EHR Analyst Application Use Guidelines. March 2010

Transcription

1 EHR Analyst Application Use Guidelines March 2010

2 Table of Contents Welcome to the EHR Team!... 3 Modules... 6 Access Administration... 7 Administration Module... 8 Clinical Customization Module Input Manager Output Manager Reporting Module Clinical Module Summary of Typical Responsibilities March 2010 Page 2 of 21

3 Welcome to the EHR Team! Welcome to the EHR Team! We are glad you have joined us! Here are a few details you will want to know about our team dynamics: Team Boundaries Prompt arrival Timely responses (follow-up) to customers and team Honest, respectful communication Simply put, mutual purpose and respect o Team discussion = discussion of facts and not hearsay o Team decision = individual team members decision o Details of decision discussions are kept within the decision-making office. Management s Commitment to You Listening ear Straightforward communication Doing what is within our control to make you successful Constructive feedback We want you to succeed as much as we want to succeed ourselves! Hours For some, 40-hour work week with on-call weekends and after-hour upgrade duties as assigned For some, 32-hour work week with on-call weekends and after-hour upgrade duties as assigned March 2010 Page 3 of 21

4 Team Members The following grids define EHR team members, their application access, and responsibilities: Core Team Member Application Access Responsibilities Debbie Kress All Modules Customization, Support, Chart merges, Diane Smith Output Manager Administration Module Clinical Module Correction letters Forms (Chairs SWMC s Forms Committee) Helps with EHRSupport and calls Performs chart merges Gen Torberg All Modules Creates Reasons for Visit Helps with EHRSupport and calls Performs chart merges Heidi Bargerhuff All Modules Server updates, support, project planning, training, general support JC Hearn All Modules Defines administrative vision Other Team Members Member Application Access Responsibilities Brian Meyer (IS) Mike Hall (IS) Administration Module Limited Access Administration Module Limited Access IS Support role Can change passwords IS Support role Can change passwords Don Needles (IS) Administration Module IS Support role Can change passwords Limited Access Sheila Reitz (IS) Administration Module IS Support role Can change passwords Limited Access Scott Timkovich Clinical Module Limited Access Key contact for PM application and questions about PM to EHR issues. Dana Cochran Clinical Module Limited Access Key contact for PM application and questions about PM to EHR issues. Joyce Bailey Clinical Module Niles Office Director (IM/FP, Pediatrics, Walk-In Clinic) Nancy Labis Clinical Module Bridgman Coordinator (IM/FP) Marilyn Hurrle Clinical Module Stevensville Office Director (IM/FP, Pediatrics, Walk-In Clinic) Cheryl Ryno Clinical Module Royalton Coordinator (Surgery, OB/Gyn) Debbie Sprague Clinical Module Niles OB/GYN Coordinator (not on EHR completely but doing some electronic charting) Christie Case Clinical Module Clinical Customization Module Limited to Medication Catalog Adds user-defined medications Reports problem patterns in eprescribing Kathy Harbert Clinical Module Reports problem patterns in eprescribing Kim Woelfel Clinical Module Clinical Customization Module Limited to Medication Catalog Adds user-defined medications Cindy Seitenstich Clinical Module Input Manager Manages interfaces (EHR LIS, PM EHR, PM LIS) Performs chart merges March 2010 Page 4 of 21

5 Functional Experts Functional Experts are on-site EHR/IS liaisons. They are critical as our first connection to staff when it comes to questions or problems. They also train general staff on upgrades. Clara Boardman (MA) Niles Paula Morlock (MA) - Bridgman Gloria Veres (LPN) Stevensville Judy Hindmon (MA) - Surgery Jamie Henson (RN) OB/Gyn Meetings There are routine meetings that EHR analysts attend. For some, analysts will attend as a whole team. For others, analysts will attend individually but will be expected to take notes and report back to the team. The grid below identifies routine meetings, their frequency, and attendees. Meeting Frequency GT DK HB Forms as scheduled x Application Integration Monthly x IS Monthly x x x EHR Team Weekly x x x PQRI Monthly x Research as needed x RfV as scheduled x x Steering Committee Quarterly x x Workflow Weekly x x Upgrade: Testing Team as scheduled x Harvey Monthly Meeting as scheduled x Ferrari Monthly Meeting as scheduled x O Neill Monthly Meeting as scheduled x Marten Monthly Meeting as scheduled x Kroeze Monthly Meeting 2 nd Friday of each month,12:30-1:30 p.m. x Knefelkamp Monthly Meeting TBD x March 2010 Page 5 of 21

