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IHS - EHR Version 1.1
Indian Health Service - Electronic Health Record
IHS - EHR Version 1.1
Indian Health Service - Electronic Health Record
Chris Lamer, PharmDStephanie Klepacki
Chris Lamer, PharmDStephanie Klepacki
The Wellness Tab and CRSThe Wellness Tab and CRS
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Patient EducationPatient Education
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Patient Education CodesPatient Education Codes
• Condition • Topic • Readiness to learn• Level of understanding• Provider • Time • Goal• Comment
• Condition • Topic • Readiness to learn• Level of understanding• Provider • Time • Goal• Comment
DM-EX-DIST-P-CCL-5min-GS-Will walk 3x per week-Does not exercise
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Patient Education CodesPatient Education Codes
• Local development
• Submitted and approved by PEP-C– Added to the Protocol manual & RPMS
– Protocols• Outcomes• Standards
– Lesson plans
• Local development
• Submitted and approved by PEP-C– Added to the Protocol manual & RPMS
– Protocols• Outcomes• Standards
– Lesson plans
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Patient Education and CRSPatient Education and CRS
• Used in the following GPRA measures– Tobacco Cessation (Counseling)
• Tobacco (TO-, -TO)• Secondhand Smoke (-SHS)
– Alcohol Screening (FAS Prevention)• Alcohol and Other Drugs (AOD)
– Intimate Partner/Domestic Violence Screening
• Domestic Violence (DV-, -DV)
• Used in the following GPRA measures– Tobacco Cessation (Counseling)
• Tobacco (TO-, -TO)• Secondhand Smoke (-SHS)
– Alcohol Screening (FAS Prevention)• Alcohol and Other Drugs (AOD)
– Intimate Partner/Domestic Violence Screening
• Domestic Violence (DV-, -DV)
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Patient Education and CRS (cont’d)
Patient Education and CRS (cont’d)
– Depression Screening• Depression (DEP-)• Behavioral and Social Health (BH-)• Suicidal Behavior (SB-)• Postpartum Depression (PDEP-)
– Comprehensive CVD-Related Assessment• Tobacco Screening (TO-, -TO, -SHS)• Lifestyle Counseling
– Nutrition/Medical Nutrition Therapy (-N, -MNT)
– Exercise (-EX)
– Lifestyle Adaptation (-LA)
– Depression Screening• Depression (DEP-)• Behavioral and Social Health (BH-)• Suicidal Behavior (SB-)• Postpartum Depression (PDEP-)
– Comprehensive CVD-Related Assessment• Tobacco Screening (TO-, -TO, -SHS)• Lifestyle Counseling
– Nutrition/Medical Nutrition Therapy (-N, -MNT)
– Exercise (-EX)
– Lifestyle Adaptation (-LA)
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Patient Education and CRS (cont’d)
Patient Education and CRS (cont’d)
• Used in the following non-GPRA measures– Tobacco Use and Exposure Assessment– Alcohol Screening and Brief Intervention (ASBI) in
the ER (CRS 8.0)– Nutrition and Exercise Education for At Risk Patients– Appropriate Medication Therapy after a Heart Attack
& in High Risk Patients (3 topics; breastfeeding education is used as a contraindication for statin therapy)
• Used in the following non-GPRA measures– Tobacco Use and Exposure Assessment– Alcohol Screening and Brief Intervention (ASBI) in
the ER (CRS 8.0)– Nutrition and Exercise Education for At Risk Patients– Appropriate Medication Therapy after a Heart Attack
& in High Risk Patients (3 topics; breastfeeding education is used as a contraindication for statin therapy)
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Patient Education and CRS (cont’d)
Patient Education and CRS (cont’d)
– Prenatal HIV Testing (HIV counseling measure; not HIV testing measure)
– Pre-Diabetes/Metabolic Syndrome (Tobacco Screening, Lifestyle Adaptation)
– Medications Education
– Prenatal HIV Testing (HIV counseling measure; not HIV testing measure)
