INSTRUCTIONS: To complete this training you will need to have a printed copy of this packet.

INSTRUCTIONS: To complete this training you will need to have a printed copy of this packet. To print this packet, click the Printer Icon on the Adobe Toolbar. This packet is a step by step self-guided training that will require you to be logged into the EMR Training System and performing tasks while reading the packet. The steps you will need to do are in Green. This step will be confirmed prior to granting access. After completing the packet, return to LMS, complete the quiz and evaluation. An email will be sent to you after you have completed the evaluation. This email along with the screen shot from page 25 must be forwarded to Larry.West@duke.edu and Gina.Edwards@Duke.edu in order to have your account created. Allow up to 48 hours for account creation. Copyright 2009, Technology Education Services, Duke Health Technology Solutions v2.2 7/09/2009

MD RX 2 Interim on Premise Medication Reconciliation

MD RX 3 Contents AEMR... 4 Accessing the Live System... 4 Accessing the Training System... 4 Introduction... 5 Appointment Screen... 6 Searching for a Patient... 7 Surescripts - RX Hub... 8 Allergy Information... 10 Viewing Medication List... 12 Adding Medications to Med List... 14 Medication Editor... 16 Discontinuing Medications on The Med List... 18 AEMR Safeguards... 20 Printing the Medication List... 21 Reviewing patient information... 25 Creating a Task/Message... 26 Viewing a Task/Message... 29 Quiz... 31 Testing Live Account... 31

MD RX 4 1 Introduction AEMR You should have just completed the AEMR introduction video. We reviewed that AEMR stands for Ambulatory Electronic Medical Record, which is made up of several components that you will be utilizing in your practice. AEMR e-prescribe is an information technology solution that replaces traditional hand-written prescriptions with a computer based system. It allows for a system-wide patient medication list accessible to all providers. Accessing the Live System System access is through PIN stations. It may also be accessed through the Internet via the Virtual PIN desktop application. To log into the Live System click the following icon on the PIN Desktop. Accessing the Training System To practice using the AEMR application, the training system must be accessed. This training system is to be used for training purposes only. Once training is completed, please access the AEMR system from the desktop icon on the PIN station, which is the direct link to the Live patient environment. Steps to accessing the Training System Click on the START button from the PIN station desktop.

MD RX 5 Move the cursor up to the TRAINING and over to AEMR ENTERPRISE TRAINING. Click on AEMR ENTERPRISE TRAINING No CCOW. Enter user name mdtrain and password train2. 2 User Interface Introduction AEMR should now be open displaying your worklist. This is the initial screen upon logging into the application. Patient Demographic Banner Once a patient has been selected, Patient Demographics will be shown in this area. Tool Bar Select buttons for the more common screens and tasks

MD RX 6 Note: If you have a patient active in Ebrowser this same patient will automatically be active in AEMR. Appointment Screen (only in the live system) Appointments are automatically loaded from IDX. If your patient has an appointment, you should select your patient off the appointment list. In the live system you will click the patient s name to select the patient.

MD RX 7 Searching for a Patient To search for a patient, use the Patient Selector icon in the Demographics Banner. Click the PATIENT SELECTOR icon. The Patient Selector screen has multiple options for a patient search. Most common search techniques 1. Last name/first name search is not case sensitive, enter First name to narrow search results 2. Sounds Like option to include similar sounding names in search results (i.e. Smith and Smythe) 3. Duke MRN MRN enter patients Medical Record Number Enter YOUR LAST NAME and IOP as First Name into search box. You may also enter the Date of Birth included in your email to help find your patient. Example: Smith, IOP. Click SEARCH. (If you are unable to find your patient, try searching for first name of IOP and search through choices. The last name and spelling used was supplied by IOP.)

MD RX 8 If there are multiple patients included in the search results use the selector button to choose desired patient. If the results are contained on multiple pages use the Next button to navigate to the additional pages. Choose assigned training patient if not selected. Demographic information appears in the demographic banner once chosen. Surescripts - RX Hub Surescripts-RX Hub is a database of prescriptions paid for by insurance claims and maintained by the insurance companies. When a patient fills a prescription at any pharmacy using insurance benefits, the prescription information is entered into RX Hub by the insurance company. The only two times this information is not entered into RX Hub is if the patient pays cash (including credit cards or checks) or the patient is a Medicaid patient. Horizon Ambulatory Care (HAC) (Duke s EMR system) is capable of accessing the last 120 days of prescription filled history as well as the patient s prescription insurance information. When patients arrive at the clinic, it is primarily the responsibility of the front desk staff to upload this information.