6 Modules Introduction There are currently 7 modules in the Allscripts Professional EHR application group. They are as follows: Module Access Administration Administration Module Clinical Customization Module Input Manager Output Manager Reporting Module Clinical Module Not used at this time. Module where new users are set up and site settings are maintained. Some customization tasks occur here. Module where most customization occurs (including lab information) Module where scanning occurs. Some interface tasks are maintained here. Module where Output Queue forms are created/maintained. Module offering basic reporting functions. Module where all standard users complete their charting and messaging. The remainder of this document will cover details about each of these modules, and as guidelines will continually evolve, it is best to frequently check this document for up-to-date guidelines. March 2010 Page 6 of 21

7 Access Administration Not used at this time. March 2010 Page 7 of 21

8 Administration Module The Administration Module is the core location where system settings are devised. Most settings are rarely changed as changing some settings can cause considerable ramifications for application use, legal concerns, and application performance. Caution is strongly advised when navigating this module. Any changes made in the Administration Module must be communicated to EHR Team members and any affected parties. Log In Use your username/password to log in. Settings Folder Section License and Registration Site Settings Locations Caregivers Function Access Message Subjects Dictionary Changes made to this section as authorized by team lead Changes made to this section as authorized by team lead with 1 exception: On the General Settings tab, Concurrent Encounters per Chart can be changed to 4 temporarily when an extra encounter is needed. It must be returned to 3 encounters once the problem situation has been resolved. Team lead authorization is not needed for this temporary change. Changes made to this section as authorized by team lead New users set up here (staff all analysts; providers team lead) Name changes completed here (staff all analysts; providers team lead) Terminations completed here (staff all analysts; providers team lead) Referral caregiver information checked here but not edited. Edits are completed in PM. Where security settings (per group) are set. Changes made by team lead at this time. This includes subjects for Chart messages, mail messages (not used), patient messages, and action items. Changes made by team/workflow decision. The dictionary houses a number of lists. Changes are to be made only by team/workflow decision. Caregiver Types Chart Attachment Types (not used at this time) Consent Document Types (not used at this time) Drug Interaction Override Reasons Electronic Refill Rejection Reasons (not used at this time) Encounter Types Immunization Facilities Medication Frequencies Other Problems Performance Types (not used at this time) Reasons for Keeping Chart Pulled Reminder Subjects Report Categories Report Result Tasks Vaccine Information Statements March 2010 Page 8 of 21

9 Section Web Accounts Web Servers Caregiver Enrollment Not used at this time Not used at this time Where new providers are enrolled in eprescribing Where existing providers are re-enrolled after they have not prescribed a prescription in 15 days and have thus become inactive. System Administration Folder Section System Options Scheduled Tasks Locked Charts/Patients Error Log Job Log Error Reporter Settings Changes made to this section as authorized by team lead Changes made to this section as authorized by team lead If a staff member cannot access a chart because of the message, This encounter is currently in use elsewhere by and cannot be changed, have the staff member make sure s/he doesn t have 2 Clinical Module sessions open or have another staff member move to an uneditable portion of the encounter. If these steps do not work, unlock the chart using this section. The Error Log lists typical application errors that have occurred over a given time span. Log of completed server services/tasks Changes made to this section as authorized by team lead March 2010 Page 9 of 21

10 Clinical Customization Module The Clinical Customization Module is the primary module where customization occurs, although as you have seen, some customization occurs in the Administration Module. Any changes made in the Clinical Customization Module must be communicated to EHR Team members and any affected parties. Log In Since you can only edit those things you have created, we have created a shared username/password so we can edit each other s items easily. Shared Username: customize Shared Password: xxxxxx There are certain parts of the Clinical Customization Module that deny access to the customize user. Since there are several users who use the customize username/password to do customization, some parts of the Clinical Customization Module can only be accessed by your own username for security purposes. Also, user-defined medications work uses its own username/password: Username: medication Password: xxxxxx Clinical Customization Module Sections Knowledge Reason for Visit (and sub items) Review of Systems History Physical Exam Changes made as needed after specialty/department consensus. Checklist for RfVs is as follows: Are standardized characteristics being used? (Medication Changes, etc.) Detail order should go from best to worst Other" should always be considered. For symptom lists, use (when possible) multiple positive/negative. Caution! Changes made can affect live templates. If changes are recommended by committee, then appropriate steps will be taken to make changes. Changes made per team decision. Allergy History items must be codified with a UNII item. Changes made as authorized by team lead. March 2010 Page 10 of 21

