Continuity of Care Documents

Part of MU2 says that we need to come up with a CCR or CCD (Continuity of Care Record/Document) to send with patients if their care moves to another provider/setting. See earlier post.

When we upgrade our EHR this should be available to us, as long as our EHR is 2014 ONC certified.

Currently our EHR has a document called Pediatric Emergency Information
(it show as peds_special_needs_emerg_info)

click to enlarge

You can find this in the full document section & drag it into the Pediatric chart on the left for future easy access. If you generate this note at the end of a visit, it pulls a number of things that are supposed to be part of a CCR such as: Name, DOB, Address, Phone number, PCP, Allergies, Meds, Vitals, Immunizations, Chronic Conditions, Current PE.

While this is not everything recommended for a CCR or CCD it is certainly a step toward it.

I will work with Annette to include other fields such as: Sex, Race, Ethnicity, Preferred Language, Subspecialists and the most recent Asses/Plan.

Note: On the demographics page there is a spot to list subspecialists. This maybe a good place to add specialists for complex patients. I think Annette could easily pull this list into the Pediatric Emergency Information document. We will keep you posted.

Two New My Plans: Croup & Thrush

I have built My Plans for CROUP & THRUSH.
I used Up to Date for treatment options.

For CROUP they are now recommending Dexamethasone

• a one time oral dose (0.6mg/kg - max 10 mg), if giving a steroid. 
• I did include prednisolone 2mg/kg daily x 3 days as an alternative.

Note: They also said that Budesonide - 2mg by updraft x 1 was an alternative way to give the steroid. We do not have Budesonide here at the office. Do you think it would be worth ordering some? It might be a good option for those kids who refuse po meds or are vomiting. Of course you can always give IM dexamethasone.


The THRUSH My Plan is pretty straight forward. Nystatin is still the med of choice though some studies have suggested higher cure rates with higher doses.

• I have 2 doses listed: 1 ml ( 100,000 ux/ml) in each cheek 4 X / day (200,000 ux/dose QID ) or
• 2 ml in each cheek 4 times per day(400,000 ux/dose QID) for those kids not responding to lower dose. 
• I also have included fluconazole for nystatin failure & clotrimazole lozenges for older kids (> 4 years due to choking hazard).

Let me know what you think.

Review of Systems & Quick WCC Update

Annette has fixed some of the issues with the saved ROS. Apparently she tried to see if she could line up positive & negative results and that is what set the grid off. She has fixed this so now the ROS should look better. There are a few other issues that she is working on & I will alert you when these are resolved.

The ROS should be used by the staff. Please let me know if there are any staff not using it, so we can do some training.

Also please let me know if the WCC Quick Visits are not showing up for you. Annette pushed them through to everyone today. There should now be a full set of WCC from birth to 21 years of age.

Quick WCC update

Our Quick Visit WCCs continue to be improved. Thank you Peggy for your suggestion to add a spot for elimination on all the HPIs. You should now be able to find it on all Quick Visits from Birth thru age 10 years.

Sunday Cartoon

Meaningful Use Attestations & EHR Vendor trends

I found this really interesting look at the CMS ( Centers for Medicare & Medicaid ) report on MU attestations by Eligible Providers (EPs) released in April of 2013. Dr Robert Rowley (who helped found Practice Fusion - another cloud based EHR ) took the government's information & analyzed it.

The most remarkable thing I found was that 80% of the attestations done in 2011 & 2012 were done using the top 24 EHRs! This is really astounding & helps to highlight what a lot of analysts have been saying: the EHR market is going to consolidate. A large number of EHR systems that were ONC certified for MU1, had no EPs attest for MU1. These companies , along with many others, will not be viable in the near future.

Note that Epic is the largest Ambulatory Vendor but they do not sell to individual practices. Practices who use Epic are usually Hospital owned or closely affiliated.

Here is one interesting chart but the whole Blog is linked & worth a look.

http://robertrowleymd.com/2013/04/04/trends-in-ehr-vendor-strength/

Click on chart to make larger

Physicians dissatified with their EHR systems

We are not alone. A new survey shows that a large majority of physicians are unhappy with their EHRs & would likely not purchase the system they are using again.
Since misery loves company, I am including the article here for your enjoyment!

