Monday, July 14, 2014 Code Upgrade (no changes of PowerPlans) Downtime, 6 hours, Sunday (July 13) 2100 to Monday (July 14) 0300, with reboot of campus computers needed Enhancements: Meaningful Use functionality improvements including reporting. Correction of crashing with note signing, which occurred sporadically but most affected the heaviest users. Message Center, “Review All”, for documents (not orders). Diagnosis and Problem List changes. Only IMO (Intelligent Medical Objects)(physician vocabulary) searching with ICD-9 codes Diagnosis List and SNOMED-CT Problem List. Allows background conversion of ICD-9 to SNOMED-CT for exchanging data to other EHRs (MU requirement). No longer able to search by code number. MySearch enhancements for searching orders Allows abbreviations along with adding components of the order sentence. All searches become “contains” without the “starts with” option. Medication Clinical Decision Support (mCDS) (alerts) enhancement More intuitive presentation with less clicks for interaction. Ability for system customization to turn off alerts for duplicates and interactions at the drug level. Norepinephrine (Levophed) 8 mg/250 mL (“Double-strength”) will be added to the MED Vasoactive Agents PowerPlan. Only at facilities with the product on formulary. Does not require resaving favorites since it will be an additional order to the 4 mg/250 mL (“Single-strength) option. External Rx History improved functionality to import outside prescription information. Medication History snapshots, allowing viewing changes, even crossing encounters The next CERNER update CLICK This code upgrade allows much new functionality, though the good news, at least for some physicians, is that PowerPlans are unaffected. This upgrade requires a six-hour downtime, beginning the evening of July 13 with Cerner back live early in the morning of Monday, July 14. By the way, these dates will not conflict with trauma call by participating emergency departments. CLICK Let me summarize the enhancements CLICK The upgrade improves functionality for requirements of meaningful use to include reporting tools. Sporadically, Cerner has crashed during the note signing process. This defect is now corrected. CLICK Message center now includes a "Review All" button for documents only, not orders. Some screenshots will follow later in the presentation. CLICK Changes occur in the searching tools of the diagnosis and problem list. For meaningful use, we've been required to have SNOMED CT problems. Though ICD-9, and later ICD-10, are used for diagnoses, the interoperability of meaningful use requires that they all be converted to SNOMED. A tool called Intelligent Medical Objects allows this to occur. This tool also allows physician friendly vocabulary searching, avoiding the need to memorize the exact verbiage of ICD codes. Of particular note, clinicians will no longer be able to search by the code number. Obviously many physicians, because of office billing, have key diagnosis code numbers already memorized. CLICK My search enhancements occur. Recall over the last year or so, typing into the order search window yields a drop-down of common matches. This functionality is enhanced and allows the use of abbreviations and multiple words. All searches will be "contains"; "starts with" searches will no longer be an option. CLICK A new medication clinical decision support tool is available. Rather than the traditional medication alert warnings, which are often sequential, now they will be presented together on an actionable MPage. Ultimately, the presentation is more intuitive and takes less clicks for a rich interaction. Within the backend of this tool, pharmacy has the ability for system customization to turn off alerts for duplicates and interactions at the drug level. CLICK Norepinephrine "double strength" will be added to the MED Vasoactive Agents PowerPlan. Since just an extra order that will appear in that Plan, there would be no adverse consequences to an already saved plan. CLICK. The external RX history has improved functionality, allowing importing the outside prescription information directly into the CERNER list. CLICK Medication history snapshots are available from within the orders window, allowing a view with medication history is as is it has changed over time, including prior encounters. CLICK

Here is the Message Center CLICK Note that “Documents to Review” is displayed. Sorting by column title allows sorting by name, type or whatever (existing functionality). Once important documents are reviewed, remaining ones that could be mass reviewed can be more quickly accomplished with the Review All button. CLICK Such a review all button is only available for this section of Message Center. CLICK

Here is the diagnosis search window Here is the diagnosis search window. Modifications have been made allowing only viewing of terms mapping to the terminology "IMO"--intelligent medical objects. This tool has 2 features. It allows physicians to search using common medical vocabulary and abbreviations, without the need for the physician to recollect the exact verbiage of the diagnosis and problem codes. It's more recent benefit allows mapping interoperability between the ICD and SNOMED CT code sets—and sharing of discrete data between EHRs of different vendors. In this particular example, the search was "systolic heart failure". Note the extensive list that appears. Also note that all of the matches use the "IMO" terminology. CLICK

The chosen match is "acute on chronic systolic and diastolic heart failure, New York class 1". CLICK

Once entered into the diagnosis list, notice the clinical diagnosis column displays the description of the ICD-9 code, whereas the annotated display column lists the more specific terminology chosen by the physician. Though this example illustrates using the Diagnosis list, the same functionality occurs within the Problem List. Of importance, as mentioned on the summary slide, searching by code number, 428.43 in this example, is no longer possible. The code number, though, is displayed. Furthermore, diagnosis and problem favorites can still be saved. CLICK

