EHR Patch Updates Office Hours

EHRv1.1p8, TIUv1.0p1008, BHSv1.0p5

What’s new, What’s changed

IHS-Office of Information TechnologyEHR Program

Office Hour Presenters• CDR Susan Pierce-Richards, ARNP, OIT EHR Project Lead• CDR Mary Ann Niesen, PharmD, OIT, ARRA Deployment Pharmacist• Barbara Hess, DHA, OIT EHR Project analyst

Agenda• Introduction• Presenters

– Office Hour Presenters have different specialties within the EHR system who will be responding to your questions

• Questions/Answers– Please do not put your phone “On Hold” during the conference call– “Raise your hand” through the WebEx features provided– Please state your name/site– Please state your question clearly– Please keep background noise to a minimum to better hear the

questions/answers• Patch 8 Resources

– Patch 8 resources will be placed on FTP site (RPMS patch folder) for your review after session

– If you can not access the FTP site please e-mail barbara.hess@ihs.gov for a copy

Chart Review

Supports GUI entry into the new “V Updated/Reviewed” file

This is a visit related file that stores 9 “Clinical Actions”Allergy List Reviewed

Allergy List Updated

No Active Allergies

Medication List Reviewed

Medication List Updated

No Active Medications

Problem List Reviewed

Problem List Updated

No Active Problems

Chart Review

The Chart Review component allows for the documentation of a visit related clinical action for the Allergy, Medication and Problem lists.

The Chart Review component’s primary function is to provide GUI entry of data used for Meaningful Use Reporting.– The ability to document “no active medications,” “no

active problems”

Chart Review

The Chart Review component also provides the following options to support documentation requirements for accreditation and local policy.– To document that allergies were reviewed by a

clinician at a visit – To verify “no active allergies” after initial

documentation of “no known allergies”– The ability to document that the each list was

reviewed by clinician

Chart Review

The Chart Review function also automatically captures list updates.– Add, change, discontinue medication– Add, inactivate, reactivate, review, mark

inability to assess allergies– Add or edit a problem

This will automatically store “Updated” when changing visit context/changing patients.

“Chart Review” Component

Chart Review

The Chart Review actions are available in 2 places:

“Chart Review Component” that may be placed on the toolbar or other location

Right click menu of the Adverse Reaction, Medication List and Problem List cover sheet components.

Review and No Active actions are placed in the signature and signed with the rest of the visit actions such as allergies, orders, etc.

ConfigurationAdd object using Design Mode.

Probably best suited to a toolbar so that users may access this regardless of location in chart.

You MUST add the Chart Review component to the GUI in order for the Cover Sheet right click menu top operate correctly

ConfigurationProperties

You may change the button label by changing the text in REVIEWEDCAPTION value

You may change hover hint adding local guidance by changing the text in the REVIEWHINT value

Chart Review – Business RulesThe Chart Review component is “per user per visit,” so the

buttons are “reset” for each user on a given visit.e.g.: Nurse documents that she reviewed problem list. The provider then determines that the existing problem on the list is resolved and inactivates the problem. Provider may then document “no active problems.” Both clinical actions store in the V Updated/Reviewed file with date/time stamp and user who entered data.

• Documentation of “no active medications” and “no active problems” is used in Meaningful Use Reporting.

Chart Review – Business Rules• Documentation of “reviewed” is currently at the discretion

of the site however the following is a suggested use of the “Reviewed” and “No Active Allergies” functionality– Documentation of “reviewed” on the adverse reaction

component may be used for staff to document that they reviewed the allergies/adverse reactions – a common requirement of accrediting bodies.

– Entry of no known allergies into the adverse reaction component should still be used. Once “No Known Allergies” is documented in the Adverse Reaction component, subsequent verifications can be documented by selecting “no active allergies” using the Chart Review button or right click menu.

“No Active Problems” or “No Active Medications”

When no items exist on Problem list, users may document “No Active Problems”

• Clicking corresponding chart review button• Right click in Cover Sheet component

“No Active Allergies”

• If a patient has “No Allergy Assessment” is it extremely important that if they have no allergies that an entry of “No Known Allergies” is still entered into Adverse Reaction Component

• This will enter an “Updated Allergy List” clinical action into the V Updated/Reviewed file in the background (stored when you exit the visit)

“No Active Allergies”

• When this patient returns at a later date (or the info is confirmed by another clinician later in the visit based on local policy) then use the Right Click (or Chart Review button) to document verifying “No Active Allergies”

“Reviewed”

When items exist on Medication list, for example, users may document “Reviewed”

• Clicking corresponding chart review button• Right click in Cover Sheet component