EHR adoption has grown significantly over the past several years and so too has physician dissatisfaction with this technology, according to a national survey by MPI Group and Medical Economics. In the 2014 EHR survey, nearly three-quarters of 952 respondents (70%) described their EHR investment as not worth the effort, resources, and costs.
  
/http://ehrintelligence.com/2014/02/10/what-has-physicians-so-dissatisfied-with-their-ehr-systems/

List of required data for Transition of Care

Part of Meaning Use 2 (MU2) is that we provide a transition of care summary whenever a patient transitions to a new provider or setting.

Transition of care: can mean a child going from our office to an ER, hospital or a subspecialist. It could also be a teen moving to an adult medical provider. Whatever form it takes, to meet MU, the summary must contain this information:

Note - EP means eligible provider. CAH means critical access hospital.

Click image to enlarge

Click image to enlarge

Vital Sign Machines: NextGen Integration

At the most recent EHR Committee, we reviewed  the vital sign machine usage and decided that it is working well. We have a new Vitals Station where Sandy Martin's office used to be.

The Executive Committee approved the purchase of two additional vital signs machines awhile ago. At the EHR meeting we gave Michele the go ahead to get these other machines.

We hope to place another Vitals Station in the back hallway area in OMN. The SHO office staff & administration will decide where the SHO station should be located.

There still are some issues with calculating the BMI directly on the machines and I understand that the staff has to re-enter the weight to get the BMI to calculate. We have been assured that this problem is fixed with the next upgrade.

We are still in the discussion phase of whether or not having a dedicated vital signs staff member is the optimal solution. Having one person doing the vitals would allow the result to flow into the computer & not be hand entered. If each of the staff were to do their own vitals, they would have to log on & off of the system each time to allow the vitals to flow thru the interface. Having one person doing all vitals allows them to stay signed in for their entire shift. Some of the staff feel that having one staff person doing vitals breaks up their work flow & they prefer to hand enter the results. Stay tuned as we work this out.

EHR vendors serving Massachusetts from MeHI

To see the entire MA EHR Landscape Assessment from MeHI

 http://www.mehi.masstech.org/sites/mehi/files/documents/MAEHRLandscapeAssessmentJuly2012.pdf

Note: LMR and WebOMR are Boston Hospital privately developed EHRs.

Mass Board of Registration in Medicine & HIT proficiency

The Mass BORIM is set to make HIT proficiency part of it's requirement for Mass licensure in 2015. What the exact measurement for proficiency is is still in the works.
Don't shoot the messenger!

Posting Comments

I worked on this a bit yesterday & with the help of Vicky, & my friend Linda, I think we have figured it out.

To post a comment you need to have a GMail account and you must sign in - ie not just preview blog:

• At the end of the post click on Comments 
• A dialog box will appear. Type your comment in the box & click the Publish button. 

I had to open Comments up to everyone (including anonymous)  so it may not automatically place your name on the post, so you may wish to sign your comment.

You can also check the 3 "Reactions" if you find something funny, interesting or cool.
You can also just email me directly, if you have any questions or suggestions.

Your comments will help me to determine if the stuff I am posting is interesting to you. There is so much happening in medicine right now: MU, ICD-10, PCMH, HIway that I find fascinating and I want to share it all with you. But I need to you if you want to hear it.

WCC Quick Visits - Updated

This weekend we added five new WCC Quick Visits. Thank you Scott L for doing them!

• 7-8 year WCC (no gender)
• 13-14 year WCC-Male
• 13-14 year WCC-Female
• 15-17 year WCC-Male
• 15-17 year WCC-Female 

With these,  we have completed Quick Notes for WCC.
 Enjoy!!!

Using Patient Portal Technology to Meet Stage 2 Meaningful Use

In order to meet new Meaningful Use Stage 2 guidelines promoting patient engagement, physicians will need to incorporate patient portal technology which will allow patients to gain access to their health data. Under proposed Stage 2 requirements, for example providers will need to be able to provide patients with clinical visit summaries within three business days. In addition, providers will need to provide access to information such as lab results and medication lists, upon request.

