Clinical Adoption Workshop
HEALTH SERVICES FOUNDATION
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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
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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
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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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Patient Visit Workflow
Scheduling
&
Registration
Patient
Check In
Chart Prep
Between
Visit Care
Patient
Intake
Provider
Assessment
Check Out
Care
Delivery
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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
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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?)
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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?
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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.
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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) Screenings/vaccines expectations for the patient that are monitored by the system.
b) Diabetic Management
c) 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) Order the test/procedure that is needed to satisfy the maintenance.
b) Document if the maintenance was performed elsewhere.
c) Document if the patient refuses.
d) Document if the patient/clinician postpones.
e) 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
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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)
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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!
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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 PreCert (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
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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?
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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
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
 Adhoc
 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
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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
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