– Pre-Diabetes/Metabolic Syndrome (Tobacco Screening, Lifestyle Adaptation)
– Medications Education
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Patient Education and CRS (cont’d)
Patient Education and CRS (cont’d)
• Patient Education Report– Available from the CRS Other National Reports Menu
dedicated entirely to the following patient education measures
• Rate of User Population Patients Receiving Patient Education
• Rate of Time by Provider Discipline • Rate for Top 25 Diagnoses/Disease State with Education• Rate for Top 25 Education Topics• Rate for Top 15 Provider Disciplines Who Educated• Rate of Patient Understanding of Education• Goal Setting (CRS 8.0)
• Patient Education Report– Available from the CRS Other National Reports Menu
dedicated entirely to the following patient education measures
• Rate of User Population Patients Receiving Patient Education
• Rate of Time by Provider Discipline • Rate for Top 25 Diagnoses/Disease State with Education• Rate for Top 25 Education Topics• Rate for Top 15 Provider Disciplines Who Educated• Rate of Patient Understanding of Education• Goal Setting (CRS 8.0)
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Health Factors and Exam CodesHealth Factors and Exam Codes
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Health Factors and CRSHealth Factors and CRS
• Used in the following GPRA measures– Tobacco Cessation
• Tobacco Users: Current Smoker, Current Smokeless, Current Smoker and Smokeless, Cessation-Smoker, or Cessation-Smokeless
• Quit Tobacco Use: Previous Smoker, Previous Smokeless
– Comprehensive CVD-Related Assessment• Tobacco Screening: Any Tobacco Health Factor
– Alcohol Screening (FAS Prevention)• Screening: Any Alcohol Health Factor (i.e. CAGE)
• Used in the following GPRA measures– Tobacco Cessation
• Tobacco Users: Current Smoker, Current Smokeless, Current Smoker and Smokeless, Cessation-Smoker, or Cessation-Smokeless
• Quit Tobacco Use: Previous Smoker, Previous Smokeless
– Comprehensive CVD-Related Assessment• Tobacco Screening: Any Tobacco Health Factor
– Alcohol Screening (FAS Prevention)• Screening: Any Alcohol Health Factor (i.e. CAGE)
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Health Factors and CRS (cont’d)Health Factors and CRS (cont’d)
• Used in the following non-GPRA measures– Tobacco Use and Exposure Assessment
• Screening: Any Tobacco Health Factor• Tobacco Users: Current Smoker, Current Smokeless,
Current Smoker and Smokeless, Cessation-Smoker, Cessation-Smokeless
• Smokeless Tobacco Users: Current Smokeless, Current Smoker and Smokeless, or Cessation-Smokeless
• Exposure to Tobacco Smoke: Smoker in Home or Exposure to Environmental Tobacco Smoke
• Used in the following non-GPRA measures– Tobacco Use and Exposure Assessment
• Screening: Any Tobacco Health Factor• Tobacco Users: Current Smoker, Current Smokeless,
Current Smoker and Smokeless, Cessation-Smoker, Cessation-Smokeless
• Smokeless Tobacco Users: Current Smokeless, Current Smoker and Smokeless, or Cessation-Smokeless
• Exposure to Tobacco Smoke: Smoker in Home or Exposure to Environmental Tobacco Smoke
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Health Factors and CRS (cont’d)Health Factors and CRS (cont’d)
– Alcohol Screening & Brief Intervention in the ER (CRS 8.0)
• Screening: Any Alcohol Health Factor (i.e. CAGE)• Positive Screen: CAGE 1/4, 2/4, 3/4 or 4/4
– Pre-Diabetes/Metabolic Syndrome• Tobacco Screening: Any Tobacco Health Factor
– Alcohol Screening & Brief Intervention in the ER (CRS 8.0)
• Screening: Any Alcohol Health Factor (i.e. CAGE)• Positive Screen: CAGE 1/4, 2/4, 3/4 or 4/4
– Pre-Diabetes/Metabolic Syndrome• Tobacco Screening: Any Tobacco Health Factor
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CRS and Exam CodesCRS and Exam Codes
