1 Using the Internet to Expedite Patient CareCHAPTER ELEVEN TWO Using the Internet to Expedite Patient Care

2 Secure Messaging E-VisitsAllows patient to be treated by clinician for nonurgent health problems without patient having to come into office. E-visits are secure and they gather symptom and HPI information, creating documented medical encounter. E-visits are reimbursed as a legitimate E&M visit.

3 Provider-to-Patient E-Mail CommunicationSecurity Rule allows for EPHI to be sent over electronic open network as long as it is protected. Patient can a doctor or medical facility containing information about medical condition, even if is not encrypted.

4 Provider-to-Patient E-Mail CommunicationClinician has to be very guarded replying through unencrypted . Preferred alternative is to use secure web site for communication between patient and provider.

5 Workflow of an E-Visit Begins with patient-entered symptom, history, and history of present illness information. Patient must already be established patient with practice and have medical records on file. Patient answers questions and selects reason for visit from a list. E-visits are only used for nonurgent visits.

6 Workflow of an E-Visit When interview is complete, the data entered by patient is recorded in the EHR and clinician is notified that E-visit is ready to review. E-visits can be directed to “doctor on call,” allowing practicing partners to share “E-visit” duty.

7 Workflow of an E-Visit Clinician reviews patient-entered data, reviews relevant patient medical records, and replies to patient. Clinician can prescribe electronically during the E-visit. Doctor's response can include patient education material and comments or care instructions from doctor.

8 Mayo Clinic Study of E-visitsLargest study of Internet use for online care (E-visits) using structured history was conducted in the Department of Family Medicine at Mayo Clinic in Rochester, Minnesota.

9 Mayo Clinic Study of E-visitsStudy showed feasibility of online visits to educate, treat, and bill patients. Extent of conditions possible for treatment by online care was far ranging and managed with a minimum of message exchanges by using structured histories.

10 California Study Independent study sponsored by Blue Shield of California. Most patients and doctors in study preferred a web visit to an office visit for nonurgent medical needs.

11 California Study Providers found that the E-visit gathered important details and eliminated multiple messages back and forth that occur when trying to provide patient care via . Patients found that time spent scheduling, driving, parking, and waiting was saved with an E-visit.

12 Guided Exercise 66: Patient Requests an E-VisitCase Study Jacob Silverstein is a 46-year-old male with a history of hypertension and diabetes. He is on medication and has regular check-ups at his family practice. He has an issue with his medication and is going to try an online E-visit instead of coming to the office.

13 Guided Exercise 66: Patient Requests an E-VisitStep 1 Start your web browser program. Follow steps listed inside the cover of this textbook to log into MyHealthProfessionsKit.com When welcome page is displayed, click on link “Activities and Exercises” or select “Activities” from drop-down list; click on button labeled “Go.”

14 Guided Exercise 66: Patient Requests an E-VisitStep 2 Locate and click on link Exercise 66 in the menu on the left. Information about exercise will be displayed. Locate and click link “Click here to start the web portal program.” Sample provider web portal shown in Figure 11-6 of textbook will be displayed.

15 Guided Exercise 66: Patient Requests an E-VisitStep 3 Locate section labeled “E-visits for Established Patients;” click on link “E-visit.” “Welcome to Family Care E-visit” web page is displayed.

16 Guided Exercise 66: Patient Requests an E-VisitStep 4 Key difference between E-visit and pre-visit questionnaire is that providers collect a copay at time of E-visit. Portal includes simulated payment information; you will not be charged. Do not enter any personal credit card data.

17 Guided Exercise 66: Patient Requests an E-VisitStep 4 (cont.) Locate and click on button labeled “Start Interview.” Center portion of web page will look similar to Figure

18 Guided Exercise 66: Patient Requests an E-VisitFigure 11-12: Patient interview screen for an E-visit.

19 Guided Exercise 66: Patient Requests an E-VisitStep 5 Enter the following: Enter your name or student ID. Patient information: First Name: Jacob Last Name: Silverstein Click circle next to Male

20 Guided Exercise 66: Patient Requests an E-VisitStep 5 (cont.) Click on down arrow buttons in each of the Date of Birth fields and select from the drop-down lists: April, 4, and 1966. Compare your screen to Figure When everything has been entered correctly, locate and click on button labeled “Next.”

21 Guided Exercise 66: Patient Requests an E-VisitStep 6 Reason for Visit screen will be displayed. Locate and click on “Cough” in list of reasons (Figure 11-13). Locate and click on button labeled “Next.”