“Updated”• Added a problem

• Note the [U] on the problem list Button

• Nothing will show up on the signature tool – no action is required by the user

• When you leave visit it will store the Updated Problem list to the V Updated/Reviewed file

----------------------------- V UPDATED/REVIEWED -----------------------------

CLINICAL ACTION: PROBLEM LIST UPDATED PATIENT NAME: TEST,PATIENT

VISIT: APR 29, 2011@13:08 DATE/TIME ENTERED: APR 29, 2011@13:10:33

ENTERED BY: RICHARDS,SUSAN

EVENT DATE AND TIME: APR 29, 2011@13:08:54

ENCOUNTER PROVIDER: RICHARDS,SUSAN

CLINICAL ACTION: PROBLEM LIST REVIEWED PATIENT NAME: TEST,PATIENT

VISIT: APR 29, 2011@13:08 DATE/TIME ENTERED: APR 29, 2011@13:10:33

ENTERED BY: RICHARDS,SUSAN

EVENT DATE AND TIME: APR 29, 2011@13:08:54

ENCOUNTER PROVIDER: RICHARDS,SUSAN

Signature box

• User may uncheck if did not perform action• Status changes after signature

Health Summary Display (no action by CAC needed)

------- CURRENT MEDICATIONS (TWICE DURATION OF RX - MINIMUM 60 DAYS) -------

03/24/11 MEDROXYPROGESTERONE 150MG/ML #1 (90 days) INJECT 150MG INTRA-MUSCULARLLY NOW 03/16/11 ORX-1 PILL # (30 days) Dispensed at: OUTSIDE MED TAKE ONE (1) BY MOUTH (EHR OUTSIDE MEDICATION)03/16/11 OUTSIDE OTC MEDICATION #1 (EHR OUTSIDE MEDICATION)03/16/11 OUTSIDE PRESCRIPTION #1 (EHR OUTSIDE MEDICATION)02/22/11 WARFARIN 5MG TABS #14 (14 days) -- Ran out 03/08/11 TAKE ONE (1) TABLET BY MOUTH DAILY

Medication List Reviewed On: Apr 05, 2011 By: RICHARDS,SUSANMedication List Updated On: By: No Active Medications Documented On: By:

Allergies – new menu options

• Entered in error• Inactivate (and

reactivate) allergies• Inability to assess

Allergies – Unable to Assess

• Right click from Adverse Reaction Component

• RPMS GMRA application

Allergy – Unable to Assess

• If no reactions on list, displays on header bar• If entries, displays on “agent” list• Display removed after entry of “no allergies” or

“reviewed” or adding adverse reaction (is stored for audit purposes)

Allergy – New/Updated mandatory fields

Nature of Reaction is now pre-populated and not editable

Event codes – listed from most specific to least specific

Source of info – self explanatory

Allergy – Event Code

• New event codes• Most specific to least

specific• These are SNOMED

codes (another clinical terminology system, required for EHR Certification)

Allergy – New/Updated optional fields

These fields refer to the onset of reported signs/sympoms

Date/time defaults to NOW but may be changed

Source is optional

Allergies – enhanced detail

Added to detail:

Ingredients

Inactivation info

Reactivation info

Last modified info

Allergies – enhanced verifier dialog

Button to view drug classes and ingredients

Verifier may now make changes to editable fields and this does not change the originator of the allergy

Verifier date/time is stored as is last modified

Vital Entry – Last Known WellThe ability to document “Last

Known Well”

Specifically and only used in the Meaningful Use Clinical Quality Stroke Measures.

Value is always WELL. Document the date/time as follows:

– If witnessed onset, document date/time of onset of stroke symptoms.

– If date/time of onset un-witnessed, document date/time the patient was without stroke symptoms

C32/CCD Viewer• The BJMD package is

designed to generate industry standard CCD in Healthcare Information Technology Standards Panel C32 format and transmit them to Indian Health Service C32 repositories and authorized third parties using Web Services.

C32/CCD ViewerDESCRIPTION:• The C32/Continuity of Care Documents (CCD) Clinical Summary (BJMD) software is

a component of the Indian Health Service (IHS) Resource and Patient Management System (RPMS).

• It provides facilities for generating industry standard CCD in Healthcare Information Technology Standards Panel (HITSP) C32 format (version 2.1). CCD/C32 documents are transmitted to IHS C32 repositories or to authorized third parties using Web Services (WS). C32/CCD Clinical Summary documents will be referred to as “C32 documents” and the C32/CCD Clinical Summary software will be referred to as the “C32 software” in this document.

