Introductory EMR Training Division of Staff and Patient Education, April 2010
What are the benefits of an Electronic Medical Record (EMR)? As you begin this module, please ask yourself these questions…. • How is an EMR laid out? • What five identifiers should be • used to identify patient records • in an EMR?
Discover NextGen EMR: • Layout & Language • Patient Summary Screen • Master Template Objectives: Learn the five identifiers to check for when working in a patient record. Learn the benefits of an EMR.
Service, Quality, Finance, People, and Growth EMRs put patient information at your finger tips and allow you to give better service. Critical patient data can be accessed by providers through a secure and auditable platform anytime, anywhere. EMRs can improve patient safety and quality of care. E-Prescribing through the EMR automatically checks prescriptions against a patient’s medications and allergies. EMRs meet Federal Meaningful Use requirements, awarding monies to physician practice areas. Finances improve through improved accuracy of coding and reimbursement.
With an EMR there is easy fingertip access to data , allowing staff to address and interactwith patients knowledgeably. Interactions and interoperability with labs, pharmacies and specialties are improved with the secure exchange of information. EMRs can improve data management and analysis setting the stage for growth. Reporting for outcomes analysis, recalls, patient populations, business analysis and more are generated from the EMR. Compliance with clinical reporting guidelines is facilitated with disease management templates designed to capture patient information at the point of care.
January 2010 was NextGen’s first “Go Live” in the Farmington IMA clinic.
NextGen provides a system of templates that are easily accessed through menus and toolbars. • Pre-built clinical templates and workflow to ensure complete, accurate • documentation stored in a standard format. • Disease management templates to capture discrete data at the point of care to meet clinical reporting guidelines for pay-for-performance programs. • ePrescribing automatically checks prescriptions against a patient’s • medication profile; medication, dose, route, directions. • IDX integrates with NextGen allowing patient data to cross over enabling consistent, real-time clinical and administrative workflow among nursing, office staff and providers.
Now that you understand some of the benefits of EMRs, this next section will take you through a series of NextGen simulations to help you become familiar with some of NextGen’s basics.
Log on to NextGen Click the NextGen Desktop Icon Your NextGen login and password will be given you at your first scheduled training session. -To access NextGen you will enter your User Name and Password in the lines provided and then choose “University Medical Group” from the two dropdown menus. -Click the “Sign on” radio button to get to the NextGen opening screen.
Opening Screen: Menu Bar The Menu Bar provides access to screens and functions through drop down lists. At your first live training session you will be shown how to select default settings for things like “provider choice” and “user preferences”. To log out of NextGen click on File. The drop drop down menu opens. Click Exit. Menu Bar
The Top Toolbar Main Menu Bar Practice Site Provider Name Top Toolbar • The Top Toolbar is located directly under the Main Menu Bar. It consists of ten buttons and two drop down lists (Practice Site and Provider Name): Exit, Save, Clear, Delete, Patient, History, Inbox, PAQ, Apps, Close. From Left to Right: • Exit provides a soft close and is used when you step away from your computer and want to exit out of NextGen without closing the program. The most recent activity spot in NextGen remains. This allows a quick return to a particular chart section for you or for the next caregiver. • Save, saves the work in the active window. • Clear, clears the indicated data in the active window. • Delete, deletes all the data you have entered in the active window. • Practice Site, choose the practice site where the provider is seeing the patient. • Provider Name, choose the name of the provider who is seeing the patient at the visit
The Top Toolbar • Patient prompts the patient lookup dialog box. • History toggles the History Toolbar on/off. • Inbox toggles the Inbox on/off. • PAQ prompts the Provider Approval Queue. • Apps enables opening of other licensed applications. *Not active at this time • Close closes the current open window. • The PAQ, Inbox, History, and Patient Icons are explained more fully on the • next pages.The History Icon will be explained with the Chart Summary.
The PAQ Icon The Provider Approval Queue is where the provider will sign off on all Labs, Radiology and Pathology reports. It is password protected and only Providers have access to it. Click on the the PAQ button to gain access.
The Inbox Icon : Click the Inbox Icon to open the Workflow. - The left side of the Workflow Inbox displays patient appointments that are in IDX scheduling systems. The various appointment status will display from IDX to NextGen as: A=Arrival, P=Pending, C=Cancelled, R=Rescheduled, and B=Bump. The right side displays the listing of a staff’s workflow, or “tasks”.
Patient Icon: Click the Patient icon from the Main Toolbar for the Patient Lookup screen to appear.
Patient Lookup Opens a Patient Chart Summary 1. Enter patient identification information into Patient Lookup. 2. Click ‘find’. 3. Choose the correct patient in the Matching Records window. 4. Click ‘open.’ The Patient Chart Summary opens. 1 3 2 4
Closing a Patient Chart : Once you open a chart the Patient’s name will appear in the upper left hand corner of the window, in the dark blue banner . The Patient’s name remains visible here and the chart active until the chart is closed. • Close the chart. Click File in the Main Menu. - Click Close Patient Now let’s return to learn more about the Adult Chart Summary.
Adult Chart Summary The Chart Summary contains an overview of the patient chart: demographics, medications, visit history, problem lists, alerts, allergies, medical orders, blood pressure readings, and more.It offers a quick overview of the patient for the beginning of an office visit or when speaking to a patient on the phone. With permission, patients will have their pictures taken by the front desk staff and added to the Chart Summary template.
