4/11/2014

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P R E S E N T E R S :

E . J O Y W O O D K E , C O E , O C S

J A I M E L A N D O N , C O A , O C S

Electronic Health Records in a Retina Practice

Financial Disclosure

� Joy Woodke, COE, OCS

◦ This presenter does not have a financial interest or relationship to disclose relative to this activity.

◦ NOTE: Ms. Woodke has disclosed that she serves as an AAOE CODEquest Instructor.

Financial Disclosure

� Jaime Landon, COA, OCS

◦ This presenter does not have a financial interest or relationship to disclose relative to this activity.

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NEW CHALLENGES

New challenges in a Retina practice

ShrinkingReimbursements

and tighter Medicare scrutiny

More burdensome documentation requirements

Increase in officeBased procedures and older patients

Adoption of Electonic

Health Records

Objectives

� EHRs in the Retina Practice

� Efficiencies

� Workflow Analysis

� Chart Documentation

� Scribes

� Meaningful Use / Incentive Program tips

Efficiencies

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�Improved cl inic f low

�No more PAPER CHARTS

�More face to face time with patients

�Less dictation

�Ophthalmoscopy efficiency

�Communication between physicians

�View test immediately (PAC System)

�Meet MU, avoid penalties

What can your retina practice gain by implementing EHR?

Patient Locator

*Example------------

*Follows the patient

through the clinic

*Put in a color holder to represent each physician

*Helps identify quickly reason for visit

View Clinic InformationView Clinic Information Quickly and EasilyQuickly and Easily

Clinic Flow

�Quick view of Vision/IOP over time�Quickly see if there is a change

�View current diagnosis codes�View onset date of diagnosis�View previous procedures�Dates surgeries or procedures were performed

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Chart Review in the room

� Determine if your physician likes his scribe to dictate the patient’s current information to them or if they

prefer to review the chart prior to the scribe entering the room

Test

Interpretation

*Requires separately identifiable

interpretation

*Create a template that makes the

interpretation easy and error free

•Findings•Comparative Data•Clinical Management

Ophthalmoscopies

*Draw on paper

and scan into EHR chart

*Draw on computer based

program that loads directly to

the chart

Pros and Cons

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Send communication that a letter is required

Send communication that a letter is required

Pull information from exam to create a letter; Edit as needed

Pull information from exam to create a letter; Edit as needed

Communication

Communication

Secure Messaging

� Send correspondence directly to physicians

� Send tests directly to physicians

� Send chart notes securely to patients

Send orders immediately to the front desk to schedule follow up

Send orders immediately to the front desk to schedule follow up

Communication

Eliminate missing follow up orders/wrong orders

Eliminate missing follow up orders/wrong orders

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View Testing Immediately

�Open images directly from EHR �Open images in a PAC System�Allows you to view pre and post op photos in the same screen

Workflow

Analysis

Analyze

� Start with the OLD…

� Early in your EHR planning process

� Collect and document the current processes

�Interview staff and physicians

� Consider new software functionality

�Start to connect the dots

� Review the OLD

using the following tool…

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Analyze

� “Workflow Process Analysis”

� Dream of your perfect world

� Envision the future

� Is the workflow outdated?

� Consider employee skill level

�Knowledge, Skill, Ability (KSA)

� Are we:

�overlooking tasks

�avoiding technology

�duplicating efforts

Workflow Before EHR: Preparing Surgery Paperwork (19 Steps)

Patient needs surgery, exam

complete

Surgery coordinator notified

either verbally, by email, or note on chart

Surgery paperwork needs to be completed

Have paper chart?

YES NO

Locate chart

Attach surgery flow sheet in paper protector, place in technician inbox

Technician writes on H&P on forms using chart as a reference

Technician writes physician’s orders on

forms, using charts as a reference

Patient scheduled for retinal

detachment repair

Technician prepares patient health history

form

Technician puts completed

paperwork in protector, attached

to chart

Charts & paperwork placed in MD inbox

by tech

MD reviews paperwork

Paperwork needs

revision?

Technician prepares corrected

document(s)

Charts & paperwork placed in MD inbox

by tech

MD reviews paperwork, signs

and returns

Surgery coordinator gets chart and paperwork

Paperwork delivered to

surgery center

Workflow After EHR: Preparing Surgery Paperwork (10 Steps)

Patient needs surgery, exam

complete

Technician sends EHR order to Surgery Coordinator

desktop

MD reviews exam, signs document in EHR

(creates discrete data for H&P)

Surgery coordinator starts surgery flow sheet document in

EHR, routes to technician desktop

Technician starts H&P update in

EHR, confirms and signs

(creates discrete data for all surgery

documents)

Patient schedules

retina surgery

Surgery coordinator starts physician orders & patient

health history updated in EHR

(discrete data pulls from H&P/exam)

All documents are routed to MD, EHR

desktop for signature

MD reviews documents, makes any revisions and signs documents

Surgery coordinator routes all

documents electronically to Surgery Center

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Chart

Documentation

Chart Documentation

�What is the goal?

�Why is efficiency necessary?

Data Display

*Use data display to show your work-up technicians the last plan

by the physician and/or urgent directives. This will allow them to not

miss any pertinent orders or important directives from the

physician.

Data display does not appear in the text of the exam it is

only viewable.

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**Quick view to see C/D ratio, previous location of

tear/detachment, etc.

Data Display

*Can be used by scribes

and physicians to make sure data entry is correct from visit to visit.

*Data display from previous exam is not

recorded in chart.

*Only new information is translated into the chart.