• Used in the following GPRA measures– Diabetic Retinopathy
• Diabetic Retinal Exam: Exam Code 03
– Access to Dental Service• Annual Dental Visit: Exam Code 30
– Alcohol Screening (FAS Prevention)• Alcohol Screening: Exam Code 35
– Intimate Partner/Domestic Violence Screening• Domestic Violence Screening: Exam Code 34
– Depression Screening, Comprehensive CVD-Related Assessment
• Depression Screening: Exam Code 36
• Used in the following GPRA measures– Diabetic Retinopathy
• Diabetic Retinal Exam: Exam Code 03
– Access to Dental Service• Annual Dental Visit: Exam Code 30
– Alcohol Screening (FAS Prevention)• Alcohol Screening: Exam Code 35
– Intimate Partner/Domestic Violence Screening• Domestic Violence Screening: Exam Code 34
– Depression Screening, Comprehensive CVD-Related Assessment
• Depression Screening: Exam Code 36
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CRS and Exam Codes (cont’d)CRS and Exam Codes (cont’d)• Used in the following non-GPRA measures
– Diabetes Comprehensive Care• Diabetic Retinal Exam: Exam Code 03• Diabetic Foot Exam: Exam Code 28
– Diabetes: Access to Dental Service• Annual Dental Visit: Exam Code 30
– Alcohol Screening & Brief Intervention in the ER (CRS 8.0)
• Alcohol Screening: Exam Code 35• Positive Screen: Exam Code 35 w/positive result
– Pre-Diabetes/Metabolic Syndrome• Depression Screen: Exam Code 36
– Fall Risk Assessment• Fall Risk Screen: Exam Code 37
• Used in the following non-GPRA measures– Diabetes Comprehensive Care
• Diabetic Retinal Exam: Exam Code 03• Diabetic Foot Exam: Exam Code 28
– Diabetes: Access to Dental Service• Annual Dental Visit: Exam Code 30
– Alcohol Screening & Brief Intervention in the ER (CRS 8.0)
• Alcohol Screening: Exam Code 35• Positive Screen: Exam Code 35 w/positive result
– Pre-Diabetes/Metabolic Syndrome• Depression Screen: Exam Code 36
– Fall Risk Assessment• Fall Risk Screen: Exam Code 37
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Personal Health ComponentPersonal Health Component
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CRS Asthma MeasuresCRS Asthma Measures
• Non-GPRA asthma topics included in the Selected Measures (Local) Reports– Asthma
• Active Clinical patients with two asthma-related visits (Dx of 493) during the Report Period or categorized in ARS as persistent (active patients as Severity 2, 3 or 4). Broken down by age groups 0-5, 5-64, 65+.
• Active Clinical patients from measure above who were hospitalized for asthma during the report period.
• Non-GPRA asthma topics included in the Selected Measures (Local) Reports– Asthma
• Active Clinical patients with two asthma-related visits (Dx of 493) during the Report Period or categorized in ARS as persistent (active patients as Severity 2, 3 or 4). Broken down by age groups 0-5, 5-64, 65+.
• Active Clinical patients from measure above who were hospitalized for asthma during the report period.
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CRS Asthma Measures (cont’d)CRS Asthma Measures (cont’d)
– Asthma Quality of Care (HEDIS measure)• Active Clinical patients ages 5-56 with persistent
asthma w/o emphysema or COPD who received one dispensed prescription for primary asthma therapy medication during the report period. Broken down by age groups: 5-9, 10-17, 18-56.
– Persistent asthma defined by diagnosis and/or medication data or inclusion in ARS as active patient with severity level of 2, 3, or 4.
– Primary asthma therapy includes: Inhaled Corticosteroids, Nedocromil, Cromolyn Sodium, Leukotriene Modifiers or Methylxanthines
– Asthma Quality of Care (HEDIS measure)• Active Clinical patients ages 5-56 with persistent
asthma w/o emphysema or COPD who received one dispensed prescription for primary asthma therapy medication during the report period. Broken down by age groups: 5-9, 10-17, 18-56.