11 Short Lists Reason for Visit Allergy History Family History Past Medical History Social History Travel History Medication History Changes can be made as requested after specialty/department consensus. Changes can be made as requested after specialty/department consensus. Changes can be made as requested after specialty/department consensus. Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code in the line. Changes can be made as requested after specialty/department consensus. Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code in the line. Changes can be made as requested after specialty/department consensus. Changes can be made as requested after specialty/department consensus. Changes can be made as requested after specialty/department consensus. Medications: If any pre-dosed medications are added to the list, add them in the following way: should read with the SIG so users can clearly see what they are selecting. (medication name, strength, type, dose, frequency, any additional notes, quantity/refills). Abbreviations (BID, TID, QID, etc.) may be used in description but not in attributes. Attributes should be defined to match the SIG. Pregnancy/Birth History Assessment & Plan IM/FP Short List Changes can be made as requested after specialty/department consensus. Changes can be made as requested after specialty/department consensus. See guidelines for individual lists below Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code after the name in the line. Example: CBC (85025) For Diagnostic Imaging/Testing subfolder, item/code order is as follows: Subfolder items are from head to toe Side Order: Left, Right Contrast Order: +/- Contrast, with Contrast, no Contrast View Order: Single View, 2 views, etc. Medications: If any pre-dosed medications are added to the list, add them in the following way: should read with the SIG so users can clearly see what they are selecting. (medication name, strength, type, dose, frequency, any additional notes, quantity/refills). Abbreviations (BID, TID, QID, etc.) may be used in description but not in attributes. Attributes should be defined to match the SIG. Laboratories: Cindy Seitenstich adds these. Pass any requests to her. Referrals: Do not use. Add referrals as discharge text. Patient Education: Add as needed. Title appropriately. Office Procedures/Discharge Plans/Nursing Services: See Team Lead for more details on these items. Forms/Letters: Do not use. Forms/letters are not used and thus are not added to a short list. March 2010 Page 11 of 21

12 Pediatric Short List Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code in the line. Example: CBC (85025) For Diagnostic Imaging/Testing subfolder, order is as follows: Subfolder items are from head to toe Side Order: Left, Right Contrast Order: +/- Contrast, with Contrast, no Contrast View Order: Single View, 2 views, etc. Medications: If any pre-dosed medications are added to the list, add them in the following way: should read with the SIG so users can clearly see what they are selecting. (medication name, strength, type, dose, frequency, any additional notes, quantity/refills). Abbreviations (BID, TID, QID, etc.) may be used in description but not in attributes. Attributes should be defined to match the SIG. Laboratories: Cindy Seitenstich adds these. Pass any requests to her. Referrals: Do not use. Add referrals as discharge text. Patient Education: Add as needed. Title appropriately. Office Procedures/Discharge Plans/Nursing Services: See Team Lead for more details on these items. Forms/Letters: Do not use. Forms/letters are not used and thus are not added to a short list. Surgery Short List Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code in the line. Example: CBC (85025) For Diagnostic Imaging/Testing subfolder, order is as follows: Folders as well as subfolders and their items are listed alphabetically Side Order: Left, Right Contrast Order: +/- Contrast, with Contrast, no Contrast View Order: Single View, 2 views, etc. Medications: If any pre-dosed medications are added to the list, add them in the following way: should read with the SIG so users can clearly see what they are selecting. (medication name, strength, type, dose, frequency, any additional notes, quantity/refills). Abbreviations (BID, TID, QID, etc.) may be used in description but not in attributes. Attributes should be defined to match the SIG. Laboratories: Cindy Seitenstich adds these. Pass any requests to her. Referrals: Do not use. Add referrals as discharge text. Patient Education: Add as needed. Title appropriately. March 2010 Page 12 of 21

