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Clinical Adoption Workshop

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Ambulatory EHR Project Vision

Commitment to Improve Patient Care and Outcomes through Effective Implementation and Optimal Use of Information Management and Technology

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Ambulatory EHR Project Goals

 Improve the Quality and Safety of Patient Care  Improve Communication Across the Organization  Ensure Continuity of Care Across Settings  Facilitate Research  Provide Data Extraction and Reporting  Comply with Regulations  Qualify for Stimulus Incentives and Avoid Future Penalties  Improve Overall Efficiency Page 4

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Clinical Adoption Workshop - Objectives

 Help clinics envision the transition from their   current workflows to future workflows Work with clinics to identify process issues Help clinics identify resource requirements for  system use Highlight points in the workflows that ARRA (American Recovery and Reinvestment Act) effects Page 5

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Clinical Adoption Workshop - Objectives

 Develop a strategy for next steps for clinic participants to address issues identified in the workshop with the appropriate personnel in their clinics  Provide a mechanism for dissemination of information back to all clinic staff

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Chart Prep

Patient Visit Workflow

Scheduling & Registration Patient Check In Between Visit Care

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Check Out Care Delivery Page 7 Provider Assessment Patient Intake

Scheduling and Registration

 Patients will continue to be scheduled and registered in IDX.

 There are some additional demographic data that we will be gathering for future reporting: Ethnicity and Preferred Language. These will be items that will be collected and entered into IDX.

 Scheduling information will be sent to Cerner IMPACT Ambulatory via interface.  Scheduling in IDX: You must be scheduling in IDX in order to access or update a patient chart for clinic visits.  Currently, are there any appointments scheduled outside of IDX? If so, what are they?

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Patient Check-In

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CHECK-IN

Patient Check-In

 Check-In  Arrive Patient in IDX (pt will change color in IMPACT to     indicate arrival in schedule viewer) Confirm and update all demographic information in IDX Encounter Form (Charge Ticket) will continue to print HIPAA Form will continue to print if needed Decision needs to be made about what will happen with external records that are presented at check-in  Pharmacy Information  Patient’s preferred pharmacy can be entered into the system before or during the visit.

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Patient Intake

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Patient Intake

 Device Consideration: • Are the devices planned for the locations where patient data is collected?  Timeliness Consideration: • How can you reduce the time it takes to collect and enter data during the intake process to prevent delays in getting patients ready for the provider visit? • Are there other options for handling new patients (or patients seen for the first time after the EHR is live?) Page 13

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Patient Intake

 Data Collection:  Are there obstacles that would prevent data from being entered prior to the patient seeing the Provider? Add these to your issues.  Are there situations where either height, weight or blood pressure are not routinely measured during your visits?

 New patients  Returning patients.

 Would this present a problem if required every time? Page 14

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Patient Intake

 Those patients without allergy entries into IMPACT could require additional time during the intake process to get allergies recorded. Allergies could be entered prior to clinic and validated during visits for updates.  Do you have the right roles available to manage medication histories?

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Patient Intake

 Always open a patient’s chart from the schedule viewer  If your clinic is completing documentation prior to the visit (chart management) or if you have a series of staff that will complete documentation, go to “Form Browser” to see if any   Adhoc Charting was done prior to you seeing the patient. If so, right click on the form, select modify and update the form. This will work well in clinics where multiple staff may see patients before the provider.

If no form is present, you will start a new Adhoc Intake form.

 Who will complete Intake in your clinic?

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Patient Intake

 Evaluate your patient self-assessment form in your clinic.  Do you feel that a face-to-face interview with the intake histories would accomplish this task faster?  If you continue to use your patient self-assessment, they should be used as a worksheet. You can shred them after the data is entered into the system (make sure you are only asking the questions that you need answered for the visit)  At subsequent visits, histories can be marked as reviewed and time/date stamped for this visit if there are no changes.  Histories carry over from the previous encounter. Page 17

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Discussion Points – Patient Intake

 Based on what you’ve observed is needed for intake, consider what types of changes need to be considered to optimize patient care and workflow in your clinic • Device placement for data entry, scanning and printing? • Roles and certification to manage EHR Records? • Workflow changes to optimize patient care without unnecessary delays? • Access to information from previous visits?