• The primary function of the C32 Viewer component is so that the user will have the ability to see transmitted patient health summaries from an external source through a view component in the EHR. The user will then be able to create a C32 extract from EHR based patient and encounter context selected in the EHR header bar.

C32/CCD viewer

C32/CCD Viewer Configuration

• Add “C32 Viewer Launch Button” component to EHR – best suited to a toolbar or header area – using design mode

C32/CCD Viewer Configuration

C32/CCD Viewer Configuration• SiteUrl: http://<your site’s RPMS server

address><port>/csp/C32<your site’s UCI>/BJMD.Prod.Service.DocumentRepository.cls

• Replace the parts between and including the brackets with your site specific information. It will look like this.

• The number in italics below (57772) is the default port for Ensemble Web Services, so it should work for most sites, but if a site is running multiple instances of Ensemble, the correct port number may be 57773 or 57774/5/6/etc.

• http://10.243.60.7:57772/csp/C32WSP/BJMD.Prod.Service.DocumentRepository.cls

• NOTE: this component depends on the Vangent supplied C32 package which may need to be set up separately

Parameters – BEHOXQ SHOW HINT

– BEHOXQ SHOW HINT• This option sets the hover hint on the notifications to show or not

show.• You may set this to NO to hide the hover hint or YES to display• Option accessible from XPAR General parameters menu and

BEH-NOT-PAR-HNT (Set Show Hint Dialog option)

Parameters BEHOXQ SHOW HINT

Right click on notifications tab

User may turn on or off Show Hint

Parameter sets default

Parameters -BEHORX DOSAGE FORM

– BEHORX DOSAGE FORM• This option sets the dosage form used in the outside meds for

Unknown medication documentation to set the action to “validate”. Recommend setting this to MISCELLANEOUS now.

• Option accessible from XPAR General parameters menu and BEH-MED-OMD (Outside Med Dosage Form)

Parameters -BEHORX SPLITTER PANE

– BEHORX DOSAGE FORM– BEHORX SPLITTER SIZE

• This parameter sets the proportions of the panes on the medication management component.

• Option accessible from XPAR General parameters menu and BEH-MED-SPL (Med Tab Splitter Pane)

Parameters –BEHORX SPLITTER PANEThe input format is: 20;25;60;75

<inpatient top>;<inpatient bottom>;<outpatient top>;<outpatient bottom>

The numbers represent the size percentage of the two splitters.

Outpt Meds

=========Top Splitter=============

Outside Meds

=========Bottom Splitter==========

Inpatient Meds

Default values are:

If your patient is Inpatient: 20;25

If your patient is Outpatient: 60;75

Non Hospital sites

Set for System

25;50;75;99 (the ‘99’ effectively hides the inpatient pane)

 

The percentages speaks to where the pane starts – so in the Non-hospital site example above 25;50;75;99

Inpatients: the outside meds pane starts 25% down from top and inpatient meds in the middle. At a site with no hospital you will never see this.

Outpatients: the outside meds pane starts 75% down from top and the inpatient is not visible but you can see the splitter control to move into view. (good for a site that is NOT a hospital and would NEVER look at inpatient.

BEHORX SPLITTER PANE example

BEHORX SPLITTER PANE example

So in the following examples

------- Setting BEHORX SPLITTER SIZE for System: DEMO-HO.BEM.IHS.GOV -------

Value: 25;50;75;99//

The first 2 numbers represents the display when you view a patient who is an INPATIENT

The second 2 numbers represents a patient who is not admitted, so is outpatient

Parameters –BEHOVM NEW DATE DEFAULT

– BEHOVM NEW DATE DEFAULT• This option sets the default radio button for Select New Date/Time

on the Vital Entry component. You may default this to “Now” or “Current Visit”

• Option accesable from the XPAR General Parameters menu and BEH – VIT – SND (Select New Date Default option

Patient is INPATIENT status

Patient is OUTPATIENT(not Inpatient status)

TIU 1.0 p1008

Read notes carefully – there is a post install routine that must be run by the individual who installs your patch– Includes a new document class and title named DISCHARGE

INSTRUCTIONS– New fields and parameter were added to allow sites to

configure the header and footer printout of the DISCHARGE INSTRUCTION note.

– Includes new document titles that will be used in meaningful use reporting logic

– E-COPY DISCHARGE INSTR RECEIVED – E-COPY DISCHARGE INSTR NOT RECEIVED

TIU 1.0 p1008Create the special TIU TEMPLATES that you wish to use

in the headers and footers. – These templates should be created in the EHR as you would

create any TIU TEMPLATE. – TIU OBJECTS are OK but TIU TEMPLATE FIELDS cannot be

used since the header and footer are only called by the printing routine.