MD RX 9 Prior to updating the patient s medication list you must ensure this step has been performed by confirming the date of Elig Status, if there is no date shown in the information banner or the date is not current, you must Update Eligibility/History prior to updating the Med List. Once it has been updated, you should wait a couple of minutes to allow the Med List to update. When you access a patient s record, prior to doing anything else, check the Elig Status Date. If this date is not within a day or two of the current date or erx Unknown is displayed, you will need to update the information yourself. If you see erx Not Found or erx Error BUT the date is current, you do not need to perform this update. Click PATIENT on the MENU BAR. Click UPDATE ELIGIBILITY/HISTORY. The following will not occur since Surescripts-RX Hub is not active in the training system. The first time RX Hub is accessed, you will be presented with a screen asking if the patient gave their consent to access their medical records. All patients at any Duke Clinic give their consent for Duke Health Systems to access their medical records. You would then Click YES and SUBMIT HAC will access RX Hub and upload any medications filled using insurance benefits in the last 120 days. Occasionally due to issues with RX Hub your patient may not be found in RX Hub, their medication list will not be automatically updated and you will have to update their medication list manually. In addition to the medications filled, specific formulary information for the patient s insurance company will be downloaded and indicated as you prescribe medications.

MD RX 10 This may also be done as a batch process from the appt screen. To perform this process on multiple patients select the patient by clicking on the box to the left of the Date and Time on the appt list and clicking Process Selected Eligibility in the lower right hand corner. Allergy Information Allergy information can be entered into the AEMR system by clicking on the allergy field in the demographics window. This information is interactive with ebrowser, changes and additions in AEMR will be reflected in ebrowser and vice versa. Click on the ALLERGY button in the patient banner to utilize the allergy search feature.

MD RX 11 To enter new allergies use the NEW button. Search functions for allergies and over-the-counter (OTC) medications. The pull-down menu labeled CODED as well as the search box has coding in the background that allows information to cross over to other applications used within DUHS. In addition, using the search box or pulldown menu allows EMR to cross check Prescriptions against allergies. The Allergies screen also allows for the entering of free-text food and other allergies if absolutely needed. Reaction and severity can be added for each allergy entered To enter multiply allergies use the ADD AND START NEXT button at bottom of search page.

MD RX 12 Choose CODIENE from the Coded pull-down menu and add the reaction of HIVES with MODERATE severity to the patient s profile. Click ADD to save the allergy information. Allergy information will refresh in the demographic window. Allergy information is highlighted by different colors. Red Allergy present (Specific Allergies will be listed) Gray NKA (No Known Allergies) Yellow No information entered 3 Modifying Medication List Viewing Medication List The Medication list displays both Active and Inactive Medications. Once a medication is added to the medication list, it will always remain with the patient. After it has been discontinued, it will move to the Inactive Medication list, where it can be renewed or made active at anytime. Click MED LIST on the Quick Task Bar.

MD RX 13 The Medication list has multiple functions available. Each medication can be renewed based upon the current sig., Modified or D/C d (discontinued). Multiple medications can be selected by checking the box in front of the medication name on the left of the screen. Select all medications by checking the first box on the list at the top. By default, inactive medications are not shown; use the Show Inactive Meds button to display

MD RX 14 Adding Medications to Med List To add a medication that has been previously prescribed to the medication list, use the Add to Med List button located at the bottom of screen. Adding to the medication list does not create a new prescription for submission to a pharmacy. Click the ADD TO MED LIST button. The medication search function allows for the searching of prescription (Rx) and over-thecounter (OTC) medications. The database used in HAC for medications, whether prescription or over-the-counter, is a 3 rd party national used database named First Data Bank (FDB). Enter either the generic or brand name into the search field to find a prescription medication. To find medications that are available as OTC you must check the OTC button before searching.

MD RX 15 Enter LASIX into the search box and click SEARCH. The available forms of the medication are displayed. Dose forms are based upon the medication form selected. If the dosage form or strength is unknown, select that option at the top of the Dose Form list Dosage form or strength Unknown. Dose forms are the strength available from the manufacturer. The actual dose the patient is taking will be entered on the next screen. Choose LASIX ORAL > TABLET 80MG.

