AHLTA 3 3 The Good the Bad and

AHLTA 3. 3: The Good, the Bad and The UGLY! Sharon Meng, CNM

Declarations n n n I do not work for Ahlta (although I feel like I do sometimes!) All “Good” slides shamelessly plagiarized from command training site (link below) http: //nmc-sdcacdsp 07/sites/cmt/AHLTASustainment/NEW %20 AHLTA%20 Version%2033/Initial%20 O verview%20 of%203. 3%20 Functionality. Tweaked. ppt

The “New” Look of AHLTA 3. 3

The “New” Look of AHLTA

The Good n n More options for editing your Autocites Can choose Family history, Social history, etc.

The Good n n In S/O, any time you open a screen (rads, labs, previous encounters, etc), a tab is created You can flip from S/O to any tab without the hour glass!

The “New” Look of AHLTA

The Bad n Easy to click the wrong button (Add to default template) instead of add to encounter

Review New Results Redesign The “New Results” Redesign Allows the user to view results without being navigated out of the New Results module and allows the users to view multiple results in a more efficient manner.

The New Results Module

The Good: n n n You can review results in Ahlta and mark “Sign and remove” You can mark reviewed and keep it on your screen You can view an abnormal result, hit the Tcon button and create a Tcon for that patient

The BAD n n n You can’t print abnormals from Ahlta To print, you need to open CHCS I Rationale: no need to print in a “paperless system”

Notifications (Alert Review) n n Now in 3. 3 when there is an item that needs addressing in a module, the module name appears in bold in the Folder List and the number of unresolved items display next to it. When the folder is bolded in red it denotes that there are items of high priority or severity that have not yet been addressed.

Health History n n n The Health History module has been replaced with a more flexible and usable Health History Panel. The Health History Panel overlays the AHLTA desktop when it is first opened. The panel can be auto-hidden, or docked within the active module area.

Health History Panel

Telcon Redesign The redesign of the Telcon Module makes telephone consults easier to navigate and more efficient to use via changes to the New Telcon window and Quick Entry screen.

The Telephone Consults Module with the new Preview Pane

Free text written in the Note field is written to the S/O section of the Encounter Summary. New Tcon Entry Screen TO ADD A/P ITEMS OTHER THAN DIAGNOSIS, CLICK CURRENT ENCOUNTER TO OPEN THE A/P MODULE Free text comments entered in the Comments field are not written to the Encounter Summary.

The GOOD: n n Presently once you have used the Quick Entry screen, you don’t get another 3. 3 save your entry. For example “Left message for pt to call” Next time you open Tcon, you have a fresh quick entry screen Can add notes which will not show up in completed encounter

The Drawing Tool n This feature allows the user to indicate a condition graphically rather than describing the location and condition via text.

The Drawing Tool n Images can be loaded by: n Selecting an image from the drop-down list of pre-loaded graphics in AHLTA. n Browsing for and selecting an image from another location. n Making a selection from the Template drop -down list… (yes, you can attach a graphic to a template the same way you can now attach associated diagnoses or order sets).

You access the Drawing Tool from the SF 600.

First: Select an image from the Index drop-down.

The drop-down list accesses the database of pre-loaded images. Or… you may also choose to Import an image from another source.

To choose the image you want, simply double click on the thumbnail.

(2) When you have finished, click Close to exit the drawing module. Your drawing will be saved to the encounter. (1) You can then use the stamp, drawing, and text tools to mark up the image as needed.

The BAD: n Limited OB/GYN preset drawings

The GOOD: n n We can load our own drawings Suggestions: n Cervix n Breasts n Pelvis

The Tasking Module The new tasking module will allow users to create, assign and track tasks that are neither patient nor encounter specific. This is particularly useful for treatment environments where a team approach is used or where treatment involves multiple clinics or personnel.

Grayed items indicate that this user submitted the task assigned to another user, and has checked “track”. In this area of the screen you can edit and assign the task.