One of the biggest obstacles with patient portal integration will be attracting patients to the online resource. This will depend largely on the site’s ease of use and appearance; therefore, choosing the right patient portal will be key. To read more about using patient portal software to meet Stage 2 Meaningful Use guidelines, click here.

Extracted from Health Technology Review

Patient Portal - The Basics

A patient portal is a secure online website that gives patients convenient 24-hour access to personal health information from anywhere with an Internet connection. Using a secure username and password, patients can view health information such as:

• Recent doctor visits
• Discharge summaries
• Medications
• Immunizations
• Allergies
• Lab results

Some patient portals also allow patients to:

• Exchange secure e-mail with their health care teams
• Request prescription refills
• Schedule non-urgent appointments
• Check benefits and coverage
• Update contact information
• Make payments
• Download and complete forms
• View educational materials

 For More Information: Using Patient Portals in Ambulatory Care Settings Fact Sheet

EHR Cartoon

Menu Requirements for MU2 - need 3 out of 6

Report on 3 of 6 Menu Objectives:

1. Submit electronic syndromic surveillance data to public health agencies
2. Record electronic notes in patient records
3. Imaging results accessible through CEHRT
4. Record patient family health history
5. Identify and report cancer cases to a State cancer registry
6. Identify and report specific cases to a specialized registry (other than a cancer registry)

We are able to do #2 & 4. I am not sure which other menu objective we can do. Michele has a meeting with Chris West from Mass ehealth collaborative this week to discuss.
I seem to remember BMC trying to set up an interface for radiology. I am not sure what happened with that. I will follow up with Michele.

Core Requirements for MU2 - 17 of Them!!

Eligible Professionals

Report on all 17 Core Objectives:

1. Use computerized provider order entry (CPOE) for medication, laboratory and radiology orders
2. Generate and transmit permissible prescriptions electronically (eRx)
3. Record demographic information
4. Record and chart changes in vital signs
5. Record smoking status for patients 13 years old or older
6. Use clinical decision support to improve performance on high-priority health conditions
7. Provide patients the ability to view online, download and transmit their health information
8. Provide clinical summaries for patients for each office visit
9. Protect electronic health information created or maintained by the Certified EHR Technology
10. Incorporate clinical lab-test results into Certified EHR Technology
11. Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research, or outreach
12. Use clinically relevant information to identify patients who should receive reminders for preventive/follow-up care
13. Use certified EHR technology to identify patient-specific education resources
14. Perform medication reconciliation
15. Provide summary of care record for each transition of care or referral
16. Submit electronic data to immunization registries
17. Use secure electronic messaging to communicate with patients on relevant health information 

From what I can see, our current implementation of NextGen 8.1 satisfies 11 of these requirements. It may also satisfy #9 and #15. We are actively working on meeting #16.

Patient Portal is required for #7.
NextGen 8.3 (5.8) will satisfy the remaining two (#6 and #17)

The Direct Project - Important Part of HIE

OK, I know I said I would list the 17 Core requirements for MU2 over the next couple of blogs but I found this information about how we are going to be able to exchange Health Info in a secure way. NextGen is one of many vendors who are working on this collaborative project. 

Extracted from the Direct Project Website:

• How the Direct Project Fits with Other Exchanges

  The Direct Project is one part of a broad national strategy to connect healthcare providers through a Nationwide Health Information Network. The Nationwide Health Information Network consists of standards, services, and policies; a group of organizations is already exchanging information using existing components. The Direct Project was created to focus on a subset of the scenarios handled by the Nationwide Health Information Network, and to find a way to make them simpler and more achievable by all healthcare providers. That means that the Direct Project is complementary to other approaches.
  
  Many electronic health records and healthcare information organizations can exchange information today. Some exchanges may already be similar to scenarios covered by the Direct Project, while others may be beyond the Direct Project's scope. An organization is not required to support the Direct Project's services and specifications, but it may choose to do so in order to add to its existing approaches.