– Users will NOT see these headers and footers inside the EHR. – If you want to use visit data in a header or footer, it must be an

object that starts with VISIT and not with V (those are only for the GUI)

– Site may wish to put these templates into a special folder so that people don't use them in regular notes although there is no reason why they would not work inside a regular note

TIU 1.0 p1008

Add TIU TITLEs to the DOCUMENT CLASS of DISCHARGE INSTRUCTIONS.– One title is sent with this patch. – Any other titles that the site wishes to use these special

headers and footers will need to be created for this special DOCUMENT CLASS

TIU 1.0 p1008

Add the headers and footers to the title(s) you have created. Use the following menu options:

Start in the RPMS-EHR CONFIGURATION MANAGER menu and choose TIU.

CLN TIU Menu for Clinicians ...

HIS TIU Menu for Medical Records ...<- THIS ITEM

PAR TIU Parameters ...

TIU 1.0 p1008

HIMS Special HIMS TIU Reports ...

IPD Individual Patient Document

LAD List of Active Document Titles

MPD Multiple Patient Documents

PDM Print Documents Menu ...

SIG Awaiting Signature Listing

SSD Search for Selected Documents

STR Statistical Reports ...

TMM TIU Maintenance Menu ...<- This item

UPL TIU Upload Menu ...

VUA View a User's Alerts

TIU 1.0 p1008

DDM Document Definitions (Manager) ...<==THIS ITEM

TAT TIU Alert Tools

TPM TIU Parameters Menu ...

TTM TIU Template Mgmt Functions ...

UCM User Class Management Menu ..

TIU 1.0 p1008

DDM1 Edit Document Definitions

DDM2 Sort Document Definitions

DDM3 Create Document Definitions

DDM4 Create Objects

DDM5 List Object Descriptions

DDM6 Create TIU/Health Summary Objects

DDM7 Title Headers/Footers <==THIS ITEM

TIU 1.0 p1008Use the option BTIU TITLE HEADER/FOOTER to add the titles with their headers and

footers. These titles need to be in the DOCUMENT CLASS of DISCHARGE INSTRUCTIONS. This menu option is added to the DOCUMENT DEFINITIONS MENU (BTIU MENU DOC DEF MGR)

Select Document Definitions (Manager) Option:

DDM7 Title Headers/Footers

Select Division for PNs Outpatient Batch Print: DEMO

Select the title you wish to add headers/footers to Select NOTE TITLE: DISCHARGE INSTRUCTIONS TITLE TITLE

...OK? Yes// (Yes)

HEADER TEMPLATE: SAMPLE HEADER// <=name of template you made

FOOTER TEMPLATE: SAMPLE FOOTER//<=name of template you made

BHS V1.0 p5

• Updated allergy components to reflect the changes in the allergy package delivered with GMRA 4.0 patch 1001 and EHRv1.1 patch 8 (which included GMRA 4.0 patch 1002)

• New “Detailed Adr/Alg” which is a highly detailed report for case review, problem resolution

• Fixed display of measurement object to display both systolic and diastolic blood pressure.

Detailed Allergy report-------------------------- DALL - Detailed Allergies

---------------

Title: ALL ALLERGY/ADVERSE REACTION (AR)

Drug:

ALLERGY: DIGOXIN

Drug Classes: DIGITALIS GLYCOSIDES

Ingredients: DIGITALIS

(V/Historical)

REACTION: BRACHYCARDIA

Originator: CAROLYNN D HOSEY

Title: Carolynn Hosey RN

Date/Time: 12/21/2010 11:15

Verified on: Dec 22, 2010@15:39:48

Verified by: NELSON,GARY

INACTIVE-UNKNOWN: THIS IS SILLY

Drug Classes: TETRACYCLINES

Ingredients: TETRACYCLINE

OXYCODONE

(V/Historical)

REACTION: AGITATION

Inactivation: MAY 31, 2011@08:44:29( REACTION IS TOLERABLE )

Inactivated by: RICHARDS,SUSAN P

Originator: Susan Pierce-Richards, ARNP

Title: Nurse Practitioner

Date/Time: 12/14/2007 17:25

Verified on: Dec 28, 2007@17:34:48

Verified by: RICHARDS,SUSAN P

Resourceslinks will be active AFTER patches released!

EHRv1.1p8 guideftp://ftp.ihs.gov/rpms/patches/ehr_0110.08o.pdfTIUv1.0p1008 notesftp://ftp.ihs.gov/rpms/patches/tiu_0100.1008nBHSv1.0p5 notes (Health Summary Components)ftp://ftp.ihs.gov/rpms/patches/bhs_0100.05n