnostic Tests Test Set Up

16 Diagnostic Tests Results in Visit/Chart

17 Well and Sick Visit Template Procedure Tab: looks like Coding tab in notes add CPT codes to you template, along with Modifiers Units Procedure Note - can template notes template procedure notes here Uses: Inhouse Meds: Units of Rocephin, Circumcision, Nebulizer Treatments, Wart Destruction, Umbilical Cautery, Cerumen Removal, Suturing, etc.

18 Clinical Recall tab Care Plan recall, Vaccine Status Recall, Vaccines Given tabs remain unchanged Recalls for Problem Noted (Dx), Med Allergy, Medication Given, Lab Results, Lab Value Range or any Combination Creating a patient demographic list is still required to move forward in querying and generating recalls Each field can be sorted, or grouped. Each field except PATNO and Patient Name can be filtered. Search is by SNOMED or ICD

19 Clinical Decision Support (Care Plans) OP will deliver a set of care plans Care Plan has 3 sections: Definition, Triggers and Actions Client can create own BJB

20 Care Plans Clinical Decision Support (Care Plans) OP will deliver each client a set of Care Plans As a default: All patients will be enrolled in the Bright Futures Preventative Care Plan BJB

21 Manage Care Plans: Global > Utilities > Manage Clinical Features > Care Plans Definition: Purpose: Description Active: Indicates whether or not the care plan is turned on. If not Active: Users will not be presented with the opportunity to enroll a patient even if all triggers are met AND the recommended actions will be removed from the patient s chart and any reporting Auto-enroll: Allows user to set the care plan where if a patient meets all the triggers, he/she will be automatically enrolled in the care plan without the user being asked to enroll the patient. An example: Bright Future Preventive as it follows the AAP periodicity schedule. Privacy Level: Indicates at what level in the practice can a user enroll a patient in the care plan. There may be some care plans where the practice feels their nursing staff is capable of making that decision, but there may be others where the decision needs to be left to a physician who has the appropriate medical decision making capability. Bibliographic Citation: This citation should usually always reference evidence based guidelines. URL: A link to the evidence based guidelines referenced in the citation. Developed by, Funding source and Released/Revised dates are related to the citation BJB

22 Manage Care Plans: Global Triggers: Actions: Triggers represents the elements of a patient chart that would qualify the patient for enrollment in the care plan. There can be multiple variables and more than one trigger. The Grouping Rules determine how and item is considered. What is important to note here is the grouping rule OR Begin Group indicates a new trigger set. the clinical interventions the user will be reminded to perform an action can be disabled (suppress) but not necessarily removed from the care plan all together BJB

23 Manage Care Plans: Global Care Plan Items tab each item is defined and the default interval can be edited the item can be marked as a trigger and action or both Care Plan Item Types tab is where available care plan items will be managed. BJB

24 Care Plans F8 Patient Chart and Care Plan tab now shows the Care Plan the action is triggered by along with a hyperlink to the citation By clicking Customize from the care plan screen All active care plans the patient is enrolled will be listed disenrolled will appear for those available but not yet indicated BJB

25 Care Plans F8 Patient Chart and Care Plan tab Available Care Plans tab staff can make a decision about the patient s enrollment once he/she qualifies or it can be manually forced even though the patient may not meet all of the triggers at the time If a patient does meet the triggers for a care plan, the user will be presented with an opportunity to confirm whether or not they would like to enroll the patient in the care plan BJB

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