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Provider Assessment

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Provider Assessment/Care Initiation

 If they start the PowerNote during the visit, it will stamp the correct date and time on the note.  The note can be saved at any stage of the note generation and finished at a later time.

 Providers will need to address any orders that the patient may need.

 Prescriptions should be routed electronically to pharmacies when possible  Prescriptions for scheduled medications will need to print for provider signature  Where will these print and who will be responsible for them?

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Orders

 CPOE – Computerized Provider Order Entry  These orders are placed and signed by eligible providers  Proposed Orders  These orders may be placed by anyone and are not active until the order has been signed by the provider  Protocol or Verbal Orders  These orders are placed by staff (clinic driven decision) and are active orders. These orders can be acted upon before the order is signed by the provider.

 All Orders route back to the appropriate provider for signature

***CPOE & Proposed orders meet ARRA requirements while protocol & verbal orders do not.

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Future Orders

 All Lab and Radiology orders are defaulted to future orders  An estimated date will need to be entered for these orders (this will be very important for the lab and radiology areas to get the right time frame to complete tests)  Future Orders can be activated by the lab or radiology staff 14 days prior to +30 days from the expected date and time on the order.

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Health Maintenance

Health Maintenance functionality allows the Clinician to access a list of preventive or planned tasks that are due for a specific Patient allowing for real-time notification of health screening, prevention, and management of diseases for patients based on age, risk factors, gender, documented conditions, and documented procedures.

The improvements in preventative care monitoring and the at-a-glance reminders to the clinician can result in higher quality patient care, as well as increased revenue generation surrounding covered procedures that are recommended in Health Maintenance guidelines. Health Maintenance planning aligns with PQRI measures for the population.  Health Maintenance 1.

Consists of: a) b) c) Screenings/vaccines expectations for the patient that are monitored by the system.

Diabetic Management Traveler’s clinic vaccinations (Ad hoc only) 2.

Auto-population of the specific maintenance is based on the patient's age, sex and/or diagnosis.

3.

Many of these elements include PQRI components.

4.

The clinician has the option to: a) b) Order the test/procedure that is needed to satisfy the maintenance.

Document if the maintenance was performed elsewhere.

c) d) e) Document if the patient refuses.

Document if the patient/clinician postpones.

Document if the maintenance needs to be canceled for this patient.

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Chronic Condition Management

Chronic Condition Management functionality includes the ability to view condition summary screens based on the conditions on the patients’ problem list. Additionally, performance reports aggregate the status for the population in performance metrics allowing physicians to compare and improve their individual clinical performance against standardized performance targets and peers' performance. It is also the mechanism to submit data to CMS for the incentive bonus for the 2009 Physician Quality Reporting Initiative (PQRI) through a qualified registry.

Both Health Maintenance and Chronic Condition Management automate data collection when the correct elements of the chart are captured electronically. Chronic Condition Management 1.

Consists of: a) Mpage based Patient and 4 condition summaries (4 for Phase 1) b) Linked algorithms for each condition c) Linked Discern Analytics for measurement of key parameters of care 2.

The documentation of the Chronic Conditions in the Problem/Diagnosis List controls the summary pages and analytics.

3.

The performance measures include PQRI components Page 24

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Care Delivery

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Care Delivery

 Are there devices planned where the medications are prepared and administered?  Are there devices planned where POC tests are performed?

***If not, this will create problems with efficient documentation

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Care Delivery-Testing during the Patient Visit

 POC testing will require an order to be carried out  EKG  Blood Glucose  Urine Dipstick  Pregnancy Test  Once the order has been placed, staff will access the single patient task list (Start with the Schedule viewer)  Staff will double click on the POC task and result the test in the form that is activated or chart done to complete the task  Do not chart POC results in adhoc forms without going through the task list (you will not be able to satisfy the task later without double-charting) Page 27

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Care Delivery-In Clinic Order Activation

 If your clinic actually draws the blood or collects the specimen to send to the lab, the clinic will activate the future order by right-clicking the order and choosing to activate the order.

 This should trigger a requisition to print that will need to accompany the sample to the lab. This requisition will act as your order sheet. It actually assigns the accession number to your specimen that will follow it through the lab.