Data Display**No Cloning

Improve efficiency by reviewing previous information, making any

appropriate changes. This will confirm no cloning is done in

your exam forms

Once everything is updated into can be loaded into the chart

documentation

*Monitor that your technicians are not just pulling information in and not reviewing. This can be a huge problem in an audit.

Drop Downs/Radio Buttons

Improve efficiency by using drop downs/pick lists/radio

buttons

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Quicktext/Macros

*Use quicktext/macros to create efficiency when documenting plan for physician

.ivaod=IntravitrealAvastin Injection

OD

.ref=Chart notes from referring

physician reviewed today

.dryamd=Discussed diagnosis of dry age related macular

degeneration. Recommend monitoring vision with amsler

grid, start AREDS formula vitamins, and have UV protection

put in all glasses. This can be done by referring doctor.

Scribing

Why are scribes a necessity in a retina practice?

�Increased retina volume

�Increased in office procedures

�Increase in aging population

�Documentation

�Meaningful Use Requirements

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Key Components of a Retina Scribe

Personality

Detail Oriented

Good Work Ethic

Ophthalmology Background

PersonalityPersonalityOphthalmology

Background

Ophthalmology

Background

� Retina scribing can be just like an assembly line that never stops

� Scribes must be able to ask questions of and work well with

physicians quickly and efficiently

� Scribes are essentially an extension

of the physician

� Be able to translate laymen terms into medical terminology and vice versa

� Example: The physician tells the

patient the OCT shows swelling from the diabetes and they need treatment. The scribe would write clinically

significant macular edema in the chart note.

� Scribes should be able to detect

decreased acuities or a significant change in C/D ratio and relay concerning information to the

physician

Character Traits

Detail OrientedDetail Oriented Good Work EthicGood Work Ethic

� Scribes will have a multitude of duties required by them in a short

period of time.

� Retrieving patient data

� Documenting assessments

� Entering new data

� Coding visits

� Performing patient education

� Assisting with procedures

� Must be reliable. At times they may be the only scribe available

that day, if they do not show this can cause a huge impact on the

team.

� There advanced knowledge, skills

and detail can increase the number of patients visits from 25% -100 %

while allowing the physician to spend more time with their

patients .

Character Traits

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How do you choose a scribe in your practice?

� Begin to evaluate your current staff.

� Allow each one the opportunity to prove they have the skills you are looking for

� Get physician input (your physicians may choose for you)

Skills to Test

� Accuracy� Can they go from one room with a patient with

BDR/CSME needing an injection in the right eye to a patient with AMD needing an injection in the left eye and not mix them up (THIS HAPPENS)

� Writing Skills� Can they take what the physician says in laymen

terms and write it so it addresses the specific issues

� Do not want people who scribe like they talk

(Writing plans that talk in circles)

� Order/Efficiency� Can they do things in an efficient order (or the

order which your office requires) and complete everything that needs to be done.

Train your scribes

Pick your scribesRetina surgeries=corresponding

diagnosis

In Office procedures =corresponding diagnosis

Findings=Diagnosis

Chart DocumentationModifiers

E/M Codes v Eye Codes

Test Interps and Ophthalmoscopies

Clinic Flow

�T E A C H T H E M T O T R A N S C R I B E C O N S I S T E N T L Y

�D I C T A T E I N O R D E R E A C H T I M E

�D I C T A T E I N O R D E R O F Y O U R T E M P L A T E

�D E T E R M I N E H O W E A C H P H Y S I C I A N W I L L D I C T A T E T H E P L A N

� Will they tell you the plan then talk to the patient?

� Will the scribe write in medical terminology the plan while the physician

discusses the treatment plan with the patient?

Train your doctors

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Meaningful Use/Incentive

Programs

�I D E N T I F Y A T E A M T O M A K E D E C I S I O N S

�I D E N T I F Y W H I C H C O R E M E A S U R E S A N D M E N U

O B J E C T I V E S W O R K B E S T F O R Y O U R P R A C T I C E

�D E V E L O P A T E S T I N G M E T H O D

�T R A I N Y O U R T E A M

�M O N I T O R R E P O R T S , M A K E A D J U S T M E N T S A S N E C E S S A R Y

Identify

Clinical Visit Summaries

Print clinical visit summary directly from

the chart.

�Print in exam room�Print to front desk�Print to PDF�Print to patient portal

Printing options? Efficiency?

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Clinical Visit Summaries/Patient Portal

Add sentence at the end of clinical visit summary to drive

patients to your website

Paper SuperbillPaper Superbill Electronic SuperbillElectronic Superbill

Paper Superbill v. Electronic Superbill

PQRS

Efficiency: Create forms

within orders to send codes

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Create Efficiencies

Update forms to meet documentation requirements“absence of hemorrhage and thickness”

Lab Orders

�Review current processes

�Paper v. Electronic

�Enter clinical lab information as

structured data meets MU requirement

�Import directly into chart?

�Avoid waiting for faxed copy of results

*Run MU reports

*Review results,

make adjustments

as needed.

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QUESTIONS?

Joy Woodke, COE, OCSJoy Woodke, COE, OCSJoy Woodke, COE, OCSJoy Woodke, COE, OCSjoy@oregoneyeconsultants.comjoy@oregoneyeconsultants.comjoy@oregoneyeconsultants.comjoy@oregoneyeconsultants.com

(541) 349(541) 349(541) 349(541) 349----5129512951295129

Jaime Maldonado, COAJaime Maldonado, COAJaime Maldonado, COAJaime Maldonado, COAjaime@oregoneyeconsultants.comjaime@oregoneyeconsultants.comjaime@oregoneyeconsultants.comjaime@oregoneyeconsultants.com

(541) 687(541) 687(541) 687(541) 687----1927192719271927

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