Quick Review of Co-signing and adding Attestation in new CIS

Quick post with slide set today.

Remember to click on the icon in the bottom right corner directly adjacent to "authorSTREAM" to open to full screen and do the same when you want to return to normal screen when done with viewing.


Uploaded on authorSTREAM by nrk99

Back to blogging

It has been quite a couple of weeks for all of us, no doubt. I have learned a tremendous amount, not only about the new CIS interface (some would call it the Enhanced View), but also about fielding both constructive and... let's just say, not-so-constructive critique. As I hope you've experienced and heard, the CIS team has done an unbelievable job of preparing, deploying and supporting what it takes to make for a system-wide rollout. As we now know, there are deficiencies to the enhancements and folks have not been shy to point them out. I can personally say that I have logged dozens of issues with Cerner, most pertaining to the new prescribing process and the problem/diagnosis lists. While we can do some of the fixes locally, I believe we have the attention of Cerner and will be able to make some improvements over the coming weeks.

You may have heard about or participated in a webinar I ran today during the noon hour. I hope it was useful and plan to do another one next Wednesday at noon. I will be focusing on the Medication List and Prescription Writer and, if we have time, will touch on documentation.

I've made these three videos to review the Procedure/Surgical Hx function. One is for entering a surgical procedure, another for an obstetrical delivery and the last for a routine colonoscopy. They run 3-5 min each.

Surgical Hx This view appears to be truncated for no particular reason. I think you'll get the idea though (and it takes 2-3 hours to make these!)

Obstetrical Hx

Screening Colonoscopy

New CIS Homepage

This is the text I sent in an email earlier today to the BMP primary care practice sites' medical directors and practice managers. While the first bullet regarding the split screen may not hold true for you, all else is generalizable and so I thought to post it for the wider audience as well.

A few highlighted points about the new CIS Primary Care Physician/NP/PA Homepage:

Ø All providers will have the “split screen” such that the Message Center menu will reside at the left side of the screen and the office schedule will fill the page

o Double click on a Message Center element and the contents of the selected folder will populate the area where the schedule sits

Ø Message Center in Enhanced View = Inbox of CIS-Office

Ø Proxies will need to be reassigned

Ø Messages will operate in similar fashion to pre-EV and office policy and protocol should continue accordingly

Ø Orders folder does not change re: review and co-signature

Ø The Sign & Review folder in CIS-Office becomes the Documents and Saved Documents folders in the new CIS. Saved Documents are those that have been started and saved, but not yet signed by the author

New items:

Ø Consults, Reminders, Notify Receipts

o The use of these new tools will depend on workflows determined by individual practices and providers.

o Consults, in particular, should not be used as the sole means of referring a patient to a consultant. The soon-to-be introduced Pools will facilitate the development of effective workflows for electronic consultation requests.

Ø Results

o The delivery of Results does not imply or create a requirement to manage results electronically at this time. As part of the so-called build of the Enhanced View, the Results folder will be available for all practices/providers for viewing and results management if so desired.

o If your practice currently receives paper results, this routine will continue until your group has chosen to stop their delivery.

o It is the choice of the individual practice to determine the timing and transition strategy to a paperless electronic medical record.

o Scanning of paper documentation will begin by incremental rollout beginning in the late spring. This integration will be instrumental to creating a paperless EMR.

As always, feel free to contact me with any questions. The coming week promises to be both challenging and exciting. Having “lived” with the Enhanced View for the last few months, I am confident that it will live up to its moniker.

Neil

On March 24, CIS Enhanced View=CIS

Here is a slide set that tries to summarize what you should know about the functional improvements and changes with the Enhanced View. Get to the CIS Enhanced Information Site today to find review and training materials.