 You will still need to label your specimen as you do today. **If the requisition does not print, you can right-click on the order and reprint, but this reprint will be missing the barcode-this needs to be reported to the help desk! Page 28

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Care Delivery-How To Use Task Lists

 Tasks will fire based off of the order placed  Clinical staff will be able to see clinical & clerical tasks  Clerical staff will only be able to see clerical tasks  Multi-Patient Task List (MPTL)  Allows you to see all the tasks for the selected group of patients (patients in clinic that day, etc) This list can be filtered in different ways  You can only see the types of tasks that your position allows you to see

**Orders placed on the documentation encounter will not show up on this list, only the single patient task list.

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Care Delivery-How To Use Task Lists

 Single Patient Task List  Allows you to see all of the outstanding tasks at the patient level  This is the preferred method to review outstanding tasks to be completed for the patient.

 Supervisors should review the multi-patient task list periodically to ensure that tasks are being completed by the staff.

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Patient Check Out

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Check out

 Do you see the last clinical person seeing the patient or the back desk completing the depart process?  The Depart Summary will include any orders placed today (this includes future orders), med list, allergies, and problem list.

 These are the discrete elements that are needed to improve communication to the patient as well as meeting ARRA “meaningful use”.  Message Center should aid your clinic in communicating to academic, centralized scheduling or other areas as needed.

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Check out

 Check-out : Select the patient from the schedule viewer  The patient’s task list will need to be reviewed before the patient leaves the clinic.   Complete the tasks that are appropriate to complete.

Message Center can be used to remind yourself of future  tasks or to communicate to other staff that there is a task that they need to complete.

For Department of Medicine procedural areas (Cardiology,  GI, Pulmonary and Rheumatology) a message must be sent to the respective scheduling inbox and the scheduling area will complete the tasks.

The Depart Summary must be printed and given to each patient – this may be initiated by the clinical or clerical staff depending on the clinic.

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Check out

 Exit Care (Patient Education) can be added during the depart process.

 Anyone can initiate the patient education. If the provider initiates, they would only mark that the patient had verbalized understanding and sign. If the back desk or clinical staff initiate the education, they will mark understanding and use the “Sign & Print” button.

 There is a catalog of standard exit care available in the system, but it can be customized for your clinic.

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Check out

•     You can select your patient, right-click on the patient’s name and check the patient out of Cerner if you wish (this will turn the patient purple)-this is not a requirement, but merely a comvenient way to see that a patient has left the clinic The patient will still need to be checked out in IDX because check out in Cerner does not flow back into IDX Follow up appointments will still be made in IDX.

 You can type those appointment dates into the depart summary in the follow up or continue to print IDX appointment cards The Depart Summary includes: allergies, medications, prescriptions added that visit, problem list, any orders completed that day, future orders and any exit care that was selected.

Ask patients if they have any questions before departing the clinic.

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Check out

 Process for Scheduling Exams that Require Pre-Certifications  If the exam ordered is greater than 45 days out  Schedule the appointment in IDX as pending  Send a reminder through message center to obtain Pre Cert (set the reminder to appear 30 days before the scheduled exam)  Chart the task done in the task list  If the exam ordered is within 45 days  Obtain Pre-Cert  Use Administrative Note to let co-workers know you are   working this task Schedule Appointment in IDX Chart the task done in the task list Page 36

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Between Visit Care

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Between-visit Care

 Message Center • Consider the current processes for "calls" to the office. • If you pull the paper chart today to help clinicians manage the message, will this be necessary? How will the person taking the call know? • Examples: medication refills, nurse inquiry, results inquiry and authorization questions • Can the messages be routed to one mailbox for management, or will it need to go to an individual? • What will you do if that individual is out of the office and someone needs to manage the messages? Page 38

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Between-visit Care Message Center Should be checked many times throughout the day!

 Creating an address book of the people you send to frequently will be key to efficiency – this works like email  If possible, always find and open your patient’s chart before sending a message. This will pull the patient’s chart into the message.

 Use this as a tool to remind yourself or others to check on things like lab or radiology results.

 You will have the ability to access messages for yourself, any pools to which you have been assigned and any proxies you have been granted access to, or taken from the Home Page or Message Center

Communication is the key to our success!