The GOOD: n n May be useful for OB/GYN problems that don’t necessarily need to be in problem list Examples: n Varicella titer with QMS n Valtrex suppression at 36 wks n Repeat US at 28 wks r/o previa

The OB Summary Module n The OB Summary Module is a “read only” page that provides users with a variety of relevant information related to current or past pregnancies, including: n A Flow Sheet n Standard Labs Normally Related to Pregnancy n The Patient’s Pregnancy Problem List n Additional Results n Information on Previous Pregnancies

By Double-clicking on any of these areas you can access the Previous Encounter information related to the entry.

The GOOD: n n n Populates from entered LMP only (does not show any data prior to LMP) Allows visualization of VS trends Shows pertinent labs

The BAD: n n Populates from present visit only after values entered in S/O, not from VS entry by MA No Rads Can’t cut and paste to OB Summary Unclear which bullets in S/O note transfer to the OB Summary

S/O Enhancements – Positive ROS to HPI n You can now have a default set so all positive ROS findings are listed together under the HPI heading. The result is a more readable note, with all of the positive symptoms in the HPI and all of the negative symptoms in the ROS.

S/O Enhancements – Dx Prompt Changes n n This enhancement allows you to search and view the results in one box. The Dx Prompt Dialog Box now includes items from the patient’s problem list and diagnoses from the current encounter.

A/P Enhancements – The Dx Tab n The Diagnosis Tab of the A/P module now automatically displays the patient’s problem list from the Problems module and any Dx Prompt search terms selected by you in the S/O module.

Additional Enhancements n n n You can now print JUST the “Add Note” without having to print the entire encounter with it. You may also print Clinical Notes from the Preview Pane. You can now select and print multiple encounters in the Appointments and Telcon modules

Problems Module Enhancements n n n An acute problem with a status of active automatically becomes inactive after 30 days, rather than the current 6 -month timeframe. Problems can be copied directly into a current encounter, S/O section. Problems may also be copied to the patient’s Family History section.

Disposition n n The layout of the Disposition module, especially the E&M coding section, has been enhanced. The AHLTA E&M calculator now takes into account the Appointment Type, Service Type, Setting, Patient Status and Time Factors, as well as each structured term documented in the Vital Signs, S/O and A/P modules, and the settings of key filters.

Disposition n The following factors are automatically used in the calculated E&M Code: n Auto. Cited Information n Vital Signs Data n Diagnoses and Procedures for Medical Decision Making (MDM) calculation n Orders for MDM Calculation n Service Type n Patient Status

The BAD: n Despite these changes, seems office visits come out often come out with lower codes (99212)

Unassigned Provider n n n An appointment can now be made and the encounter worked on without having to have a provider assigned to it. It must still have a provider to sign it, though. In processing these appointments, providers with signing rights have the option of assigning themselves as the Primary Provider when first opening the appointment. Users without signing rights or who decline to take over the appointment, may open it with no primary provider assigned.

The Good n n Can book a clinic without knowing who will be seeing the patient ahead of time Example: new providers coming in, etc.

Sensitive Encounter Printing Details of Sensitive Encounters will not be printed if the user does not have the appropriate privileges assigned to their user account or if they decline to be audited.

Signing/Co-Signing Multiple Encounters n n Users may sign, co-sign, or print multiple encounters with a single action from the Appointments, Telephone Consults, and Cosigns modules. The user’s password is required for first encounter, then pre-filled for each encounter thereafter.

Designation & Selection of Co-Signers Co-signers now have the option to assign an additional co-signer.

Selection of Radiology Location n A new field on the Order Rad tab of the A/P module allows you to define a location other than the default location for RAD orders.

Patient Labels n Users now have the option to print patient labels from the Appointments and Telephone Consults modules.

Future Appointments n n n Future appointments generated and downloaded from CHCS for dates greater than the current date can be opened to create orders and enter documentation without being checked in. These appointments will then have a status of “Open. Not. Checked. In” Future appointments can also be cancelled (Patient and Facility Cancelled only).

The GOOD: n n NOBs and SPECS can be “prepped” in advance with labs and rads ordered Visits can still be canceled if patient reschedules/does not keep the appointment

When a user attempts to open a future appointment, a pop-up warning will display.