22 Guided Exercise 66: Patient Requests an E-VisitFigure 11-13: Reason for visit “Cough” selected from list.

23 Guided Exercise 66: Patient Requests an E-VisitStep 7 Interview process will start. For each question in the Table on page 449 and 450 in the text locate and click on indicated button. If you make an error, click on button labeled “Previous Question,” and correct your error.

24 Guided Exercise 66: Patient Requests an E-VisitStep 8 When you have reached end of interview, a free-text note box is displayed to allow patient to enter messages in their own words. Leave box empty. Locate and click on button labeled “Next.”

25 Guided Exercise 66: Patient Requests an E-VisitStep 9 Final screen of interview allows you to review your work. Compare your screen to Figure of the textbook by scrolling window as necessary. If any differences (other than patient's age), repeat exercise, making certain you answer each of the questions in steps 6 through 8 correctly.

26 Guided Exercise 66: Patient Requests an E-VisitFigure 11-14: Completed interview for E-visit.

27 Guided Exercise 66: Patient Requests an E-VisitStep 10 At bottom of Interview Report screen are two buttons labeled “Print” and “Save.” When everything is correct, locate and click on button to either print or save to a file. Once you have your print out or file output, close browser and proceed to Exercise 67.

28 Guided Exercise 67: Clinician Completes the E-VisitStep 1 Start Student Edition software. Click Select on Menu bar; then click Patient. In Patient Selection window, locate and click on Jacob Silverstein. Figure 11-15: Select patient Jacob Silverstein.

29 Guided Exercise 67: Clinician Completes the E-VisitStep 2 Click Select on Menu bar again; then click Existing Encounter. Select 5/29/2012 7:30 PM e-Visit. Encounter note data from E-visit will be displayed. Figure 11-16: Select the E-visit encounter for 5/29/2012.

30 Guided Exercise 67: Clinician Completes the E-VisitStep 3 When encounter is displayed, locate and click on Manage tab at bottom of screen. Review HPI data supplied by patient displayed in right pane; locate and click on tab labeled “Medications” in left pane. Compare your screen to Figure Review Mr. Silverstein's prescription history. Note that new drug was prescribed on 5/11/2012.

31 Guided Exercise 67: Clinician Completes the E-VisitFigure 11-17: Medications tab showing prescription history.

32 Guided Exercise 67: Clinician Completes the E-VisitStep 4 Locate and click on tab labeled “Problem List” and then click on “Hypertension” to highlight it. Click on Flowsheet button on Toolbar. Figure 11-18: Problem tab with Hypertension highlighted.

33 Guided Exercise 67: Clinician Completes the E-VisitStep 5 Scroll Flowsheet downward until your screen looks like Figure Locate and click on red button for Assessment: Hypertension (red button) Locate Medications, Vaccines section near bottom of Flowsheet.

34 Guided Exercise 67: Clinician Completes the E-VisitFigure 11-19: Flowsheet with Hypertension and Lisinopril circled in red.

35 Guided Exercise 67: Clinician Completes the E-VisitStep 5 (cont.) Click on description “Ordered Lisinopril” (circled in Figure 11-19). The entire row will become highlighted. Do not click the red or blue buttons.

36 Guided Exercise 67: Clinician Completes the E-VisitStep 6 Locate and click on down arrow in Entry Details “Prefix” field. Select “discontinue” from drop-down list. Locate and click on Flowsheet button on Toolbar to close Flowsheet. Locate and click on Encounter tab at bottom of screen.

37 Guided Exercise 67: Clinician Completes the E-VisitFigure 11-20: Select “discontinue” from Prefix drop-down list.

38 Guided Exercise 67: Clinician Completes the E-VisitStep 7 Click on Dx tab in left pane. Locate and click on Search button on Toolbar at top of screen. When search dialog window is displayed, type “adverse,” and then click on button in dialog window labeled “Search.”

39 Guided Exercise 67: Clinician Completes the E-VisitStep 7 (cont.) Compare your results to left pane of Figure Locate and click on red button for following finding: Adverse effect of drug therapy (red button)

40 Guided Exercise 67: Clinician Completes the E-VisitFigure 11-21: Dx: Adverse effect of drug therapy.

41 Guided Exercise 67: Clinician Completes the E-VisitStep 8 Click on Rx tab in left pane. Locate and click on Search button on Toolbar at top of screen. When search dialog window displayed, type “Amlodipine;” then click on button in dialog window labeled “Search.”

42 Guided Exercise 67: Clinician Completes the E-VisitStep 8 (cont.) Highlight finding “Calcium Channel Blockers Amlodipine Maleate;” then click Rx button on Toolbar at top of screen. This will invoke Rx Writer. Figure 11-22: Highlight Calcium Channel Blockers Amlodpine Maleate.

