1. EHR Patch Updates Office Hours EHRv1.1p8, TIUv1.0p1008, BHSv1.0p5 What’s new, What’s changed IHS-Office of Information Technology EHR Program

2. 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

3. 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 copybarbara.hess@ihs.gov

4. 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

5. 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”

6. 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

7. 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.

8. “Chart Review” Component

9. 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.

10. Configuration Add 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

11. Configuration Properties 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

12. Chart Review – Business Rules The 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.

13. 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.

14. “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

15. “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)

16. “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”

17. “Reviewed” When items exist on Medication list, for example, users may document “Reviewed” Clicking corresponding chart review button Right click in Cover Sheet component

18. “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

19. Signature box User may uncheck if did not perform action Status changes after signature

20. 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,SUSAN Medication List Updated On: By: No Active Medications Documented On: By:

21. Allergies – new menu options Entered in error Inactivate (and reactivate) allergies Inability to assess

22. Allergies – Unable to Assess Right click from Adverse Reaction Component RPMS GMRA application

23. 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)

24. 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

25. Allergy – Event Code New event codes Most specific to least specific These are SNOMED codes (another clinical terminology system, required for EHR Certification)

26. 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

27. Allergies – enhanced detail Added to detail: Ingredients Inactivation info Reactivation info Last modified info

28. 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

29. Vital Entry – Last Known Well The 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

30. 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.

31. C32/CCD Viewer DESCRIPTION: 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.

32. C32/CCD viewer

33. C32/CCD Viewer Configuration Add “C32 Viewer Launch Button” component to EHR – best suited to a toolbar or header area – using design mode

34. C32/CCD Viewer Configuration

35. SiteUrl: http:// /csp/C32 /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.Docum entRepository.clshttp://10.243.60.7:57772/csp/C32WSP/BJMD.Prod.Service.Docum entRepository.cls NOTE: this component depends on the Vangent supplied C32 package which may need to be set up separately

36. 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)

37. Parameters BEHOXQ SHOW HINT Right click on notifications tab User may turn on or off Show Hint Parameter sets default

38. 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)

39. 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)

40. Parameters –BEHORX SPLITTER PANE The input format is: 20;25;60;75 ; ; ; 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.

41. BEHORX SPLITTER PANE example

42. 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

43. 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

44. Patient is INPATIENT status

45. Patient is OUTPATIENT (not Inpatient status)

46. 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

47. TIU 1.0 p1008 Create 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

48. 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

49. 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...

50. 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

51. 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..

52. 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

53. TIU 1.0 p1008 Use 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

54. 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.

55. 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

56. Resources links will be active AFTER patches released! EHRv1.1p8 guide ftp://ftp.ihs.gov/rpms/patches/ehr_0110.08o.pdf TIUv1.0p1008 notes ftp://ftp.ihs.gov/rpms/patches/tiu_0100.1008n BHSv1.0p5 notes (Health Summary Components) ftp://ftp.ihs.gov/rpms/patches/bhs_0100.05n