Uploaded on authorSTREAM by nrk99

Medication List - writing a prescription

Transparent Informatics: writing prescriptions quickly and efficiently on Prescription Writer will take time and practice. Oddly enough, there are a couple of crucial tricks to getting them done without losing your mind. For instance, make sure that you select Dose as well as Duration in the Details section lest you risk your sanity. I can't say for sure why we are not prompted to select these two elements. Dose refers to the "1 tablet" part of the sig and, if you add Duration, e.g. 30 days, you will not be forced to go back and enter the unit, e.g. tablet, from the bottom of a scroll down list. I know that doesn't make much sense, but do it any other way and you will know what I mean.

I am being as honest as I can be here. I really do think the Enhanced View is a major step forward for CIS, particularly for the ambulatory setting. However, I also agree with all those who have raised concerns about the Prescription Writer. It is Change with a capital C. I've been working for a few hours on the following video and hope it clarifies the prescription writing process. Let me know what you think of the video and whether it needs more help.

Medication List 5 - Prescription Writing

Health Information Management Post

A special posting at the request of the folks behind the scenes who help to ensure that our documentation is of the highest integrity. HIM plays a significant role in bringing a level of sophistication to our PowerNotes, helping the health system not only meet coding requirements, but improve the structured templates to facilitate the best means of recording clinical events.

FYI: the information pertains to Hospital-based documentation

A note from Health Information Management –

We would like to thank you for your work and strides with documenting in CIS.
As you are know the details provided in your documentation regarding diagnoses, therapies and procedures - will paint a picture of the patient’s severity of illness, and describes the quality of care provided.

Great documentation will accurately reflect your great work.
Take credit for the excellent care you provide.

We would like to inform you about the “Diagnosis Specificity” field within most CIS progress note templates.
• By utilizing this field you will (with just a mouse click)–
o Identify acute exacerbations of certain chronic conditions
o Document site and stage of decubitus ulcers.
o Stage the level of chronic kidney disease
o Define Diabetic related conditions
Terry Gosselin - Lead Coding Compliance Analyst phone #322-4302

…AND something everyone can appreciate –by using this field you can eliminate a potential post discharge query from coding staff!

REMEMBER…If it is not documented…it did not happen…or did not exist.
So be as specific as possible when documenting.

Thank you!
Jennifer Cavagnac - Senior Documentation and Coding Analyst phone #322-4366
o Provide information useful to case management, quality review, resource utilization, coding, research, and other clinical staff.

Edit in Line Mode - DO NOT USE!

This is a note from the "Senior Navigator Strategist" at Cerner regarding a problematic option in the Medication List:
We recommend to not turning ON Edit on Line mode (EOL), as turning this preference ON will limit the amount of order details screen that the Physician or other clinician can view during the ordering/prescribing process. Currently, one is not able to modify multiple orders with common order details when the mode is activated. It is possible to do one of the following, but not both at once: either edit on the line mode, or edit multiple orders with common order details. However, in order to perform the latter, make sure that the edit on the line mode functionality is turned off by right-clicking on an order and making sure the Edit on Line mode is unchecked.

Bottom line: if your prescribing efforts seem to be completely whacked, right click on an order and make sure that the Edit on Line does not have a check next to it.

Web-Based Training for Enhanced View

Since I last posted, a host of new training materials have been launched and should be available to you whether at work or home. The latest includes the beginnings of a compendium of WBTs, or web-based training modules, similar to what was used when we first went live with CIS a few years back. If you remember, these are texted instructions (no voiceover) and so, technically speaking, should be straightforward to access when logging in from home. They consist of click-through screens with some "try on your own" areas within each module. Here is the link to the so-called Master List. Keep in mind that you will need to login to the Baystate site and navigate to the CIS Enhanced View Information site if you want to access these remotely (the link below won't work).

Web-Based Training Modules - The Master List

In addition, many of you have accessed the newly posted webinars. These are pre-recorded instructional sessions done over the past couple of weeks. While we've had some technical difficulties related to the Baystate firewall, I think we've got the problem figured out and list all the links here today.

(An enormous thanks go to the CIS training team led by the formidable Dave Lapierre!)

