Quadramed – for the 9/23 rollover affecting 9/26
ambulatory visits

Meaningful Use
(Accountable Care Act) requirements for patient visit summary which we must
give to patients:

·
Allergies,
medication list & diagnostic tests will auto-populate.

·
Problem list–
enter all that were thought about/discussed/acted upon in any fashion by you,
the provider, during this visit; old list will become view only.  Input problems with type and severity to make
a new list which you must maintain with only active chronic and acute
diagnoses.  Do Not input “routine
health visit.” Remove inactive/redundant

·
 Subjective,
assessment and plan  (SAP)

o
a new field in
Genmed z-out (after return visit choice) and visit note

o
Fill out only
once, it will flow to the other field, doesn’t matter which one you fill

o
BRIEF, patient
friendly, what they need to know from this visit

o
subjective,
problem-oriented A/P

o
Example:

§
today for diabetes
and 3 days cough

§
Cough because of
cold – Robitussin 2 teaspoons 4 times daily as needed, fluids

§
Diabetes
improving – increase Lantus to 20 units at night, strict diet, check blood
tests 1 week before next appointment

§
Health
maintenance-keep mammogram appointment

§
return
appointment – December

o
do not repeat everything else already on the summary (problem list, medication list, labs)

·
 The visit summary will print out with Z.-out
and given to patient before they leave

FYI:  Visit Summary
details

·
problem list of
the active diagnoses you choose on this visit: Chronic & acute

·
medication list-active
going back 3 months from current visit

·
Labs & diagnostic tests -going back from current visit to immediately previous
visit summary  only:

o
date     study/test name          normal/abnormal

            5/2/11mammogram               normal

            6/1/11CBC                             normal

·
If you do the SAP
at Z.-out, it will flow to the visit note, you
do not need to repeat it when you do your formal patient note if it
contains everything you want to say, if not refer to and supplement it.

·
If you complete
your documentation before the patient leaves the SAP will flow automatically to
the visit summary for the patient

·
The visit summary
is intended for patients for the single visit. Any further information/details
can be obtained from Medical Records

Meaningful Use in
ambulatory – 9/24/11

Hospital required to use a federally certified version of
the EMR piloted in Coney Island Hospital. Rollout 9/23. Compliance is required
by 10/1. This certified version is not changeable, but allows us to define
where we get the data. Many have worked to figure where we are already entering
the relevant data and as well as patient flow.
Applies to primary and subspecialty
care practices. Patients  will
receive a visit summary at the end of each ambulatory encounter containing:                                                                                                                         Medication
Allergies

                                                Problem
list

                                                Medication
list

                                                Diagnostic
and lab studies

                                                Brief
Note

that requires
completion of the note before exiting the patient, replaces medication list
at Z-out. In brief:

v
Medication Allergies – pulled from Quadramed

v
Problem List: will have to enter a new problem
list with severity and type of problem and maintain it, old problem list will
become “view only” create
standard work to keep this up to date

v
“Problem list”  for this summary will be from the diagnoses
chosen for the current visit (note or Z.-out), therefore must enter every
diagnosis that is touched, required consideration, education, assessment,
intervention. Pull these from problem list that will pop up.

v
Medication list will be the list of active
medications from past 3-6 months. maintain
medication list.

v
Diagnostic and lab studies (blood work,
pathology, cardiology, PFTs, radiology etc.) occurring in the interval from the
previous visit to current visit, the date, name of the examination and whether
or not it was normal or abnormal by the laboratory reference values or
determined by the interpreter. There is a possibility that the patient may
visit a subspecialty practice and primary care testing will display on their
summary before they see primary care and vice versa.

v
Brief note will be pulled from a new field
“assessment and plan” that follows the old “note.” I will
try to add subjective

Ø
keep brief and simple, is going to the patient

Ø
assessment/plan from the problem list, including
health maintenance

v
The old “visit note” field will be
changed to PMHx, Data, physical examination and can continue all the
ruminations and documentation that will not be given to the patient

There will be a explanation and disclaimer at the bottom
stating something approximating:

“This is a summary of your current visit only and any
questions about its contents should be discussed with your provider. Additional
information available upon request from HIM.”

·
residents require orientation, will request 5
minutes before noon conference for a few days in the beginning of each rotation
for the next several months until we catch everyone

·
Review and reinforce during ambulatory team
meetings

·
Review and reinforce during precepting

·
Give feedback when signing notes

·
Please audit for compliance, look at the notes
from encounter, can use residents during block time for peer reviewing quality
improvement (ACGME requirement)

Pending:  add
subjective to A/P,  delete DME (alcohol
pads, lancets etc.) from the medication list.