NEXTGENCHRONIC CONDITIONS VISIT

DEMONSTRATIONThis example demonstrates some workflow options for a visit that primarily deals with the management of chronic diseases, using the “Advanced Template Set” employed by Family Medicine, Internal Medicine, and Pediatrics. Details of the workflow will vary somewhat depending on specialty and practice policy, but this should give you a good idea of NextGen functionality.

This has been prepared with EHR 5.6.5.63 and KBM 7.9.2, though some screen shots may display the appearance of earlier versions if they are not directly pertinent to the issue being discussed. Wherever germane, however, screen shots have been updated to the most recent appearance.

Use the keyboard or mouse to pause, review, and resume as necessary.

There is no audio with this exercise.

Warning• At present Protocols, which are an integral

part of chronic disease management, manifest in an undesirable and misleading manner in visit notes. While they can be used, the user will have to manually review and edit the Assessment/Plan section of the visit note to correct inaccuracies.

• As a result of this and other current technical problems, most users may be better off avoiding the use of protocols for now.

Introduction

• There is a “Chronic Conditions HPI” template, which allows the management of chronic diseases in a comprehensive manner, and in parallel with any acute presenting problems.

• This tool has great potential, and is being incrementally improved over time. However, there are still a few quirks we have to work around.

• This exercise will provide some pointers on how we can best use this template in its current condition.

• The Chronic Conditions HPI popup will be launched if any of the following chief complaints are activated:– Chronic conditions– Diabetes (follow-up)– Heart disease (follow-up)– Congestive heart failure (follow-up)– Hypertension (follow-up)– Hyperlipidemia (follow-up)– Kidney disease (follow-up)

• But other chronic diseases may be addressed through the Chronic Conditions HPI popup as well.

Introduction

• “Protocols” are set up and activated for the patient, to assist with chronic disease management (and health maintenance).

• These protocols can be modified as desired by the provider to personalize them for the patient. (The setup of protocols will be reviewed in another lesson.)

• After that, the recommended measures are incorporated into the regular visit workflow.

The nurse opens the chart to the Intake template. Select New/Established, Template set, and Visit type as necessary.

In this example, the patient is a 40 year old male in for follow-up on diabetes and hypertension.

Perform the 4-Point check.

Patient

Location

Provider

Date

Click Add to enter Vital Signs.

Enter Vital Signs. (Details are reviewed in a separate exercise.)

Data used in this example:

Ht 6 ft, 1 inch. Wt 199 lbs, dressed without shoes.T 98.8, orally.BP 148/86 sitting, left arm.HR 80. Resp 16. BMI of 26.12 will be calculated.

When done, click Save, then Close.

Review the patient’s chronic medical problems. We note the diagnoses of diabetes, hypertension, and tobacco abuse; there is nothing new to add.

Review the medication list. If desired or necessary, double-click on the Medications grid to open the full Medication Module.

In this example, we note he’s on Cozaar 50 mg daily and metformin 500 mg BID, but have nothing else to add, so close the Med Module. (Use of the Med Module is reviewed in another exercise.)

Review the allergy list. We have nothing to add, so click Reviewed, no change.

Next, click in the 1st Reason for Visit box.

There are a few appropriate choices, including chronic conditions, the DM/HTN combination, and diabetes and hypertension separately.Here we’ll select DM/HTN. (He has no acute complaints today.)

In this example, the office has a standing order for the nurse to perform a sugar and a HbA1c on diabetics.

The nurse performs these tests. To enter them, click Office Services (sometimes labeled Office Diagnostics).

Scroll down until you see Glucose blood test associated with Diabetes 250.00; click on this line.

Click in the Display order set box and select Office Tests.

Click in the Detail box and enter the result of 188.

Click Submit to Superbill, then Place Order.

In a similar fashion, select Hemoglobin A1c associated with Diabetes 250.00, enter a result of 8.2, Submit to Superbill, then Place Order.

When done, click Close.

Move to the Histories tab and review details. In this example, we have no changes to make. (It may have been more convenient to do this earlier while discussing the items on the Intake tab with the patient.)

The patient is ready for the provider.Click the Tracking icon.

In the Room box, enter Exam 1.In the Status box, enter waiting for provider.

Click Save and Close.

The provider then opens the chart, performs the 4-point check, and reviews the data on the Intake tab. (Alternatively, the provider may start on the Summary or SOAP tabs.)