Watch this interesting video. It is an hour long but I think it is worth your time to see where Health IT is going ( or hoping to go). It discussed interoperability. It really will be a game changer.

if video does not load click here

Meaningful Use Basics

I found this short, easy to watch, video that describes MU in simple terms.
It was designed to explain MU1. The changes for MU2 include:

• needing a 2014 ONC certified EHR
• 17 Core requirements (instead of the 15 needed for MU1)
• 3 out of 6 Menu requirements (instead of 5 out of 10 needed for MU1)
• you can attest for MU2 in a 90 day cycle in 2014

Over the few blogs I will list what the Core requirements and Menu requirements are and we can discuss how close we are to meeting them and what do we need to move forward.

 

if video does not load click here

The Mass Health Information HIway

The Mass HIway enables the electronic movement of health related information among diverse organizations, such as doctors’ offices, hospitals, laboratories, pharmacies, skilled  nursing facilities and health plans.
For more information visit the The Mass HIway website

Michele and Jackie are working with Baycare to get HPA connected to this HIE (Health Information Exchange) via Baystate. Part of Meaningful Use 2 is the ability to connect to an HIE.

Patti & Paula's Excellent Adventure

Patti & Paula will travel to Exeter N.H. on 2/7/14 to see how the CORE Physicians Group is using Nextgen. We will be meeting with Dr Kristen Johnson who is also a pediatrician. She is a physician leader on their Nextgen team. We hope she will have tips on how they improved workflow. We plan to share what we have been doing here.We will also be able to see their patient portal.
If you have anything you wish  us to try & find out while we are visiting, please let us know today.

Snow day Cartoon - Enjoy

Best Practices for Provider Test Action & Telephone Template

Provider Test Action:

Always make sure you are using a current date ( not yesterday's )
Can view appt, meds, vitals, allergies
Can result diagnostics & referrals
Can pull results of diagnostics & referrals into note
How to use : 1- category, 2-action detail, 3-To Do
You can task from here
Generate note
See action log

Telephone Template:

See contact info with confidential cell, parents names, pharmacy
See appt info, telephone summary

Allergy buttons in Immunization Template

As requested Annette turned off these buttons so you no longer need to click the 3 allergy buttons to order immunizations. Your MA or nurse still needs to check allergies as part of their workflow and before giving immunizations.

Best Practice workflow for Sick Visits

Here is the Best Practice workflow for sick visits. Thanks again to our small working group.

Best Practice workflow for Sick Visits

Start at History or Summary tab
Go to SOAP
Will be training staff to use ROS only
Do history under comments in HPI
You can add X-rays to HPI if you wish
Use saved PEs - ie URI PE or ADD PE
Use My Plan if available
See menu bar across top: Plan Details, Labs, Diagnostics, Referrals - this is a quick way to move around
See Impression Comments - these are comments you want in your note but not on the patient plan
Set up Referrals, Follow Ups at bottom of My Plan
See how it shows up in Check Out

Best Practice for WCC

I would like to thank the 2 Scotts, Vicky & Patti for helping to figure out the best work flow for the providers when doing WCC, sick visits, Provider test action & telephone template. We will discuss this at length tomorrow but here is the work flow for WCC.

Best Practice for WCC

Start at history tab
Update chronic conditions
Review summary - at least sections immunizations thru plan/HPI
Use Quick Visit
Enter thru Show All button
Address chronic conditions in HPI if needed
Complete note thru Plan Details
Add orders thru My Plan if you wish

Show lab template
Show updated pedi folder for documents
Show care metrics

My Plan for WCC

From MY Plan WCC you can order labs, office procedures, office labs, and meds.
These are real orders that display in Check Out & Order Management where they can be completed.

Notes:

• Quick Visit does not open automatically to My Plan. Quick Visit (as well as its Plan Detail) is  a language/description of what needs to be ordered but it is not the actual order. 
• My Plan pushes the real orders. 
• My Plan is possibly the best place for the staff to push these orders until Clinical Guidelines goes live.
• Immunizations cannot be ordered from My Plan

Access to Med Module from Plan Details

Do you think there is a way to give access to the med module through the "HPA Plan Detail" template?
I just find its helpful to be able to look at that sometimes while I'm putting in my assessment rather than having to go out and back in again.
Thanks, Lesley

Great idea Lesley,
There is now a Med Module button on the Plan Detail template.

Try it! 

Note: the button is not pretty yet, but we are testing if this works.