Webinars:

1. General Overview
   
2. Documentation
3. Prescribing
4. Documenting Medication Compliance
5. Medication Reconciliation for Providers
6. Message Center
7. Histories
8. Patient Instructions for Discharge

All of the above are relevant to physician/provider users of CIS except for Documenting Medication Compliance (inpt and ambulatory RNs and MAs) and Patient Instructions for Discharge (inpt RNs).

NOTE: as of 5:30PM today, I am not yet able to access these webinar links outside of the firewall. I can assure you that this will be figured out sooner rather than later.

UPDATE: I'm on my iMac at this very moment and, after downloading the GP4 program, I am able to seamlessly listen to the pre-recorded webinars. No need to enter an access code; just cancel out of that mini-screen. You might then see another dialogue box or two-just ignore them. So for all you mac users, it's a simple download and then click to use the GP4, not the Java.

UPDATE AGAIN: The first Webinar, General Overview, takes about 30 seconds for the audio portion to begin. I thought this was a problem with the software; it was only my lack of patience that was problematic!

More on the Medication List - Using Start & Stop Columns

So I think I'm onto something for the tracking of meds in the Medication List. In fact, and in spite of first impressions, I think tracking meds for refill will be easier and more accurate in the Enhanced View. Take a look at the video and tell me what you think. I tried to keep down the time and still provide a meaningful description.

Medication List 4 - Start & Stop Columns

Medication List on Enhanced View

Of all the new features of the Enhanced View, the Medication List presents the greatest challenge. I've heard from far and near that this is an obstacle to care. EasyScript has become the tried and true CIS tool that most docs prefer. While I can recall a time when I found EasyScript a nuisance, I tend to agree that EasyScript, in conjunction with the Medication Profile, is more intuitive, easier to read and easier to track prescriptions.

The hitch, however, is that in order for us to be eligible for the CMS incentive reimbursement for ePrescribing (CMS ePrescribing Incentive Program), we need a unified orders entry strategy and the Medication List is the prescribing mechanism of that strategy. The development of ambulatory CPOE is the bigger picture to keep in mind and this is just around the corner. We are in the midst of ACPOE design with the goal of customization for ambulatory practice, be it primary or specialty care.

So whether we keep EasyScript for now or not, we will ultimately need to move towards the Medication List and its Prescription Writer to enable ePrescribing. The Informatics and IS teams are reviewing the feasibility of maintaining some or all of the current-state prescription tools while introducing these new features. In the meantime, I will do my best to provide commentary and counsel on optimal use of CIS Enhanced View.

On that note, I have found another cool Web 2.0 site, jingproject.com, that allows me to create quick video links for your viewing pleasure. The following provide relatively brief introductory instructions on the use of the Medication List. Let me know what you think.

Medication List 1 - Real Estate
Medication List 2 - Drop-Down Menu
Medication List 3 - Customize View

Medication Allergy Alerts -

Question: If a patient reports an allergy to codeine but has tolerated Demerol in the past, can that information should be stored such that an alert is not fired when Demerol is ordered? Also, if you are prescribing a narcotic that fires an alert and you override it, can the information be saved for that patient so that you don't have to override it every time you prescribe that drug?


Medications are entered into the allergy profile for a variety of reasons. Physicians, RNs and other clinical staff will enter a particular drug into the allergy profile as allergies when, in fact, it would be more accurate to report intolerance, side effect, idiosyncratic reaction, or another more fitting reason to avoid the drug. While it is virtually unheard of that a patient is truly allergic to a narcotic/synthetic opioid, there are a variety of intolerances that warrant notation. Though it might seem gratuitous to fire an allergy alert when trying to prescribe Demerol in a patient with a documented codeine intolerance, we must remain mindful of potential issues with drugs within the same class.