Patient

Location

Provider

Date

Note the solid diamond at Office Services. This indicates that the nurse has entered something, so click that.

Note the HbA1c and glucose results. When done, click Close.

Review the Histories tab. (Update information as necessary, and note items you may wish to discuss further with the patient.) Select a Review Bullet in each section to indicate the amount of detail you would like in today’s note.When done, move to the SOAP tab.

Click HPI Detail.

The Chronic Conditions-HPI popup appears.

There’s a lot to review here, so let’s orient ourselves. Click the Flowsheets button.

In these two screenshots, we’ve displayed brief examples of the Diabetes and Hypertension flowsheets.

When done, click Save and Close or Cancel.

Home glucose readings can be entered by clicking Home Glucose Readings.

You can enter his home BPs, or a range of home BPs.

When done click Save and Close.

Lab results can be reviewed. Click Lab Review.

In-house labs can be reviewed, if not noted earlier.You can also review outside labs that have been done at LabCorp.

When done click Save and Close.

Associated symptoms/pertinent negatives is the Review of Systems section. You can document a few symptoms directly, or click the Add button for a more complete ROS.

This is the regular Review of Systems popup.

Note you have access to your ROS presets.

When done click Save and Close.

The med list appears here.Click Medication Review.

Review meds, noting that he sometimes misses Cozaar—especially pertinent since his BP is up a little.

When done click Save and Close.

(Reconciliation takes on a different meaning when you are transferring care from one location to another, and you have another electronic med list to compare to, but we’re not in a position to demonstrate that yet.)

One way to record the “HPI” aspect of a chronic disease is to click the Address button.

Select one of the chronic conditions to address.

Select a Status if desired. (You’re not required to do so.)

Add your notes. (You can use My Phrases for this as well.)

When done, click Add.

Repeat the process as desired for the other diagnoses. When done, click Save and Close.

In addition to (or instead of) the comments you just added, you can add further notes by typing in the Free text (comments) box.

For example, here you might type:Sometimes missing Cozaar; not following low-salt diet. Using metformin as directed; sugars running 110-150 on home checks. Still smoking; not interested in quitting at present.

Note the Protocols section; several protocols have been activated for this patient. Here we’ve selected to view items Due within 1 Month.

You can double-click on an item to manage details about it without having to go to the Protocols tab.

This is useful to document items done during the visit, or things previously done, though items like referrals and outside tests will be ordered later.When done, click Save and Close.

Finally, look at the Recommended Care section. You can select the Addressed today bullet to show recommendations for diagnoses you’ve addressed today, or All to display recommendations for all the patient’s chronic conditions.

To demonstrate, double-click on Smoking Cessation.

This Recommended Care section can be used as a “reminder list” for things you’ll document/order later, or you can complete some of them here.

Complete the information in the popup, then click Save and Close.

Scrolling down further, we’re reminded that he’s not taking an antiplatelet drug.(We’ll discuss this with him and add it in the Medication Module later.)

When done, click Save and Close.

Note that Recommended Care is somewhat liberal, and may include items that the provider does not deem appropriate for every patient. Sometimes multiple alternatives are presented, e.g. ACE-Is and ARBs for diabetics. You’d probably only pick one of these, but it will still show all the recommendations. These measures should be addressed on a case-by-case basis.

Also recognize that it may not be feasible to address all of the Protocol and Recommended Care items within the time constraints of a single visit, but they serve as useful reminders to help you avoid repeatedly overlooking these measures.

If you used the “Address” popup to enter comments on Chronic Conditions HPI, the problems you’ve just addressed are added to the assessment list. (If they’re not added, you’ll see how to manually add them shortly.)

Now click Physical Exam.

Note you can save and use preset physical exams.

Enter your physical exam.

Note that you can add exam notes, and click the Carry forward comments checkbox. This way these notes will appear on future exams without having to re-enter them—and will help you avoid inadvertently documenting conflicting normal findings.

Click Save and Close when done.

Note that your exam comments also display here.

If you’ve addressed chronic problems through the Chronic Conditions HPI popup, they may already be listed among today’s assessments. If not, click in the first available Assessment field.

Note that hypertension, diabetes, and tobacco abuse appear on the Diagnosis History and Active Chronic Problems lists. You can click on these, and they will be added to Today’s Assessments.

When done, click Save and Close.

To enter plans, click My Plan/Orders.

The Plan Details tab gives you the chance to type instructions/plans for each problem. You can also use My Phrases to insert text that you use repeatedly. (Use of My Phrases is reviewed in another exercise.)

