Workflow a.k.a. Avoiding Paralysis (& Bankruptcy)

Transcription

1 Workflow a.k.a. Avoiding Paralysis (& Bankruptcy) James McCulley MD,FACS,FRCOphth(UK) Department of Ophthalmology The University of Texas Southwestern Medical Center

2 And EMR s

3 EMR s are here to stay!

4 Effective communication is critical and essential!

5 EMR ese is a foreign language!

6 EMR ese uses common words to mean something different from normal usage!

7 Typical IT person!

8 Typical IT approach!

9 Have an effective super-user team!

10 Chair must be the leader! Or Equivalent SOB

11 Some Basic Issues Which EMR in use? Epic 2009, 2010, or Kaliedescope Other Meaningful Use status attestation status for 2011 & plans for 2012 (only do what needs to be done for good eye care we are not the patient s PCP!!!) PQRS (PQRI/eRx) Group or Individual or Registry

12 Challenges to EPIC in Ophthalmology Challenges Visit Navigator Navigator was set up for Internal Medicine Seeing 1 2 patients per hour Provide Patient with electronic access (Meaningful Use) Patient ID Section National Patient Safety Goal Vitals Section (Meaningful Use) Section designed for Internal Medicine BMI automatically calculates. Designed BMI management w/list of options on referral Resolutions We worked with IR to customize our own Encounter and Navigator to follow our workflow in Ophthalmology Our front desk staff offers our patients MyChart access Techs obtain/verify for identification purposes only (Techs measure BP with wrist cuff, sitting only. Weight and Height by history). No pulse, no respiration, no temperature Refer to PCP for Nutritional assessment, Weight loss/gain diet info given. Techs are to click the marked as review button

13 Challenges to EPIC in Ophthalmology Smoking/Alcohol History (Meaningful Use) Section designed for Internal Medicine Best Practice Alerts (Meaningful Use) Techs to ask minimal questions Tobacco Use if patient smokes/non smoker Counseling button Alcohol Use (yes or no) Only thing in this section not previously covered is greater than 65 year old pneumococcal vaccination by history. If all elements not completed section is automatically highlighted. Review of Systems (we created under Smart Forms) EPIC did not have in software Techs complete this section. Created form in EPIC identical to the hard copy ROS that our patient fills out. Chief Complaint Customized section for Ophthalmology with alphabetized drop downs based on Medicare approved reasons for visits.

14 HPI Challenges to EPIC in Ophthalmology Medication Reconciliation Allergies (Meaningful Use) Past History Designed for Internal Medicine Took out of Assessment/Plan so it can be edited. Customized section for Ophthalmology with drop downs in each section: Quality Signs Location Severity Timing Duration Context Modifying Factors New patients all meds are documented and reviewed. Existing patients techs obtain and review ophthalmology meds on each visit. Obtained authorization for techs to mark as reviewed. Techs obtain info and mark as reviewed Customized Past History section for Ophthalmology including: Past Ocular History (customized with drop downs ) Ocular Surgical History (customized with drop downs ) Past Medical History Past Surgical History Family History (customized for ocular conditions)

15 Challenges to EPIC in Ophthalmology Problem List (Meaningful Use) Ophth Exam EyeRoute Diagnosis in Visit Navigator Can do in Smart Sets as well but.. Assessment/Plan LOS and Follow up Techs review old paper chart and list all previous diagnoses in EMR before 1 st EMR visit. Physicians review and confirm. Physicians update with all diagnoses as they occur. Obtained authorization for Techs to mark as reviewed. Using EPIC Ophthalmology module at all locations except for CMC where we use Kaleidoscope. Tech and resident/fellow enter exam & faculty reviews and edits PRN. (mark as reviewed or do something in each exam screen) Access to images of ancillary testing. Allows side by side viewing with problem list (need to indicate primary diagnosis for visit).can update Problem List by dragging. Either Physician can type free text or can click icon that brings all Diagnoses into Assessment/Plan. Physicians place CPT code for visit and return appointment directions.

16 Challenges to EPIC in Ophthalmology Smart Sets Meds/Orders (Meaningful Use) Designed for Physician order/signature only, which measured as CPOE Designed Ophthalmology smartsets for each subspecialty. Typically duplicates much but not all in the visit navigator. (varies by subspecialty) Created a workflow by having our techs enter the orders/meds, and pend. Allows the Physician as the first signature on the orders/meds. Ancillary Service techs needed orders to perform the ancillary procedure. Workflow found in Chart Review and Procedure tab. So we can print the order before the physician signature. Utilizing our Imaging software EyeRoute integrated with EPIC. Auditors wanted interpretation entered in EPIC. Created workflow for tech to enter/pend all medication orders. Physician to sign order prior to closing the encounter. (Hard stops are in place for this to occur) Created a Perform/Interpretation Folder in Physician s In Basket. All interpretations are individually documented in Eye Route.

17 Challenges to EPIC in Ophthalmology Ancillary Service/Charge Capture Designed for Physicians to charge all ancillary testing/procedures Obtained authorization for Techs to charge and pend. When physician signs encounter charge is dropped into Resolute. Close Encounter Provide Patient with After Visit Summary (Meaningful Use) Cataract Questionnaire (Under More Activities) EPIC did not have in software Designed for Physician Only to close once encounter is completed. Created workflow for our Checkout staff to print and hand AVS to every patient (shred if patient does not want) Created form in EPIC identical to the Cataract Questionnaire that Medicare requires. (patient manually completes) Filed Documents Storage section for documents once completed (ROS, & Cataract Questionnaire etc.)

18 Ophthalmology not using in EPIC Health Maintenance (Designed for Internal Medicine) Pain Screen Section designed for Internal Medicine Verify Rx Benefits(E Prescribe) Sure Scripts Meds(E Prescribe) Patient Instructions Send Reminders to Patients (Meaningful Use) Dragon software is not yet fully integrated with EPIC Section not used in Ophthalmology (e.g. flu vaccination info) Section not completed by Ophthalmology Section not used in Ophthalmology Section not used in Ophthalmology Section not used in Ophthalmology Info is printed on AVS and Prescriptions Not yet activated in EPIC MyChart, but we call patients to remind Created a workflow for Physicians to use the Dragon system if they choose. Dragon is designed for physicians to speak into a hand held device, creating text that can be loaded into EPIC

19 Avoid a big bang! - Do in phases!

20 EMR s will bring a new world our way It really isn t that bad once you get used to it