New Problem List Dictionary (IMO) Workflow Recommendations

Transcription

1 Catherine Hill, RN May 15, 2014

2 The Problem List Overview What is SNOMED-CT? Mapping ICD SNOMED One-to-one (Bulk mapping) One-to-many (Manual mapping) Mapping Required Basic Navigation Data Display Grid Data Display Grid Toolbar Data-Entry Grid Top Toolbar Data-Entry Grid New Problem List Dictionary (IMO) Workflow Recommendations

3 Enables the User to record and update a patient s problems using SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms) Concepts to meet Meaningful Use 2 requirements. Clinical Terms linked to a Concept ID i.e. codified for standardized communication of health information. Problem List is Demographic and is NOT associated to an encounter. Comprises chronic conditions or conditions that will be managed over a period of time.

4 The Problem List is located in the Problem Module, Tab 1 in 5.8 / 8.3 and supports the following: Requirement for SNOMED-CT coding for Meaningful Use Stage 2 Patient Level Used for Clinical Patient Care and Treatment, interoperability of clinical data, and reporting Existing ICD-9 chronic problems in older KBMs are moved to the new SNOMED Problem List over time Many codes have been mapped to the new SNOMED coding format prior to the 8.3 upgrade, i.e. many Diagnoses listed in the Chronic Conditions grid under the Histories tab. Remaining chronic problems will be mapped by clinical users at the patient level after the upgrade Where did they come from? As stated above many of the diagnoses listed in the Chronic Conditions in the patient s History have been converted. Some will require mapping at the patient level. More to come on this subject. New Features within the Problem List Re-Coding My tracked problems Multiple Notes

5 Acronym for Systematized Nomenclature of Medicine Clinical Terminology Provides clinical content and expressivity for clinical documentation and reporting Different than ICD-9 or ICD-10 More clinically oriented / descriptive 250,000 clinical terms Required for clinical Problem List to qualify for Meaningful Use 2 certification SNOMED-CT and SNOMED frequently used interchangeably SNOMED Webinar: Tuesday, May 20, 2014, presented by Dr. Greg Fraser

6 A little Terminology and History One-to-one = One ICD-9 Code to One SNOMED Code Users will notice the majority of the Patient s chronic conditions have been mapped prior to Go-Live with the assistance of IMO in a process referred to as Bulk mapping. One-to-many = One ICD-9 Code to many SNOMED codes In some of these cases the ICD-9 Codes may require Manual mapping at the Patient level Upon accessing a Patient s chart, Histories tab, Problems List or Add or Update Assessments pop-up, Clinical Conditions, the User will see an indicator displaying Mapping Required which is an active text link to access and perform this process.

7 One-to-one Hypertension (401.9) Essential Hypertension ( ) One-to-many Diabetes mellitus - Diabetes type II ( ) without mention of - Diabetes type II, without complication type II complication ( ) or unspecified type - Diabetes type II, well controlled not stated as ( ) uncontrolled (250.00) - Diabetes type II, poorly controlled ( )

8 MAPPING required Users can Map to Existing Problems - OR Resolve the Condition SNOMED SEARCH WINDOW

9 Using the Chronic Problem List & Module Panel on Home Page, Histories, Chronic Conditions HPI, Today s Assessments templates Add or Edit buttons open the Problems Module Encourage the use of Notes for each problem can have several editable in Problem Module or on Chronic Conditions HPI Problems can be filtered by setting some as My Tracked useful in multi-specialty practice Most chronic problems should have chronic flag set

10 Check boxes to filter display To Refresh Screen Data To Change and Set Data Display Grid Column Header Preferences

11 Displays all Active, Inactive, and Resolved problems. Displays Column Headers selected in Preferences.

12 #1 #2 #4 #3 #5

13 To Add a Problem to the Problem List select the Add Problem button to launch the SNOMED Search window Free text Term, Search, Highlight, and Select the specific Problem

14 Re-Code Ability to modify problems as the patient s condition evolves, as new information is received, and/or for clarification. SNOMED SEARCH WINDOW

15 View History Ability to visualize who, when, and what modifications were made to problems within the Problems List.

16 View/Add Notes Ability to Add / Update / Delete Notes within the Problems List for the tracking and management of problems.

17 If the Problem has not already been added to the Billing ICD List, it is VERY important to do so for any Orders to be submitted and processed related to this Problem. Highlight the Problem and Click the Add to Billing ICD List button

18 Use the Data-Entry Grid to Update/Edit/Resolve Problems within the Problems List Remember to Accept or Cancel

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20 The Add or Update Assessment and IMO Diagnosis Searching will remain the same in 5.8, launching from the Templates Click to Search IMO aka The Problem List Dictionary

21 Free Text in Field to Search Filter Options Drop down to display more search results Assessments Display Grid Select to Add To: Assessments, Problems, or Both Problems & History Display Grid

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23 Utilize Add and Update Assessment Screen Billing Diagnosis History One Click Assessment (pitfalls) Search Window Status Clinical Problems Search Window Warning: Add in Problems Module Workaround (use IMO) Assure all Chronic Problems are on the Billing List for Orders Note: All orders must have a valid ICD-9 Code Re-Code Problems as the patient s condition evolves, changes, and/or for clarification (Problem List) Reminder: PLD (IMO) is NOT available in the Problems Module

24 Avoid by Navigating Across the TOP WARNING occurs with SAVE & CLOSE

25 Ngkbm Config System/Practice Template Practice Preferences Practices choosing BOTH the Require Assessment Status and Add Assessments on 1 Click may experience the Assessment Description incorrectly displaying on the Add/Update Assessment Template (Issue ID: 49853) Work Around - Select One or the Other or Neither

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27 SNOMED Webinar presented by Dr. Greg Fraser, Tuesday, May 20, 12:15pm Immunizations & Diagnostics Webinar presented by Robyn Scott, Thursday, May 22, 12:15pm Patient Education Webinar presented by Cathy Hill, Thursday, May 29, 12:15pm Open House for Template Configuration June 17 20, & 24 27, 2014, at WVP EHR Training Room, Help Desk preferred date and time. Friendly Friday Webinars, Q&A Sessions, beginning June 6 th, 2014 through July 18 th, 2014.

28 Thank You!