MD RX 16 Medication Editor The Medication Editor allows for many functions regarding the chosen medication. 1. Cost information based upon national averages for drug-to-drug comparison only. This does not reflect actual cost patient will be charged at the pharmacy. 2. DAW check to have drug DAW (Dispensed as Written) 3. Common Sigs. system default sigs, the most common ways selected medication prescribed. Select default Sig by selecting button in front of form. 4. Sig Builder pull-down menus to build custom sig, you may also free-text special sigs not available. (I.e. 1-2 tabs) from pull-down menu. Check the PRN box for PRN medications. 5. Special Instructions- instructions to be printed on prescription bottle (free-text can be added by double clicking the blank box). 6. Med List Comments internal comments that do not get transmitted to pharmacy or printed on the med list that is printed for the patient. (This is commonly used to denote no further renewals until next visit.) 7. Indications- used to categorize the indication for the medication. Will also be used as part of the future Order Entry process. NOTE: NURSING STAFF ONLY ENTER WHAT YOU AND THE PATIENT ARE SURE OF. IF YOU OR THE PATIENT ARE NOT 100% SURE THE INFORMATION IS CORRECT DO NOT ENTER IT.

MD RX 17 Choose 2 TAB(S) BY MOUTH DAILY from Common sigs. Enter Special Instructions AS DIRECTED. Enter Med List Comments QUESTIONABLE COMPLIANCE. To save medication Click SAVE. The medication list is updated with the new medication. Add NEXIUM 40MG 1 CAPSULE BY MOUTH DAILY. Add LIPITOR 20MG 1 TAB BY MOUTH DAILY. Add ZOLOFT WITHOUT A DOSE OR SIG. (No information from the patient other then they are taking the medication, they do not know how much or how many.) Add NORVASC 1 TAB DAILY BY MOUTH. (Pt does not know the dose of their medication).

MD RX 18 Discontinuing Medications on the Medication List Note: Discontinuing medications does not delete them from the system. They are placed on the inactive List. There are two different ways to discontinue a medication depending on whether you are discontinuing a single medication or multiple medications from the Active Med list. 1. If you are discontinuing a single medication, you may click the D/C button that is on the far right of the Medication row. Note- This will only D/C the medication on that row. 2. To delete multiple medications, click the box to the left of the word active for each medication you want to D/C. This will select those medications. 3. Once you have selected all your medications to D/C click the Discontinue Selected button. Note- If you click the D/C after selecting several medications, only the medication on the row of the D/C button will be discontinued.

MD RX 19 You will be asked for the reason the medication is being discontinued. There are 3 options you may use. Leave Reason Blank You do not have to enter a reason if you or the patient is not sure of the exact reason the medication was discontinued, leave the reason blank. Drop Down Always look in the drop down first for the reason the medication was discontinued. Free Text If you cannot find the reason for discontinuing the medication in the drop down, you may free text the reason in the right hand box.

MD RX 20 Notice there is now 3 medications in the Inactive Medication Section. This section is normally collapsed by default but you can see if there are discontinued medications by noting the number in the Inactive Medication Section Heading. AEMR Safeguards There are many safeguards built into the AEMR system including Drug to Drug Interactions, Drug- Disease interaction (if indication selected when medication prescribed) and Drug-Allergy interactions. Warning Screens only appear when prescribing/renewing a medication. They will not appear when adding a medication to the Med List.

MD RX 21 5 Printing and Reviewing Printing the Medication List As per Joint Commission standards, except under specific situations, all patients must be given a current patient friendly medication list at the end of all clinic visits. AEMR has the ability to provide the patient with an easily readable medication list of their current medications. To print a medication list, choose a patient or during an office visit select Med List (As part of training, the training patient remains selected.) Click on MED LIST.

MD RX 22 There are two ways you may print the patient s medication list. 1) Print a patient s medication list Click Print Medlist button in the lower right hand corner. You will receive the Windows Print Dialogue box to ensure you are not printing to the Rx Printer.

MD RX 23 Click Cancel to close this box. 2) Print Patient s Medlist with detailed drug information and/or Large Font. Click Print in the middle of the screen. Detailed drug information is available from the First DataBank medication database. This information includes details such as indications, how to take the medication and side effects, similar to the package insert information provided by the pharmacy.