43 Guided Exercise 67: Clinician Completes the E-VisitStep 9 Select dosage “10 milligram tab” and then double-click on it. Figure 11-23: Select the 10 milligram tablet in the Rx Dosage Inquiry window.

44 Guided Exercise 67: Clinician Completes the E-VisitStep 10 Rx Brand window will be displayed (not shown in textbook). There is only one brand, “Amvaz”; double-click on it.

45 Guided Exercise 67: Clinician Completes the E-VisitStep 11 Rx Writer will display; enter the information in Sig fields. When everything is correct, locate and click button labeled “Save Rx.” Sig Information: Quantity: 1 Freq: daily Per Day: 1 Route: by mouthDays: 30 Amount: 30 Refills: 3 Generic: Y

46 Guided Exercise 67: Clinician Completes the E-VisitFigure 11-24: Rx Writer prescription for Amlodipine.

47 Guided Exercise 67: Clinician Completes the E-VisitStep 12 Click on Print button on Toolbar at top of your screen to invoke Print Data window. Be certain there is check mark in box next to “Current Encounter;” click on button to either print or export a file. Compare your printout or file output to Figure in the textbook.

48 Patient Access to Electronic Health RecordsProviding patients with timely electronic access to their health information. Providing patients with electronic copy of their health information upon request.

49 Patient Access to Electronic Health RecordsProviding inpatients with electronic copy of their discharge instructions and procedures at time of discharge, upon request. Sending reminders to patients per patient preference for preventive/follow-up care.

50 The Patient-Centered Medical HomePatient-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults. PCMH Standards Access and Communication Patient Tracking and Registry Functions Care Management Patient Self-Management Support

51 The Patient-Centered Medical HomePCMH Standards (cont.) Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communication

52 The Personal Health RecordPersonal Health Record (PHR): Online services independent of any one medical group offer patients ability to maintain their own medical records online. Record maintained online by patient can contain data from patient visits at multiple practices. Online PHR is available everywhere.

53 The Personal Health RecordKaiser-Permanente, one of the largest healthcare providers in United States, has implemented what is perhaps largest PHR to date. There are numerous organizations developing and sponsoring web-based PHR.

54 Critical Thinking Exercise 68: Researching the PHRYou will need access to the Internet to complete this exercise.

55 Critical Thinking Exercise 68: Researching the PHRStep 1 Start your web browser. Listed below are six PHR web sites. Your local hospital, health insurance plan, or certain government programs may also offer PHR that you may use for this exercise. Select at least two sites to use for your research.

56 Critical Thinking Exercise 68: Researching the PHRStep 1 (cont.)

57 Critical Thinking Exercise 68: Researching the PHRStep 2 Type URL of your first choice in address field of your web browser. When web site is displayed, read information provided about that organization's PHR. Many of the sites offer a demonstration version; if one is available click on it. Take notes or print pages of the web site. You will use these in step 4.

58 Critical Thinking Exercise 68: Researching the PHRStep 3 Type second URL you have chosen in address field of your web browser. Study information presented on second site, taking notes or printing pages as you did in step 2.

59 Critical Thinking Exercise 68: Researching the PHRStep 4 Write a comparative analysis of web sites you have visited. Include following information in your report: What entity owns or operates the PHR web site? Is the owner a nonprofit or for-profit corporation?

60 Critical Thinking Exercise 68: Researching the PHRStep 4 (cont.) Compare features offered by the two PHR. Were there any significant advantages of one over the other? Compare the two PHR for ease of use. When you have finished, give your completed report to your instructor.

61 Chapter Summary Internet is one of the key technologies impacting healthcare. It not only facilitates remote access for clinician, but gives provider instant access to medical research and medical libraries for decision support. Patients research their conditions using the Internet.

62 Chapter Summary Patients are sending to their doctors asking medical questions. EPHI, which is sent over Internet, needs to be secured. Remote provider access to EHR via Internet usually involves setting up a VPN or using SSL encryption.

63 Chapter Summary Telemedicine provides specialist consultation to patients in remote locations. Teleradiology allows a radiologist to interpret diagnostic images from another location.

64 Chapter Summary Providers are setting up secure web sites, where patients can see their medical information and consult with their doctor using secure messaging. Patient data can become a significant contributor to the EHR.

65 Chapter Summary E-visit allows patients to be treated by their regular physician for nonurgent health problems without having to come into office. E-visit gathers symptom and HPI information and creates a documented encounter.

66 Chapter Summary Patient-Centered Medical Home is a model for providing primary care. PCMH standards encourage electronic orders, results, and communication with patients.

67 Chapter Summary PHR (Personal Health Records) enable patients to manage their health by maintaining their own electronic copies of their health records. PHR is secure, private, owned, and managed by patient. Patients control who can access their records.