Presented By:HCN Clinical Operations

ACHIEVING MEANINGFUL USEINTERGY V9

THE GOALThe goal of this presentation is to demonstrate how to

correctly document within Intergy EHR v9 to:

Improve Patient Care

Standardize documentations for easier/faster review of patient’s chart

Achieving Meaningful Use requirements

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TOPIC PAGE

Workflow 4

Registration Check List 5

Patient Information 6

Contacts 7

Imaging Results 8

Patient Visit: Clinical Support Staff Check List 9

Problems, Allergies, and Medication List 10

Vital Signs 11

Smoking Status and Family History 13

Patient-Specific Education 17

Lab Results 19

Immunizations 24

Patient Visit: Provider Check List 26

Problem List 27

Medication Reconciliation 28

CPOE 29

e-Prescriptions 32

Electronic Note Signed 33

Post Visit Check List 34

Clinical Summaries 35

Patient Portal: Pin Letter 40

TABLE

OF

3

CONTENTS

RegistrationPatient Visit:

Clinical Support Staff

Patient Visit: Provider Post Visit

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REGISTRATIONCheck List for Front Desk Staff

Patient Information Sex DOB (Date of Birth)

Race Ethnicity Language (Preferred)

eMail

Contacts Patient Internet Access Preferred Communication

Method

Imaging Results

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Race/Ethnicity are separate fields and each must be completed

PATIENT INFORMATION

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Once your organization has set up the Patient Portal, the ‘Preferred Comm. Method’ field will allow for documentation.

This field defaults to ‘Paper’ and must be manually changed to ‘Secure Message.’

CONTACTS

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A standardized folder labeled ‘Routine Health Maintenance’ has been created for your organization

to capture and report on the following images:

IMAGING RESULTS

• Colonoscopy• Mammogram

• Ophthalmology/Optometry• Podiatry Report• Sigmoidoscopy

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Clinical Support Staff Check List Summary Page

Problems Allergies Medications List

Encounter Note Vital Signs Smoking Status Family History (First Degree)

Patient-Specific Education Lab Results Immunization(s)

PATIENT VISIT

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Maintaining a Patient’s chart up-to-date includes

documenting:

• No Known Allergies

• No Active Problems

• No Active Medications

• Reported Medications

PROBLEMS, ALLERGIES, AND MEDICATIONS LIST

You can also mark the medication list ‘Reconciled’ in this window

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Blood Pressure is to be taken for patients 3 and older

Height and Weight should be documented for all ages

Height and Weight must be documented within the same encounter to obtain and calculate the BMI

CMS is looking for growth charts of patients 0-20 years

VITAL SIGNS

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For audit purposes of patients 0-20 years, you can graph the vital signs within the ‘Vitals’ tab in the patient’s chart. You only need to check the Blood Pressure, Height, Weight, and Body Mass Index before selecting ‘Graph’ on the top right corner of the screen

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SMOKING STATUS AND FAMILY HISTORY

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New Patient

EstablishedPatient

SMOKING STATUS

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FAMILY HISTORY – ESTABLISHED PATIENT

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FAMILY HISTORY – NEW PATIENT Marking any ONE finding under the

Mother, Father, Sister, or Brother columns will count your patient compliant for Meaningful Use.

- OR –

Select ANY diagnosis and change or add any of the following ‘Prefix’ to mark your patient compliant:

• Maternal history of• Paternal history of• Sororal history of• Fraternal history of• Daughter’s history of• Son’s history of

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PATIENT-SPECIFIC EDUCATION

You can now ‘right click’ on either a diagnosis, a medication, a lab

results’ component and generate patient-specific education

referencing the item you have selected.

Selecting this functionality defaults to the National Institutes of Health’s (NIH) Medline Plus website.

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PATIENT-SPECIFIC EDUCATIONDocumentation in the patient’s encounter note which states that

patient education was provided is still required.

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LAB RESULTSIf you are setup with a lab interface and you receive

more than 40% of lab results that your providers have

ordered using the CPOE, your lab results are Automatically updating the patient’s record and satisfying this measures.

For those that Do Not have a lab interface set up in your organization or do not receive more than 40% of

lab results automatically to your EHR, manual lab entry will be

required.The following slide provides you

with step-by-step instructions followed by screen shots of these

steps.19

1) From the Top left corner, click on Intergy EHR> Tools> Lab Information (this opens the Lab Information screen within Intergy)

2) Select from list of options on the right side> Result Entry and then below that, select> New

3) Select the patient and the ‘New Lab Results’ window opens

4) The minimum fields requiring data are: Lab; Ordered By; Ordered; Received by Lab; Reported by Lab. Once these fields have been completed, select Test

5) The final window opens at which point at minimum you will complete: Test Code; Flag (abnormal, normal, high, low, etc.); Result Value (if a numeric value is applicable); Reported (date you are entering the lab); and Stat (final report, preliminary report, etc.)

6) Upon completed the necessary fields, select ‘Add’ on the top right corner. You will then proceed to repeat step 5 above for all the lab results you need to enter for said patient.