MD RX 24 1. Patient Level Drug Instructions Print patient information sheets for selected medications 2. Language This option not yet available 3. Optional Comments Add any comments to the medlist you wish. 4. Print in Large Font. Click OK. The medication list should be sent to the PIN printer. CLOSE print preview window.

MD RX 25 Reviewing Patient Information You may review all patient information via the Summary page. > Click Summary on the Tool Bar. While viewing the chart summary, clicking the date associated with an encounter will open the encounter and show any prescriptions or medication list alterations that where performed during the encounter. NOTE: You must perform the next two steps and send the screen shot email as per the initial instructions. While the Summary screen is displayed, press the Print Screen button on your keyboard. (It may be labeled Print Screen, PrtScr or PrntScrn. It is usually located near the number keypad around the Insert/Delete Key). This will take a screenshot of what is on the screen. Open a Word document or email draft and paste the screen image into the document. (You can right mouse click and use paste or Ctrl+V to do this.) Note: This screen shot will need to be sent with your program completion email.

MD RX 26 6 Tasking and Messaging Creating a Task/Message The worklist is used as an inter-office messaging system. Depending on the clinic you are at, this feature may or may not be used. Remember that everything typed into this system is part of the patient s medical record and if requested by medical release, will be given to the patient and/or courts. Before creating a message, you must select a patient. To create a new message click NEW TASK on the QUICK TASK BAR Click NEW TASK on the Quick Task Bar.

MD RX 27 You must select the type of TASK you would like to send. The only two tasks being used in the initial deployment of the system are Reminder for and Return Call for. Always choose the task that includes your patient s name. Choose RETURN CALL FOR your patient. Never use a task that is not associated with a Patient s Name You can send this task to anyone who works in your clinic and has access to AEMR. If you are sending a task to yourself, you will select SELF.

MD RX 28 Select SELF as the person you are assigning this task to. If you have access to AEMR for more than one clinic, ensure you have the correct location selected. For training purposes, ensure HAC TRAINING CLINIC is chosen for your LOCATION. If this is an urgent message, you can select ALERT as your PRIORITY and it will highlight the message as yellow on the worklist of the person you sent it to, otherwise leave it at the default, which is Medium.

MD RX 29 Select ALERT for your PRIORITY. Type your message into the DESCRIPTION field and click SUBMIT at the bottom of the screen. Your message has now been sent to the WORKLIST of the person you selected under ASSIGN TO. In this case if went to your worklist. (The worklist of Train, MD). Viewing a Task/Message Click Worklist on the Quick Task Bar.

MD RX 30 Notice that since we set this as an ALERT PRIORTY, it is not only highlighted yellow but it is also at the top of the WORKLIST as well as being in the Phone Calls category. To open a message, click on the blue link under description. Click on PLEASE CALL MR. PATIENT in blue. From this screen, you may handle the task one of three ways; a.) Re-assign task by choosing another person in the ASSIGN TO box. You may want to type a message in the DESCRIPTION box prior to re-assigning this task. Click update to send the task to the person you are re-assigning it to

MD RX 31 b.) Update the task with more information by entering the information into the DESCRIPTION box and clicking UPDATE. c.) Complete the task by clicking COMPLETE. You may enter final notes into the DESCRIPTION box. Quiz Return to LMS to complete the Quiz and Course Evaluation. 7 LIVE ACCOUNT ACCESS Testing Live Account Proper credentialing as well as evidence of training is required to access the AEMR application. Once your training has been fully completed, please send an email including the following to Larry.West@duke.edu and Gina.Edwards@Duke.edu: Name Title PIN Log-In User Name Clinic Also, please include a screen print of your summary page. See (Refer back to Page 34) for directions on how to obtain this. Once we have this email, your signature sheets, and the request from your supervisor, we can grant you access to the system. Allow 2 business days for account creation. To log into the Live system click on the following icon from the PIN Desktop. Enter your personal username (i.e. smith001). Enter initial user password (supplied by system administrator).

MD RX 32 The first time accessing the application, the system prompts the user to change the default password to a user specific password. Old Password - Enter the system administrator supplied password New Password Create new password Confirmation type new password for confirmation Click SUBMIT to change your password. You must click submit. Pressing the enter key will not submit your password change. Click LOGOUT and then EXIT to close the application.