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Between-visit Care-Results To Endorse

 The goal is to reduce the number of times someone picks up and "handles" a particular message.  Lab and Radiology results route to the provider’s inbox in Message Center  Pools may be set up to route results to in addition to the provider  Result Letters  If your clinic wishes to use result letters, these will need to be initiated before results are actually endorsed.

 Multiple results can be pulled into one letter.

 Providers can initiate letters and forward to their staff to print as they endorse. (these letters will appear in the staff’s inbox under “documents”)  If clinic staff are handling endorsement, letters will need to be printed as they work the list.

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Sample Workflow Changes: Current State

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Rx Renewals

 Once a prescription has been sent electronically, the renewal will come back into the provider’s inbox (instead of the current fax/phone call)  This functionality will not be activated at go-live. It will be activated at some point in the future after a clinic is live  Pools may also be set up to manage these requests for the providers – they will route directly to the assigned pool’s inbox  The provider will have the ability to approve, modify or deny the renewal.  If there is any question, you can route the request back to the appropriate provider.

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Future: Refills using Message Center

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Rx Renewals

 All Prescriptions will route back to the appropriate provider for signature.

 Make sure to modify meds if you are making a change to an existing medication. Do not add another line of the same medication unless you intend for both to be active at the same time.

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Medical Record Print (MRP)

 Not everyone will have access to print medical records in the new system  Healthport will need to be used where possible for release of information (UAB Health System has existing contract)  Screen Prints will be allowed for every position, but should be used sparingly (giving a patient a trending of their blood sugar results)  Screen prints are not tracked for reporting purposes  To execute MRP you must select the patient, select the folders you want to include, select the encounter(s) and send it to the queue to be printed  You should never release inpatient encounter documentation in the ambulatory setting  Requests for records should be scanned into the patient chart and logged into e-smart log for Healthport to execute ROI.

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Chart Prep

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Chart Prep

 Preload costs incurred for the first 6 weeks of clinic schedules will be covered by the project.

 This includes loading patient’s allergies, medications, problem lists and past procedures into the system.

 All information can then be reviewed as the providers see the patient.

 Each clinic should develop a plan for transitioning preload to Chart Management  Chart management will be the way clinics re-purpose their staff to stay ahead and preload data on an on-going basis.

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Chart Prep

 Schedule Viewer  Always use the schedule viewer in Cerner as you prep patients for their upcoming visit. This will allow you to choose the right encounter as you document on the patient.  The schedule viewer can be searched and appointments will appear as far out as 1 year, but registration dates do not get assigned to appointments until 5 days before the visit.

 Pharmacy Information  Patient’s preferred pharmacy can be entered into the system before or during the visit (most clinics are doing this as patients check in).

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Chart Prep

 Adhoc Charting – When does the encounter “really” begin?

 The intake form can be started over the phone, using Horizon or the paper chart as we transition  Preload becomes chart management or chart prep  It will be important that you focus these efforts on data that will cross encounters – allergies, medications, past procedures, past medical history  External Records These records can be scanned prior to the visit or can follow the patient through the visit and be scanned afterwards.

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Chart Prep/Scanning

 Device Placement Consideration • Where do you want to scan outside records? (This will determine scanner placement) • Prior to the visit?

• After the Physician/Provider has reviewed the documents?  Scanning Turnaround Consideration: • How will the providers typically turn the documentation in for scanning:  At the end of the clinic day?

 Resource Consideration: • Which skill set will be able to best manage scanning – ensuring documents are handled correctly?

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Chart Prep/Scanning

 You will only scan clinically relevant documents into the record  Scanned documents will be stored in the “Reports and Documents” tab within the chart  A standard folder structure has been established to ensure consistency within the health record  Each document scanned into the record will need 3 things: a folder will be selected, the date of the document must be entered and a title will need to be assigned  The date used should be the date of the exam or note that  is being scanned The title should follow a standard: Service, Physician, Document (Cardiology, Dr. Plumb, ECHO)  Documents can be authored into the chart by the scanner or can be sent to the provider’s inbox for review and signature Page 51

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Next Steps

 Return to clinic with information to begin discussions about how your clinic will transition.

 Meet with appropriate providers and clinic staff to identify possible issues with the transition of workflow.

 Engage Clinical Informatics with your group to answer any questions you have about workflow and how it can improve with the implementation of IMPACT.

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Questions