Alerts indicate vital patient care information such as Deaf or Language Interpreter Required and are indicated in red. Alerts come across from the IDX Registration system. Click the alert (in red) to get to an ‘Alert’ screen that gives more information.
The History Toolbar with the Chart Summary Click the History Icon from the Top Toolbar to open the History Toolbar. -The History Toolbar lists all patient encounters by date, time, and type of encounter. It also gives button or tab access to blank templates and sections of the chart. The History Toolbar is made up of: Patient/chart encounters , categories, or sections of the chart, and History Tool BarIcons that connect with specialty templatessuch as the lab module.
The History Toolbar the History Toolbar History Toolbar Icon AKA “Tic Tac Toe Square” or KBM
Encounters • An encounter is an interaction with a patient or patient information for a specific date and time. It can be a visit, a phone call, a referral, or a result of a test. A patient’s chart can have more than one encounter for a day. • New encounters can be created by clicking the New button. • Open an encounter’s file folder to see the templates that make up that encounter • Past encounters can be opened by highlighting the desired date and clicking. • Paper documents can be added to the encounter history through scanning capabilities.
Categories Categories are sections of the chart such as Progress Notes, Radiology, Pathology, Telephone Encounters, and Stress Testing. Click the Categories Tab to see the History Toolbar in this format. Progress Note Example Telephone Encounter Example
Adding Paper Documents to NextGen Internal and external paper documents are scanned into NextGen based on their documentation type. They will file under the appropriate category and appear as encounters with a date and time. • Non facility reports • Down time charting
History Toolbar Icons Also known as the “Tic Tac Toe Square” The History Toolbar Icons give click access to: -Templates - Ability to modify images to illustrate status -All available documents -View and/or add procedures - View and/or add diagnosis - View, add or modify Allergies - View and/or add prescriptions - Access to the lab Module
Lab Module Click the Lab Icon from the tick tac toe area to bring up the Lab Module. Lab results from UCHC and Quest labs will be available in NextGen.
ePrescribing E-prescribing is a two way, computer to computer communication of prescription information between the provider’s office and pharmacy , or the pharmacy to the provider’s office. NextGen links to current pharmacy databases and insurance formularies. Looking up a pharmacy address, fax and phone number is easily done through a series of drop down menus. - Click the Prescription Icon in the History Toolbar to prescribe electronically
Master Template Set Tostart a Patient visit, open the Adult Chart Summary. Click the center blue HOME button to link to the Master IM . - The Master IM template opens. *Encounters are automatically created for patients arrived in IDX.
The 5 Point Check With easy movement through the chart it is important to know where you are at all times. Check That the Right EMR & Encounter Are Open Anytime you create or move to a new section of a chart perform the 5 Point Check: Correct…. 1 - Patient Name 4 - MRN 2- Location 5 - Encounter Date & Time 3 - Provider
Master Template Set - Master IM The Master IM serves as the Home Page for Internal Medicine. Visit information is entered into the Master Template, or Specialty Template Set through drop down lists and/or free form text. In all templates the History Toolbar is visible if it is kept toggled on. History Toolbar
The Master IM Become familiar with the nine sections of the main template. 6. Reviewed and Updated Chronic Problems 7. Reviewed Alerts 8. Reviewed and documented Advance Directives Set and managed Disease Management and Health Maintenance Protocols located under Health Monitor section 5 point Check to verify correct patient: Patient, MRN, Provider location and encounter date. 2. Visit type 3. Reasons for visit from pick list Reviewed and updated allergies Reviewed and updated Medications
The Navigation Toolbar The Navigation Toolbar, located to the left in the Master IM, lists and gives access to demographics and commonly used specialty templates including notes and forms. 1. The Preview button at the bottom allows the User to generate a note. 2. Incomplete notes allows the User to track notes requiring completion. 3. Patient Tracking allows clinic staff to track patients during an office visit. 4. Nurse Doc allows the nurse to quickly access Nursing Documentation. Master IM
Notes A note is generated from the information entered into the various templates used during an encounter. To preview the note, click the preview button at the bottom of the Navigation Tool Bar.
Documents TheDocument Library in the Navigational Toolbar gives options to create documents. A download of information occurs when a note or form template is chosen. Print it out to give to a patient or send it electronically to one of the network Providers. Click on the Document Library to gain access.
Submit to Superbill: Submitting Charges Once an order or procedure has been completed the charge can be added to the patient’s bill through the Submit to Superbill button. This is found on order and result templates throughout NextGen. The patient’s Superbill should be accessed to review and check for accuracy of charges at the end of all visits.
Points To Remember • NextGen provides a system of templates that are easily accessed through menusand toolbars. • Critical patient data can be accessed shared by providers through a secure and auditable platform, anytime, anywhere. • An encounter is an interaction with a patient or patient information for a specific date and time. It can be a visit, a phone call, a referral, or a result of a test. • Anytime you create or move to a new section of a chart perform the • 5 Point Check. Check that you have the correct Patient Name, Location, Provider, MRN, & Encounter Date and Time. All five must be correct.
Points To Remember • The Chart Summary contains an overview of the patient chart in a single window. A patient’s picture will be seen in the upper right hand corner unless they do not agree to have their picture taken. • The Master IM template serves as the Home Page for Internal Medicine. Specialty templates can be easily accessed from here through the Navigation Tool Bar. • The patient’s Superbill should be accessed to review and check for accuracy of charges at the end of all visits. • Hands on NextGen education will be offered to you before the Go-Live date in your area.