Exploring OP14: EHR Features
User Conference 2014
Presented by:
BJ Bloom
Hands ON introduction to OP14
the new features:
★ Re-organization of Menus
★ Search Text Function in Summary Notes
★ Well Visit ROS change
★ Problem List
★ Allergy List
★ Rx Interaction Checks
★ Coding Tab
★ History Changes/Family History
★ Diagnostic Tests
★ Procedure Tab in Templates
★ Clinical Recalls
Re-organization of Menus
● Activities = Import Diag Tests, Vaccine
Inventory, Correspondence, Bulk
Payments, Capitation
● Reports = DAR, Grid of Vaccines,
Financial
● Utilities = Manage Codes, Manage
Practice, Manage Clinical Features,
System Admin
Search Text Function in Summary Notes
● Summary section of an open or finalized encounter
● Any letter, number, word or phrase can be found by
Well Visit ROS terms change
Reporting Wellness:
● Reports is now Confirms
GREEN
● Denies is now Concerns PINK
Problem List
● The Problem List must now be coded with SNOMED.
Therefore, by entering a key search word, the HLI engine will present associated SNOMED codes.
The SNOMED code will appear next to the text entry field
Allergy List
● The Allergies must now be coded with SNOMED. The MU indicator will be on the Medication allergy only.
● By entering a key search word, the HLI engine will present associated SNOMED codes.
Rx Interaction Checks
Drug-drug/Drug-allergy interaction checks
● Interactions default to Med/Allergy and Med/Med
● Administrative user has ability to turn on/off
Med/Med and Med/disease. Med/Allergy cannot be
turned off
Coding a Visit
● Diagnosis will be applied to the visit in the
Asses/Plan tab
● CPT coding will be done in the Coding tab
○ you will be able to apply up to 4 diagnoses to
each CPT code
○ this can also be done on the Add/Edit charges
screen
History Changes
New Look
● Past Medical History: Summary Tab removed; only PMH ● NEW Family Hx: OP 11 and OP 14
○ practice will do a one time conversion from OP 11 -> OP 14 based on contacts defined as family
○ After Conversion completed, OP 11 Fam Hx may be archived. ■ *Important: Conversion can not be undone.
● NEW Social History: now is separate; can still copy to siblings that are linked as social family
● NEW Perinatal History: now is separate; Newborn Carriage is removed; All Newborn Hx buttons have separate tabs; Neonatal course tab
Family History OP 14
New Tab
4 discrete fields:
○ Family Member - selected by
role, paternal gm
○ Problem - (from Encounter
Builder) linked to the HLI engine
and the SNOMED code is
automatically populated
○ DX Age - age ranges
○ Notes Field
Diagnostic Tests
The diagnostic test screen has been reorganized.
● The requisitions listed in each category will have orders contained within them which are categorized as such (if the original req contains a
combination it will be sorted)
Categories: This is defined in Diagnostic Test Set Up; filtered by buttons on left hand side
● Labs: Count towards MU
● Screens: Hearing and Visions (will not count towards MU) ● Imaging: Count towards MU ● Procedures (ex: Nebulizers)
will not count towards MU
Function buttons: the top right ● In-House
● Send-Out
● Legacy buttons
Diagnostic Tests
● Orders are presented below based on the requisition highlighted above
● Each order will have a Plus (+) sign to expand the grid for results to be viewed
● Results entered as alpha. All other fields can be entered as well. If results are interfaced, each field will be populated based on what is returned from the 3rd party (e.g. lab, imaging center, etc…)
requisition orders
Diagnostic Tests
F7/Practice Workflow
Diagnostic Tests
Diagnostic Tests
Well and Sick Visit Template
Procedure Tab: looks like Coding tab in notes
★ add CPT codes to you template, along with Modifiers ★ Units
★ Procedure Note - can template notes
template procedure notes here
Uses: Inhouse Meds: Units of Rocephin, Circumcision, Nebulizer Treatments, Wart Destruction, Umbilical Cautery, Cerumen Removal, Suturing, etc.
Clinical Recall tab
Care Plan recall, Vaccine Status Recall, Vaccines Given tabs remain unchanged
● Recalls for Problem Noted (Dx), Med Allergy, Medication Given, Lab Results, Lab Value Range or any Combination
● Creating a patient demographic list is still required to move forward in querying and generating recalls
● Each field can be sorted, or grouped. Each field except PATNO and Patient Name can be filtered.
Clinical Decision Support (Care Plans)
● OP will deliver a set of care plans
● Care Plan has 3 sections: Definition, Triggers and Actions ● Client can create own
Care Plans
Clinical Decision Support (Care Plans)
OP will deliver each client a set of Care Plans
BJB
As a default:
All patients will be enrolled in the Bright Futures
Manage Care Plans: Global
Definition:
● Purpose: Description
● Active: Indicates whether or not the care plan is turned on. If not Active: Users will not be presented with the opportunity to enroll a patient even if all triggers are met AND the recommended actions will be removed from the patient’s chart and any reporting
● Auto-enroll: Allows user to set the care plan where if a patient meets all the triggers, he/she will be automatically enrolled in the care plan without the user being asked to enroll the patient. An example: Bright Future Preventive as it follows the AAP periodicity schedule.
● Privacy Level: Indicates at what level in the practice can a user enroll a patient in the care plan. There may be some care plans where the practice feels their nursing staff is capable of making that decision, but there may be others where the decision needs to be left to a physician who has the appropriate medical decision making capability.
● Bibliographic Citation: This citation should usually always reference evidence based guidelines. ● URL: A link to the evidence based guidelines referenced in the citation.
● Developed by, Funding source and Released/Revised dates are related to the citation
BJB
> Utilities
> Manage Clinical Features > Care Plans
Manage Care Plans: Global
Triggers:
● Triggers represents the elements of a patient chart that would qualify the
patient for enrollment in the care plan. There can be multiple variables and more than one trigger.
● The Grouping Rules determine how and item is considered. What is
important to note here is the grouping rule ‘OR Begin Group’ indicates a new trigger set.
Actions:
● the clinical interventions the user will be reminded to perform
● an action can be disabled (suppress) but not
necessarily removed from the care plan all together
Manage Care Plans: Global
Care Plan Items tab
● each item is defined and the default interval can be edited ● the item can be marked as a trigger and action or both
Care Plan Item Types tab is where available
care plan items will be managed.
Care Plans
F8 Patient Chart and Care Plan tab
● now shows the Care Plan the action is triggered by along with a hyperlink to the
citation
● By clicking Customize from the care plan screen
○ All active care plans the patient is enrolled will be listed
○ disenrolled will appear for those available but not yet indicated
Care Plans
F8 Patient Chart and Care Plan tab
● Available Care Plans tab
○ staff can make a decision about the patient’s enrollment once he/she qualifies or it can be manually forced even though the patient may not meet all of the triggers at the time
○ If a patient does meet the triggers for a care plan, the user will be presented with an opportunity to confirm whether or not they would like to enroll the patient in the care plan
Let’s
Explore!
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