13 Office Procedures/Discharge Plans/Nursing Services: See Team Lead for more details on these items. Forms/Letters: Do not use. Forms/letters are not used and thus are not added to a short list. OB/Gyn Short List Codes: Any codes added to the list (ICD-9, HCPCS, CPT) must be added with the code in the line. Example: CBC (85025) Medications: If any pre-dosed medications are added to the list, add them in the following way: should read with the SIG so users can clearly see what they are selecting. (medication name, strength, type, dose, frequency, any additional notes, quantity/refills). Abbreviations (BID, TID, QID, etc.) may be used in description but not in attributes. Attributes should be defined to match the SIG. Laboratories: Cindy Seitenstich adds these. Pass any requests to her. Referrals: Do not use. Add referrals as discharge text. Patient Education: Add as needed. Title appropriately. Office Procedures/Discharge Plans/Nursing Services: See Team Lead for more details on these items. Forms/Letters: Do not use. Forms/letters are not used and thus are not added to a short list. Flu Shot Changes can be made as per team decision Clinic xxx Used for testing purposes only Exam Templates Review of Changes made as needed after specialty/department consensus or provider request. Systems Currently, we allow individual provider Review of Systems for everything except complete annual physicals [for which the providers are to use Adult Female (Form) and Adult Male (Form)]. We encourage team consensus if at all possible. Physical Exam Changes made as needed per provider request. Currently, we allow individual provider PE templates and recommend a minimum of an Adult Female template (for complete physicals), an Adult Male template (for complete physicals), and a brief or short template Catalogs Lab Catalog External Results Procedure Entry Rules Medications Cannot be accessed with customize password. Can only be accessed with your own password. Cindy Seitenstich maintains this catalog, and EHR analysts can make changes with Cindy s permission. Cannot be accessed with customize password. Can only be accessed with your own password. Cindy Seitenstich maintains this catalog, and EHR analysts can make changes with Cindy s permission. Changes can be made per team decision and specialty/department consensus Changes can be made per team decision and specialty/department consensus Cannot be accessed with customize password. Can only be accessed with medication username and password (meds123) March 2010 Page 13 of 21

14 Billing Modifiers Not used at this time Modifier Not used at this time Combinations Order Alerts Not used at this time Order Groups Not used at this time Anatomical Changes can be made per team decision and specialty/department consensus. Pictures Cannot be accessed with customize password. Can only be accessed with your own password. Immunizations Changes can be made per team decision and specialty/department consensus. Cannot be accessed with customize password. Can only be accessed with your own password. Templates Fast Track Prescription Discharge Plans Patient Education Office Procedures Nursing Services Form/Letter Result Summary Flow Sheet Templates Not used at this time Changes can be made per team decision and specialty/department consensus. Changes can be made per team decision and specialty/department consensus. Any text note that falls outside of office procedures and nursing procedures is added here. Changes can be made per team decision and specialty/department consensus. Changes can be made per team decision and specialty/department consensus. This template category is limited to procedures performed in the office. Changes can be made per team decision and specialty/department consensus. This template category is limited to services performed by nurses Not used at this time. No forms/letters should be created or used. Changes can be made per team decision and specialty/department consensus. Changes can be made per team decision and specialty/department consensus. Lab Order Entry Setup Cannot be accessed with customize password. Can only be accessed with your own password. Cindy Seitenstich is the team member who maintains lab order entry. EHR analysts only work in this area as requested by Cindy. March 2010 Page 14 of 21

15 Input Manager Input Manager is the module where scanning occurs. Some interface tasks also occur in this module. Any changes made in Input Manager must be communicated to EHR Team members and any affected parties. Log In Use your username and password to log in. Input Manager Sections Input Manager Section Scanned Documents External Transcriptions Internal Transcriptions Where scanning/indexing occurs. Analysts do what is needed in this section to support users. Not used at this time Not used at this time Input Manager Section Document Types Scanning Qualities Transcription Statistics Changes can be made per team decision/committee approval Changes can be made per team decision/committee approval Not used at this time Reconciler (Interface-related) Section Caregiver Matching Patient Matching Audit Log This is where new providers sent from the lab software are matched to existing EHR providers. Cindy/Lab staff manage this section. Analysts are only to make changes with Cindy s approval. This is where the lab staff matches lab results to EHR patients if the original matching logic does not work. Analysts can assist with this if Cindy requests it. This is a log Cindy and EHR analysts can use to view when results came in to the EHR, what patients the results were matched to, and what provider received the result notification. March 2010 Page 15 of 21

16 PM Interface Options (Interface-related) Section Provider Import Queue Location Import Queue When a new provider is created in PM, that provider will appear here. Provider will be added as per team discussion. When a new provider is created in PM, that provider will appear here. Provider will be added as per team discussion. March 2010 Page 16 of 21

17 Output Manager Diane Smith maintains the Output Manager and is chair of the Forms Committee. Any form creation and changes are made through her. March 2010 Page 17 of 21

18 Reporting Module EHR analysts are free to create reports as needed in the Reporting Module provided notification is made to other analysts of new reports. All analysts must notify the Team Lead of scheduled time (if applicable) report will run. Team lead will assess if there are any conflicts. Log in Use your username and password to log in. March 2010 Page 18 of 21