Of course, there are instances when patients have had a reaction to a drug that should raise a red flag when a similar drug within the same class is being prescribed. Amoxicillin would never be prescribed if a penicillin allergy was documented. We also ought to be warned about the PCN allergy when prescribing a cephalosporin, e.g. cephalexin. This alert needs to be fired even if we know that, statistically, most reported PCN allergies are not true allergies and, even if they are, it is rarely anaphylaxis, making the 10% crossover risk of a cephalosporin allergy pretty near negligible. But the physician needs to be forewarned.

We gave serious thought to parsing out the alerts based on the categorization re: allergy, intolerance, side effect, etc. and realized a few things: first, most users do not enter the correct category due to misunderstanding, misapprehension or simple omission; second, there are certain side effects and idiosyncratic reactions that should give us pause to prescribe a different medication from the same class as the inciting agent, e.g. Stevens-Johnson syndrome, dystonic reaction, acute bronchospasm; and third, most practically speaking, our nursing colleagues are not comfortable being asked to interpret a patient’s allergy report so as to discriminate between a true vs. a benign event.

We have made all efforts to keep the alerts to a reasonable baseline and have chosen, for example, to avoid posting alerts for medications that might interact with certain foods, e.g. grapefruit juice. But the computer cannot be set to discriminate one class from another as to whether a same-class alert should or should not be fired. In other words, we can’t turn off drug class alerts for narcotics and not for all other classes or vice vesa. Furthermore, if we did and there was a true allergy to warrant pan-class alerting, there would be no way to prevent the potentially harmful prescription.

The question of why the alert fires time and again if the alert had been overridden in the past is simply a matter of safety. It's the "are you sure?" double-check given the enormous incidence of medication-related morbidity and mortality in the US. I agree that this seems an absolute nuisance and I would at least like to see the last reason selected for the override, e.g. MD will monitor, stick. I will bring this up with the system architect sometime soon.

We are continuing to refine and fine tune medication management as much as possible, directing energies towards drug-drug interactions and dose-range checking . Determining the “bandwidth” for alerting thresholds is a complex process and, while practice efficiency is crucial, patient safety is paramount. It is conceivable that the narcotics class could be further divided such that synthetics and non-synthetic agents would not cause cross-class alerting. But we are not there yet.

Enhanced View Prologue

The training team is now half-way through the physician/provider introductory training sessions and I have learned a tremendous amount. First, I realize we chose a misnomer in initially calling these sessions "superuser" training sessions. This was confusing since the term superuser generally refers to non-physician/NP/PA folks who have stepped up to take a lead role in their respective practice sites and learn some of the intricacies of CIS. The providers, on the other hand, are taking these classes in order to familiarize themselves with the new interface and be exposed to new functions/features.

Second, I have learned how talented and patient the trainers are: Jeri Baker, Sally Cooper, Sandy Gagnon, Eileen Giardina, Cathy Weldon, and Dave Lapierre. I have watched them stay on topic, answer questions, maintain focus, and navigate through a complex curriculum in just two hours time. While no one walks out a pro, attendees leave with an excellent sense of what lies ahead. Great team!

Third, there is a lot that I still have to learn about the Enhanced View. There is a lot that is changing with this upgrade and a good deal of it may not seem so much for the better at the outset. Up til now, physicians have striven to achieve a measure of mastery with CIS and CIS-Office; suddenly, we are being asked to relearn many of the tasks, rework many of the processes, and rewire how we think of electronically-based patient care.

My goal is to try to address all issues and questions that arise from this potential shock to the system. The following is a list of issues that have come up since the physician training sessions began yesterday morning and, in the coming days, I will make every attempt to tackle each one of them:

• Family History [please see recent prior blog posts]
• Ambulatory divided screen to view Message Center and Schedule [this will be done prior to go-live for all BAPO and BMERF primary care physicians/PAs/NPs and any other providers who make the explicit request]
• "Stick pin" not holding [this will hold upon logging of and logging in again, as opposed to closing the patient chart and opening it again.]
• Medication List/Prescription Writer vs. Medication Profile/EasyScript: I will do an in-depth study of this major re-design and post an equally thorough review over the next couple of days
• the future of ePrescribing
• Best practices for tracking narcotics
• Banner bar changes
• Problem/Diagnosis list building and viewing
• Correct & Modify
• Edit
• Procedures/Surgery History

I know the list will get longer, but I thought to iterate what I've been asked in conversation and email.