– Persistent asthma defined by diagnosis and/or medication data or inclusion in ARS as active patient with severity level of 2, 3, or 4.
– Primary asthma therapy includes: Inhaled Corticosteroids, Nedocromil, Cromolyn Sodium, Leukotriene Modifiers or Methylxanthines
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CRS Asthma Measures (cont’d)CRS Asthma Measures (cont’d)
– Asthma and Inhaled Steroid Use• Active Clinical patients ages 1+ in ARS as
persistent or who have had two asthma-related visits during the report period who were prescribed an inhaled corticosteroid during the report period. Broken down by age groups: 1-4, 5-19, 20-44, 45-64, 65+.
– Excludes patients active in ARS with a severity of 1 during the report period.
– Inhaled corticosteroid includes: Mometasone (Asmanex), Beclovent, Qvar, Vancenase, Vanceril, Vanceril DS, Bitolerol (Tornalate), Pulmicort, Pulmicort Respules, Pulmicort Turbohaler, Salmeterol/fluticasone (Advair), Triamcinolone (Azmacort), Fluticasone (Flovent).
– Asthma and Inhaled Steroid Use• Active Clinical patients ages 1+ in ARS as
persistent or who have had two asthma-related visits during the report period who were prescribed an inhaled corticosteroid during the report period. Broken down by age groups: 1-4, 5-19, 20-44, 45-64, 65+.
– Excludes patients active in ARS with a severity of 1 during the report period.
– Inhaled corticosteroid includes: Mometasone (Asmanex), Beclovent, Qvar, Vancenase, Vanceril, Vanceril DS, Bitolerol (Tornalate), Pulmicort, Pulmicort Respules, Pulmicort Turbohaler, Salmeterol/fluticasone (Advair), Triamcinolone (Azmacort), Fluticasone (Flovent).
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CRS and RefusalsCRS and Refusals
• Refusals count for many measures. Some of the GPRA measures that count refusals include:– Diabetic Retinopathy (retinal exam)– Access to Dental Services (dental visit)– Adult Immunizations: Influenza– Pap Smear– Mammogram– Colorectal Cancer Screening– Depression Screening– Prenatal HIV Testing
• Refusals count for many measures. Some of the GPRA measures that count refusals include:– Diabetic Retinopathy (retinal exam)– Access to Dental Services (dental visit)– Adult Immunizations: Influenza– Pap Smear– Mammogram– Colorectal Cancer Screening– Depression Screening– Prenatal HIV Testing
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ImmunizationsImmunizations
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CRS Immunization MeasuresCRS Immunization Measures
• CRS uses immunization data in the following topics– Childhood Immunizations (19-35 Months): DTaP, IPV/OPV,
MMR, Hepatitis B, HiB, Varicella, Pneumococcal
– Adolescent Immunizations (13 and 13-17 Years): MMR, Hepatitis B, Varicella, Td/Tdap, Meningococcal, HPV
– Adult Immunizations (50 Years and Older): Influenza, Pneumococcal
• CRS also includes contraindications and parent/patient refusals
• CRS uses immunization data in the following topics– Childhood Immunizations (19-35 Months): DTaP, IPV/OPV,
MMR, Hepatitis B, HiB, Varicella, Pneumococcal
– Adolescent Immunizations (13 and 13-17 Years): MMR, Hepatitis B, Varicella, Td/Tdap, Meningococcal, HPV
– Adult Immunizations (50 Years and Older): Influenza, Pneumococcal
• CRS also includes contraindications and parent/patient refusals
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Skin TestsSkin Tests
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PPD ProcessPPD Process
• Create a visit
• Document administration of the PPD
• Create a visit
• Document administration of the PPD
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Documenting a PPDDocumenting a PPD
• 72 hours later - PPD reading:– Create a visit– Edit the PPD already entered
• Requires the visit to be unlocked
• 72 hours later - PPD reading:– Create a visit– Edit the PPD already entered
• Requires the visit to be unlocked
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CRS Web SiteCRS Web Site
www.ihs.gov/cio/crs