7) After entering the last lab for this patient and ‘Adding’ it to the patient’s record, select ‘Finish’

MANUAL LAB RESULT ENTRY STEP-BY-STEP INSTRUCTIONS

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MANUAL LAB RESULT ENTRY STEP-BY-STEP INSTRUCTIONS

Step 1

Step 2

Step 3

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Screen 4

Lab: Select the Manual lab created by your Organization Ordered By: Select the provider that will be tasked the lab result for review Ordered, Received by Lab, and Reported by Lab: Dates on the lab Report containing results

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Screen 5

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IMMUNIZATIONS: RECORD HISTORY

To Record History of a Vaccine:

1. Click Record Hist.2. Click the Imm. Date radio button in Entry Mode3. Select the date the Immunization was received4. Stamp the Dose field of each immunization that was received on this date

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IMMUNIZATIONS: RECORD OTHERTo Record History of Immune or

Contraindicated:

1) Click Record Hist.2) Click the Other radio button in

Entry Mode3) Select the Immune or

Contraindicated4) Stamp the Dose field of the

associated immunization

Although you can mark Prev. Hist and Refused, note that the patient’s record will not be marked compliant as this is not an

exclusion for the measure.

Flu vaccines CAN be marked refused for Meaningful Use credit.

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Check List for Providers Problem List Medication Reconciliation CPOE (Computerized Provider Order Entry)

60% Medications 30% Labs 30% Radiology

Electronic Prescriptions Patient-Specific Education (Refer back to Slide 17)

Electronic Note signed

PATIENT VISIT

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Maintaining an up-to-date problem list remains one of the most important aspects of a functional EHR. It is tied to almost all aspects of the patient’s chart as well as many reports.

You can now copy an assessment directly from the encounter note into the Problem list!

Simply right click on the diagnosis and choose ‘Copy to Problem’

PROBLEM LIST

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MEDICATION RECONCILIATION

NEW! Once you have reviewed the patient’s medication list, simply click on

‘Mark as Reconciled’

TIP!Any action (renewing, prescribing,

adding reported meds) will automatically ‘Mark as Reconciled’

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CPOE: PRESCRIPTIONS

Orders/Charges

Meds TabSummary Page

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CPOE: LAB ORDERS

Orders/Charges

Labs Tab

SummaryPage

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CPOE: RADIOLOGY ORDERSOrders/Charges

Summary PageOrders

Tab

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E-PRESCRIBING

Remember the key is to select via:

Electronic Transmission

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ELECTRONIC NOTE SIGNED

Sign

And

Seal

your

Note

Sign

And

Seal

your

Note

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Generate Exchange Document Clinical Summary Referral Summary

Provide the Patient with PIN Letter

POST VISIT

CLINICAL SUMMARIESA summary of the patient’s visit must be provider to the patient within one (1) business day. In order to generate a complete clinical summary, the following must be available/updated during the patient visit:

Patient Name Provider’s name and office contact

information Date and location of the visit Reason for the office visit Current problem list Current medication list Procedures performed during the visit Immunizations or medications

administered during the visit Vital signs taken during the visit (or other

recent vital signs) Laboratory test results

List of diagnostic tests pending Clinical instructions Future appointments Referrals to other providers Future appointments Referrals to other providers Future schedule tests Demographic information (sex, race, ethnicity,

date of birth, preferred language) Smoking status Care plan field(s), including goals and

instructions Recommended patient decision aids

Any information previously entered in the patient’s chart that is discussed in the current visit, must be cited into the note to appear in the clinical summary (e.g., Lab results received or entered on a previous date reviewed with the patient during this encounter.

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1) Once the patient encounter note is completed, click ‘Sign’

2) Verify ‘Exchange Document’ is checked and ‘Print Clinical Summary’ is selected from the drop down option

3) Click ‘Sign’

4) Select the printer and print

GENERATE AND PRINT CLINICAL SUMMARYPROVIDER’S BEST PRACTICE

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GENERATE AND SEND CLINICAL SUMMARYPROVIDER’S BEST PRACTICE

1) Once the patient encounter note is completed, and you are ready to generate and send the visit summary via the patient portal, click ‘Sign’

2) Verify ‘Exchange Document’ is checked and ‘Open Generate Dialog’ is selected from the drop down option

3) Select the following:i. To: Patientii. What: Clinical Summaryiii. Include: De-Select any data that may be harmful for the patient

4) Click ‘Send’

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GENERATE AND PRINT CLINICAL SUMMARYCLINICAL SUPPORT STAFF’S BEST PRACTICE

Once an encounter note has been created, the ‘Print Summary’ option will appear on the top right corner in the patient’s summary page. When the provider has completed the necessary information and you are ready to generate the summary:

1) Click ‘Print Summary’

2) Select the printer and ‘Print’

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GENERATE AND SEND CLINICAL SUMMARYCLINICAL SUPPORT STAFF’S BEST PRACTICE

Once an encounter note has been created, the ‘Print Summary’ option will appear on the top right corner in the patient’s summary page. When the provider has completed the necessary information and you are ready to generate and ‘send’ the visit summary via the patient portal:

1) Click ‘More’

2) The ‘Generate Exchange Document’ window will open at which point you may make any edits required.

3) When ready to generate the summary, click ‘Send’

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GENERATE PATIENT PIN LETTERWithin Intergy, under Menu:

1) Open Communications and select ‘Letters and Labels’

2) Click ‘Patient Portal Letter’3) Search for the patient4) Select ‘Run’ and print the letter

Within Intergy, under Patient Information:1) Choose ‘Reports’ from the Menu screen2) Select ‘Letters/Labels’3) Click ‘Patient Portal Letter’4) Select ‘Run’ and print the letter

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ACHIEVING MEANINGFUL USEOPEN FORUM

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THE CLINICAL OPERATIONS TEAM AND I THANK YOU

FOR ATTENDING OUR PRESENTATION