Users can access the A/P Order Entry modules to order tests, etc. , prior to the patient visit. Be sure to expand the tab with the More Detail/Less Detail button so you can change the Start Date, etc.

The GOOD: n n n Many new features which enhance usability Less time spent watching the hourglass! Easier Cosigns Prep of future appointments Easier Tcons Tabbed encounters

The Bad n System is subject to crash from “Information Overload” n More common with longer templates n Save your work frequently, every 2 -3 bullets or after writing a long free text note

The Bad n n When system autosaves, may bounce you out of S/O to encounter view Just click S/O again

The BAD: n OB visits can still be copied forward, BUT: n Bulleted lists no longer work n Anything now bulleted (Problem Summary, etc. ) will need to be in separate bullets

The UGLY: n n n Templates will have more bullets Copy forward visit, click those bullets containing information which was in Problem Summary List Extra work, but this is an ACOG requirement

ACOG Requirements for EMR n Allergies SHALL include one observation of Latex Allergy is particularly relevant for Obstetrics because of the frequency of vaginal exams that might involve the use of latex gloves. The adverse and other adverse reactions section shall contain a narrative description of the substance intolerances and the associated adverse reactions suffered by the patient. It shall include entries for intolerances and adverse reactions.

ACOG cont. n Family Medical History The family history section shall contain a narrative description of the genetic family members, to the extent that they are known, the diseases they suffered from, their ages at death, and other relevant genetic information.

ACOG cont. n Social History The social history section shall contain a narrative description of the person’s beliefs, home life, community life, work life, hobbies, and risky habits

ACOG, cont. n Pregnancy History The pregnancy history section describes the patient history of pregnancies: G/P, type of delivery, complications, etc.

ACOG cont. n Advance Directives Includes an explicit check of patients’ preference for blood transfusion because the risk of massive hemorrhage during delivery is much higher. This observation SHALL be recorded in the Advance Directives section and SHALL include a simple observation of "blood transfusion acceptable? " The advance directive section shall contain a narrative description of the list of documents that define the patient’s expectations and requests for care along with the locations of the documents.

ACOG cont. n Plan of Care APS forms SHOULD include an observation stating if an anesthesia consult is planned. The care plan section shall contain a narrative description of the expectations for care including proposals, goals, and order requests for monitoring, tracking, or improving the condition of the patient. The care plan may include observation requests in intent, goal or proposal mood to identify intended observations that are part of the care plan, goals of the plan, or proposed observations (e. g. , from clinical decision support).

ACOG cont. n Medications should include start and stop date if known. The medications section shall contain a description of the relevant medications for the patient, e. g. an ambulatory prescription list.

ACOG cont. n Problems Related Plans should be included in the Plan of Care section. The active problem section shall contain a narrative description of the conditions currently being monitored for the patient.

ACOG cont. n Estimated Delivery Dates Physician’s best estimate of the patients due date. This is generally done both on an initial evaluation, and later confirmed at 1820 weeks. The date is supported by evidence such as the patients history of last menstrual period, a physical examination, or ultrasound measurements. If an gestational age based on ultrasound is present, it is generally considered the most accurate measurement and so that date would be chosen.

ACOG cont. n Antepartum Visit Summary Flowsheet The Antepartum summary is typically used as a 'living document' where the latest information is added to the end of the flowsheet at each visit.

ACOG cont. n Elements of the summary: n n n EGA Fundal height Fetal presentation FHR, Fetal movement PTL sx n n n n Vaginal exam BP Prepregnancy weight Current weight Urine protein/glucose Edema Pain Interval to next visit

The Ugly n n n No way to make neat lists (of ultrasounds, for example) Info is paragraph style Can separate info by hitting CTRL-ENTER after each section n Looks good on current visit n Formatting lost with copy forward

SUMMARY n n CHANGE IS NEVER EASY! Overall, 3. 3 is a good program Essentially a new EMR, will go through growing pains but will improve with time Email me with any suggestions for templates.