19 Clinical Module The Clinical Module is where EHR analysts will spend the most time. This module is also where standard users complete their daily EHR tasks. The following users currently use the EHR: Providers and clinical staff (IM/FP, Pediatrics, Surgery, OB) Business Office staff Receptionists Medical Records staff Hospitalists Log in Use your username and password to log in. Tools Menu The Tools menu offers diverse lists and functions. View the grid below to see more details on these lists and functions. Option Edit Referral Caregivers Edit Insurance Carriers Edit Pharmacies Edit Institutions Patient Merges Export CCR Import CCR Pregnancy Record RxHub Absolutely no changes are to be made to this list. Absolutely no changes are to be made to this list. Changes may be made by team consensus. (This list is uploaded each evening automatically within a 50-mile radius of Berrien Springs.) No changes are to be made to this list at this time. EHR analysts may merge as needed. Not used at this time Not used at this time One location where the pregnancy record may be started (given the appropriate code and vital) Used for manual RxHub requests. Can be done at any time. Options Menu The Options menu offers options you may change for your username, but it also includes 2 options that can affect the whole site or specific locations. These 2 options are: Option Edit Printer Defaults Edit Output Settings Site and location changes only made by team consensus. Individual changes may be made at any time per user request. Site and location changes only made by team consensus. Individual changes may be made at any time per user request. March 2010 Page 19 of 21

20 Summary of Typical Responsibilities Administration Module Task Responsibility New user setup - All analysts Set up new staff Staff Name Change All analysts Change staff member s name. Staff Terminations All analysts Archive terminated staff Staff New user setup Heidi Set up new providers Provider Name Change Heidi Change provider s name Provider Terminations Heidi Archive terminated providers Provider Site Settings All analysts Make changes ONLY to Concurrent Encounters per Chart when necessary. Never go above 4 encounters, and remember to change number back to 3 within a few minutes. If you see a pattern of noncompliance (not signing off charts and/or leaving too many encounters open), report user to team lead. Referral Caregiver Changes PM Staff Real referral caregiver changes should never be made in the EHR. Contact a PM staff member to make the change, and it will be updated automatically in the EHR. Function Access Heidi Changes in this area are serious with regards to application security, so the team lead will decide when to make the change. Message Subjects All analysts Any analyst can make a change once a team decision/workflow decision has been made. Dictionary Changes All analysts Any analyst can make a change once a team decision/workflow decision has been made. Caregiver All analysts New activations are completed when a new provider is set up. All Enrollment Locked Charts/Patients All analysts Clinical Customization Module Task Responsibility analysts are free to reactivate a provider that has become inactive. Use this area to unlock a chart after all other efforts to unlock a chart have failed. Reasons for Visit Gen Debbie Create reasons for visit and collaborate with physician champions and physician groups throughout the creation/editing process. History Gen Add history items as needed Debbie Review of Gen Create ROS items as needed. Systems Debbie Physical Exam Heidi Update PE as needed. Caution! Any changes can affect templates. Short Lists All analysts Any analyst can make a change once a team decision/workflow decision has been made. Follow guidelines as given in the previous sections of this document. Exam Templates All analysts Any analyst can make a change once a team/workflow/provider decision has been made. Catalogs: Lab Cindy Seitenstich Cindy will maintain this catalog + External Results Procedure Entry Gen Changes can be made per team decision Rules Debbie Medications Gen Changes can be made per team decision March 2010 Page 20 of 21

21 (Clinical Customization continued) Task Responsibility Anatomical All analysts Changes can be made per team decision Pictures Immunizations All analysts Changes can be made per team/workflow decision Templates Gen Debbie Changes can be made per team/workflow decision For Patient Education, consider copyright law. For Fast Track and Forms/Letters, no changes will be made as these are not used. Result summaries will require Cindy Seitenstich s input. Lab Order Entry Setup Cindy Seitenstich Cindy will maintain this area. Input Manager Task Responsibility Document Types All analysts Changes can be made per team/committee approval Scanning All analysts Changes can be made per team/committee approval Qualities Caregiver Cindy Seitenstich Cindy/Lab staff will maintain this area. Matching Patient Matching Cindy Seitenstich Cindy/Lab staff will maintain this area. Provider Import Heidi New provider setup Queue Vann Location Import Queue Heidi Vann New location setup Output Manager Task Responsibility Forms Reporting Module Diane Smith TBD Create/maintain clinical forms Task Responsibility Reports All analysts Create/maintain reports per team decision Clinical Module Task Responsibility Edit Referral PM System Specialist Create/maintain referral caregiver list Caregivers Edit Pharmacies All analysts Additions/changes should only be made to pharmacies outside of our 50-mile radius. Within the 50-mile radius, problems should be called to AllScripts Patient Merges All analysts Any analyst may merge a chart per given guidelines Edit Printer Defaults All analysts Site/location changes made per team decision Individual changes made as needed. Edit Output Settings All analysts Site/location changes made per team decision Individual changes made as needed. March 2010 Page 21 of 21