Please post or email me your concerns, questions and suggestions.

Ad hoc updates

First, Twitter is not accessible while within the BH intranet. Given the fact that I would likely "tweet" after hours, it can still work. But if your were inclined, you might want to sign up for cell phone receipt.

Second, I received a flurry of concerns about the tortoise-like loading speed of Health Maintenance. Josh Wherry, one of our true IS wizards, is working with Cerner to clear up what is a script defect on their end. This issue got escalated about 10 days ago when HM speeds went from ambling to crawling and was found to be unrelated to our home system. My understanding is that this issue has received high priority attention.

More: Physician/NP/PA Enhanced View training begins tomorrow with the first session held in the Health Sciences Library in Chestnut with simulcast up at BFMC at 7AM. Get ready for two hours of power. The training team has honed its skills while training literally hundreds of nurses, medical assistants and other superusers for the last few weeks. These introductory training sessions should be incredibly useful to those who attend and, hopefully, to those who will benefit from their colleagues' newly acquired EV knowledge.

Next: I received word from the webmaster of authorstream.com, the site that hosts the posted slide sets, that all pistons are firing and that the server will remain stable since an upgrade was completed over the weekend. I also found out that the site originates from West Sumatra, explaining why the site's weekend started on our Friday midday - cool beans.

Another: I've gone through my archived posts and labeled them by subject to make it easier to search for relevant topics. I hope this is helpful.

Last: For the month of February, there were 1,219 page loads, 473 unique visitors and 125 return visitors. Not bad for a first full month. Thanks.

Transparent Informatics to Twitter

As we get closer to the Enhanced View launch, and the more I use my laptop as my primary means of entertainment (TV, ipod, stereo, smartphone all pale in comparison), I realize that Twitter might just add a little to my efforts to communicate and keep folks up to date with CIS. If you are unfamiliar with Twitter, it is essentially a marvelously narcissistic technology that allows the user to "tweet" "followers" at will, sending <=140 character text messages to computers and mobile phones.

I suppose the narcissism really doesn't set in until one has followers who might be interested to read what is being sent. On the other hand, my truthful intention is to use technology to get the word out, to help folks get as much as can be had from our EMR. I can imagine sending messages signaling new tools, quick tips, blog posts or updates on system performance questions and issues.

Sign on and let me know what you think.

Wow, check out the new Job Aids

I was just about to log off when I went for a last look at the CIS EV Info site. I clicked on Job Aids and found a terrific list of new text instructions covering a variety of tasks. These are printable, easy-to-use reference guides.

Hooray for that CIS Training Team!

PowerPoint posting malfunction

I don't know why, but the hosting site for my PowerPoint slide sets has been down for the last few hours. I can't get any info as to when they will be back up. They seem to be real players in this field, so I hope this is only temporary. Sorry for the inconvenience of not being able to see any of the old or what I wanted to post today. I will be posting later...

Assuming Authorship and Adding an Attestation

So today I thought I was going to appear the prophet to a new hardcore PowerNote user when, lo and behold, the authorship process whereby one clinician starts and another assumes the note for their own completely changed. Not to get too deep into the weeds, it had been the case that, if a note, e.g. Physician Discharge Summary, was started early in the hospital course, that, in order for the authorship to be updated and displayed properly in the Clinical Notes folder, the new author would be wise to copy to new note and the earlier author would delete the old note. In trying to teach this to a colleague today, we found that, if the saved (Active) note is opened from the Documentation--> Existing tab, a dialogue box offers Read Only or Edit. I don't know when it happened, but by simply clicking Edit, the authorship is transferred and all is well and good.