MySearch (.28 Release) Current Removes Search Type and Facility drop-downs Uses “Contains” logic and new label/icon Searching for orders is enhanced. Our previous version of "MySearch" allows choices to appear from a drop-down while typing in the name of an order. With the new changes, "starts with" and "contains" discrete search types have been removed. All searches will now be "contains". CLICK

MySearch (.28 Release) Shows 15 results (instead of 10) Hitting *Enter* will initiate normal search Scrolling with arrow keys and hitting *Enter* will select that order Orders Search respects Virtual View build for orders in Order Catalog Tool (CR 1-5212349796) In this example, the first 5 characters of "Lopressor" have been typed. A more lengthy search set of results occurs by default. I will illustrate a more efficient way to search for a specific orderable. CLICK

MySearch (.28 Release) Searches as “Contains” Searches within Order Sentences Supports ‘letter-skipping’ for alpha Does not support Phonetic searches nor Typos Searches can now contain more than one word, such as “hctz lisi”. Searches may also contain “PO” to find only the oral version of medication. The dose size can be entered to allow finding only the different forms of that specific dose. Though not directly illustrated here, “500” could be typed with “amox” to only yield 500 mg dosing sentences. CLICK

Medication Clinical Decision Support (mCDS) Medication alerts are presented in a new manner. Rather than the isolated alert window, a medication clinical decision support MPage is presented. The subsequent screens will illustrate that improved functionality. CLICK

In this particular example, 2 different medication alerts appear together, rather than sequentially. Both of these are related to medication allergy, valsartan and salicylate. The severity level is now illustrated as well as any comments about the type of reaction. CLICK

Access allergy documentation via a hyperlink The user can directly link to the allergy documentation. CLICK

Allergy documentation The allergy window is brought up for viewing or modification. Note this window is brought up in the foreground, such that the user returns to the mCDS page. CLICK

Generic name/Synonym/Order Details for medication causing the allergy warning are available Generic names and synonyms are presented to help explain the alert. In this particular example, Cozaar, brand name of losartan, might cause a similar allergic reaction to another drug of the same class for which a medication allergy was documented-valsartan. CLICK

Override Reason available for an individual alert Override reasons may be individually selected or… CLICK

Same override reason applied to multiple alerts … the same override reason applied to all alerts. CLICK

Access drug reference and patient leaflet information from hyperlink on medication order Drug reference information is a hyperlink away. CLICK

Losartan (Cozar) reference information Again notice on closure of the referenced text, the mCDS page is still present. CLICK

Drug Allergy Checking In the background, pharmacy can custom program specific alerts at the medication level. Though theoretic because furosemide contains sulfur, it very rarely causes a reaction to patients with known sulfonamide allergy. Ultimately, the design goal for this presentation of medication alerts is to enhance workflow and lesson alert fatigue. Studies have shown this functionality allows a greater percentage of the alerts becoming actionable by the providers. CLICK

External Rx History Improvement Users will now see two options under External Rx History, View and Import: “View” still looks and functions as it does today in Prod. The external prescription history functionality has much improved. This button is commonly underutilized by both nurses and physicians. There are now 2 choices, “view” and “import”. Though “view” functions as it does today, most physicians are not aware of its operation. I will summarize it. CLICK

External Rx History Current State The “External Rx History” button appears in the upper part of the orders window. Selecting it allows pulling prescription information from pharmacies subscribing to the Surescripts service, almost 90% of pharmacies. CLICK Once chosen, indicate that Consent is granted. The agreement signed by the patient upon hospital admission, covers this consent. CLICK

The prescriptions appear. CLICK In some case, there is notifications about getting more medications. A refresh is needed. CLICK Note the refresh button is the adjacent horizontal arrows. CLICK Sometimes, the patient is not on a prescription plan, but there still may be prescriptions filled at a pharmacy submitting to the system. CLICK Commonly, a refresh is needed to view any of the medications. If none appear, no wait is needed, just refresh. CLICK

As long as the prompt suggests refreshing, continue the process. CLICK In this patient, three refreshes were needed. Despite the clicks, the prescription data is quite beneficial knowledge. CLICK

External Rx History, Import Option Here is the new enhancement when the Import option is selected. The External Rx History appears in a parallel column to the Medication History currently recorded for this encounter. CLICK

External Rx History, Continued, Import In this particular example, clozapine was chosen from the External history, so it copies over to the right hand screen.. Once medications are imported, with details as needed…CLICK …then the Home Medication History can be updated by choosing Document History. CLICK

Medication History Snapshot A new section appears in the orders viewer, Medication History Snapshot CLICK This view allows looking at sequential updates to the medication history. CLICK Even over time and crossing encounters. This is a great enhancement to allow reconstructing medication list changes. CLICK

LeRoy Southmayd III, MD (405) 552-0976 leroy.Southmayd@integrisok.com Thank you LeRoy Southmayd III, MD (405) 552-0976 leroy.Southmayd@integrisok.com That’s the end of the update. Thank you for your attention.