Now move to the My Plan tab.

The My Plan tab gives you the opportunity to add labs you frequently use and associate them with all the diagnoses on the Chronic Problem List and Today’s Assessments.

Highlight the hypertension diagnosis, and any preset tests and therapeutic measures display. We’ll order a BMP, Hepatic Function Panel, and Lipid Panel.

We want to see him back in 4 weeks, so enter that here as well.

When done, click Place Order, thus ordering the BMP, hepatic panel, lipid panel, and 4-week follow-up appointment.

Since he is a diabetic, we also want to order a urine microalbumin. Highlight diabetes, and click Microalbumin/Creat Ratio.

Then click Place Order.

If you need to place a lab you can’t easily find or add to My Plan, you can use the Labs tab…

…or the Order Module.(These are demonstrated in other lessons.)

For the purposes of this exercise, we have ordered all the lab work we need today. Click Lab/Diagnostics/Radiology Order Module Processing.(Note: If you clicked Save and Close, this module would display spontaneously.)

Also note: Depending upon clinic-specific policies and workflow, these next steps may be performed by the nursing or front office staff.

The lab work ordered today displays. If LabCorp has previously been used, it will probably display in the Vendor box.

If necessary, click in the Vendor box, and select LabCorp.

Click on BMP, then click the Include selected order button.

The BMP moves to the bottom grid.

Repeat this for the 3 remaining orders. But note that if you click the Automatically perform… checkbox, the tests will move to the bottom grid just by clicking on them, saving you a few clicks.

When done, click Process/Submit, then Save and Close.

Notes:1) To avoid sending fictitious lab requests to LabCorp, please do not click Process/Submit on practice patients.2) For the near future, USA Pathology and Radiology studies will not be handled through this module.

Though they are not needed for this patient, briefly note the Diagnostics, Referrals, and Office Procedures tabs that are available. (More details on the use of these templates are reviewed in other exercises.)

The Diagnostics tab is where radiographic studies are ordered, both for in-house X-rays, and studies performed at the hospital.

The Referrals tab is where referrals to specialists and therapists are ordered.

The Office Procedures tab allows ordering of various office services, though there are often other places where it would be more convenient to order most of these items.

When done with everything here, click Save and Close.

Return to the SOAP tab.Suppose we’ve planned a flu and pneumovax; we still need to order them. In some clinics, this may just be verbally communicated to the nurse. To actually order them, however, display the Nav Bar and click Immunizations.

If necessary, answer the allergy questions.

Select pneumococcal (PPV23).

It’s his first pneumococcal vaccine, so click 1.

Similarly, order the flu shot.

He’s had a flu shot before, so click booster.

Click Place Order.(A tasking popup will appear; if you’re going to verbally communicate this to your nurse, you can just cancel out of it.)

When done, use the Nav Bar to return to the SOAP template.

If you scroll down a bit, you’ll see the ordered vaccines on the grid.

We need to prescribe some medications. Click Meds.

We’ll leave Cozaar unchanged, increase metformin to 1000 mg BID, and add daily aspirin. After making those entries and dispensing the prescriptions, close the Medication Module.(A thorough review of the Med Module is included in another exercise.)When done, close the Med Module.

You can add any closing comments you’d like to appear at the bottom of the visit note.

You can generate the Patient Plan here, or from the Finalize or Checkout tabs.

The Patient Plan is the visit summary required as one of the Meaningful Use measurements. Edit as desired, then print this for the patient.When done, close the document.

Move to the Finalize tab.

Select a level of Medical decision making and click Calculate Code.

If you are satisfied with the recommended code, click Submit Code.

Residents will submit the note to the supervising attending.

In addition, a resident needs to view encounter properties to set the Supervising Physician for billing purposes.Right-click on the encounter folder and select Properties.

The resident doctor clicks the Supervisor dropdown arrow, and selects the attending.In this example, we’ll use Dr. Duffy.

Click OK to close the popup.

Once the visit note has been generated and billing is complete, you are done with this encounter.

You’ll probably want to generate the note offline. To do this, hover the mouse over Navigation.

When the Navigation Bar displays, click Offline.

This concludes theNextGen Chronic Conditions

demonstration.

If all the world is a stage, where is the audience sitting?

This concludes theNextGen Chronic Conditions

demonstration.

If all the world is a stage, where is the audience sitting?