So for the hospitalists that I've presented to over the last couple of days, I blew it and hope not to have bungled your workflow.

I redeemed myself by demonstrating how to Modify a note when an attestation statement is needed. For example, if you provide supervision for a resident, or an NP or PA, for that matter, a signed note can be modified with an attestation statement easily dropped in as an addendum.

Check out the slide sets and let me know if I've mislead you elsewhere!


Uploaded on authorSTREAM by nrk99


Uploaded on authorSTREAM by nrk99

Quick Tips from the Past

Over the last couple of days, I've had a chance to spend time with a number of the hospital medicine docs. This is a terrific group of highly motivated CIS users who, on the whole, know how to use the system as efficiently and effectively as any. But I learned a couple of things from them today. First, I should never assume that old tricks lose their meaning. And second, much of what we know now about PowerNote documentation will hold true when we go to Enhanced View.

In response to a couple of great questions that I've answered in the past, but in another context, I've attached two slide sets: one a single compact slide on the use of Copy to New Note, a useful but potentially hazardous means of doing serial documentation; the other reviews how to select and default the Document Type, aka folder location.

I must remind you that, in order for a note to be considered clinically meaningful and legally legitimate, it must be updated and revised with integrity. The copy function is best used when passing off a note, e.g. Physician Discharge Summary, that is started by one physician and adopted by another. This allows for authorship to be assumed by the doc who has done the copying. On the other hand, when a progress note is copied one day to the next, you MUST make sure that the overnight events, vital signs, labs, and impression and plan are relevant and current. I can assure you that an auditor will catch on and this can bring serious consequences. I won't dwell on this, since I'd rather be advising you on how to make documentation easier.

I hope these are helpful. I've got more where these came from, so if you've got some basic questions about documentation or chart navigation, just ask.


Uploaded on authorSTREAM by nrk99

Uploaded on authorSTREAM by nrk99

Following a blog, maybe even this one

You might guess that, having started this blog, I also like to follow a few myself. I think it's a pretty cool technology and an easy way to keep an eye on a wide range of topics and opinions. I've set up my home web browser to open to iGoogle, a neat web tool that the 21st century's reincarnate of General Motors offers.

In Google's words:

Google offers the ability to create a personalized iGoogle page that gives you at-a-glance access to information from Google and across the web. On this self-designed page, you can choose and organize content such as the following:

• Your latest Gmail messages
• Headlines from Google News and other top news sources
• Weather forecasts, stock quotes, and movie showtimes
• Bookmarks for quick access to your favorite sites from any computer
• Your own section with content you find from across the web
  

On my page, I follow the NYTimes, my gmail inbox, a few Health IT blogs, the NEJM along with a few other medical entries, and a couple of book lover blogs. I tend to surf for new ones periodically, x-ing out the old and adding the newly found.

It's easy to follow a site from iGoogle, be it blog, newspaper or other website that changes content frequently. For most blogs, including this one, look for the "Subscribe To Posts" and choose where you would like updates to be presented. In my case, I choose "Google Homepage", though there are a number of other "feed" readers on the web. Oftentimes, you will see an icon in the www address bar (see the Subscribe To Posts orange icon below) that you can then click in order to get the updates.

Play around and you'll get the gist. To find iGoogle, go to any Google page and look under "More". It's pretty straightforward, and a bit addictive, once you get the hang of it.

Flash Player and the Blog

I'm hearing and seeing that a number of folks with BH computers (laptops, tablets and desktops) are unable to view slide sets that I've been posting due to a need for Flash Player updates. I am just off the phone with the Help Desk and have verified that they should be called for the fix.

Here are the instructions:

1. Call the Help Desk at 4-3000
2. Select 1
   
3. Have your asset tag number available. This is the number found on the bar code sticker that is found on the computer (and occasionally the monitor). IT will then be able to remotely install the software update.
4. Give me some feedback on the use of the screenshots. More, less, same, none; new topics, more depth, less detail...