NEXTGEN CHRONIC CONDITIONS VISIT DEMONSTRATION

1. NEXTGENCHRONIC CONDITIONS VISITDEMONSTRATION This example demonstrates some workflow options for a visit that primarily deals with the management of chronic diseases, since this type of visit is very common, but doesn’t really fit into the model of an acute problem-oriented visit. A variant of this workflow can be used in most all specialties. This has been prepared with EHR 5.7 and KBM 8.1. Subsequent updates may result in cosmetic or functional changes. Use the keyboard or mouse to pause, review, and resume as necessary.

2. Introduction • Many visits in any specialty are for managing chronic diseases, such as diabetes, hypertension, or hyperlipidemia. Even less serious illnesses, like atopic dermatitis or allergic rhinitis, fall into this category. • However, taking care of problems like this doesn’t really fit into the “duration/frequency/severity/location/etc.” model of the typical HPI popup in NextGen. • To help with this, there is a Chronic Conditions HPI popup, which is designed to be a more appropriate way to address the HPI component of a chronic disease visit. While this is useful, there are still a few quirks to work around. • This demonstration will provide some pointers on how to navigate a chronic disease visit.

3. The Chronic Conditions HPI popup will be launched if any of the following chief complaints are activated: • Chronic conditions • Diabetes (follow-up) • Heart disease (follow-up) • Congestive heart failure (follow-up) • Hypertension (follow-up) • Hyperlipidemia (follow-up) • Kidney disease (follow-up) • DM/HTN • DM/lipids • But other chronic diseases may be addressed through the Chronic Conditions HPI popup as well.

4. Guidelines • There is now a Guidelines tab that replaces the previous Protocols tab. • The Guidelines tab is a work aid to help address evidence-based recommended care for health maintenance & chronic diseases. • Due to some technical problems with this tool, to date we have not emphasized & taught the use of Guidelines. But we are working on this, & hope to introduce this to our usage of NextGen as soon as possible.

5. The nurse starts on the Intake tab. Our patient is here for follow-up on a number of chronic problems (which can be viewed on the Histories or Summary tabs): COPD, DM, hypertension, hypoparathyroidism, obesity, and tobacco abuse. She could try to enter all these as Reasons for Visit, but it would be easier for her to pick Chronic Conditions.

6. The nurse opens clicks on the Intake Comments link & enters info she’s gotten from the patient about today’s visit. When done, click Save & Close.

7. Moving down, the nurse enters vital signs and reviews/updates the med list and allergies as necessary.

8. The clinic has standing orders to check a sugar and HbA1c on diabetics, so the nurse performs these via the Standing Orders button and popup.

9. Next the nurse moves back to the top & goes to the Histories tab. Here she reviews the Chronic Conditions List and the Medical/Surgical/Interim List. There are no changes to the Chronic Conditions List, so she’ll click Reviewed. But this is a good time to review the risk indicators. Tobacco, HTN, & DM are set up, but CAD is not. Click Configure.

10. The patient doesn’t have documented coronary artery disease, so we’ll click No. Note that you could also document tobacco status here, but we’ll illustrate another way to do it below. Either way works the same. When done click Save & Close.

11. The nurse obtains history that the patient recently had a diabetic eye exam. Click Interim History.

12. Add this information and click Save, then Close.

13. Click the Reviewed box for this section. There are no changes in the Family History, so we’ll click the Reviewed box here as well.

14. Move down to the Social History & review that as well. The patient continues to smoke, & there are no other changes, so click the Reviewed box. But let’s do one other thing here. Click the Add button.

15. By office policy, the nurse advises the patient to stop smoking, & clicks the Tobacco cessation discussed checkbox. One suggested workflow would be to say: “Of course, we advise all our smokers to quit smoking. Would you like to talk to the doctor today about help quitting?” If the patient says yes, add Smoking Cessation to today’s Reasons for Visit. If she says no, say: “OK. Let us know when you’re ready.” The patient says no, so just click Save & Close.

16. When data recording is done, click the Intake Note button.

17. A note is generated summarizing the reason for today’s visit & the patient’s past medical history. The provider will review this note at the start of the visit to constitute the necessary history review for coding purposes, & to provide a starting point for documenting the HPI.

18. To indicate the patient is ready for the provider, hover over the Navigation Bar & click the Tracking Icon. Enter Room Number & Status, then click Save & Close.

19. After being notified the patient is ready, the provider will typically begin the encounter on the Summary tab. Here you can click on the headings on the left & review chart data by these categories. (Alternately, the provider may prefer to review this on the Intake & Histories tabs.) This is also a good time to review the nurse’s Intake Note, & perhaps expand the last encounter to review the last visit note.

20. Next move to the SOAP tab. It’s always good to glance at the Sticky Note and Alerts (which are empty in this example), & the Risk Indicators. You can review the nurse’s Intake Note again here as well.

21. You can edit or delete the Introduction if desired. One way to begin documenting the HPI is by clicking on the chronic conditions Reason for Visit.

22. This brings up the Chronic Conditions HPIpopup. There’s a lot here, so let’s get oriented.

23. Several aspects of the chart are summarized here in a small format: The Chronic Conditions List, Vital Signs, Review of Systems, Lab Results, Med List, & Guidelines. While it can be handy to have this all together here, you may find it more comfortable to review these in other areas of the chart where they are presented in a more spacious format.

24. You can also record Home BPs & Sugars that the patient reports, though you may find it a bit tedious, time-consuming, & impractical to do so.

25. Also note the Address button under Chronic Conditions. We’ll click that & take a look.

26. The idea here is to select a Chronic Problem at the top, then Add Comments by typing or using My Phrases. After that, you click Add to save these comments & add that Chronic Problem to Today’s Assessment List.

27. It’s a good idea on the surface, & some providers may wish to use it, but it has some flaws & limitations that have dogged us as long as we’ve been on NextGen. For one, if you want to make an addition or change to something you’ve entered, you have to clear it & start over. If you’re trying to record an HPI in real time, this makes it difficult, since patients are always jumping from one subject to another. For another, the My Phrases list is flawed here. So it is my recommendation not to use this. When done click Save and Close.

28. The comments you added will be posted here. Caution: Do not try to type in this box. It appears to let you, but whatever you type here will NOT be saved. Most users will find it easier to skip the Address method, & just type in the Comments box. It is annoyingly narrow, but you have 1000 characters to work with. When done click Save and Close.

29. The comments you entered display here. But there is a much simpler way to document your HPI entries. Click Comments.

30. Here you can document HPI comments for all problems all at once, & if there is a mixture of acute & chronic problems, it is easy to jump from one to another as the patient gives you the story. And you have access to My Phrases for all of this. And there are at least 1000 characters available for each box, so you’re unlikely to run out of space. Most people will find this a far more efficient way to document the HPI for both acute & chronic problems. When done, click Save & Close.

31. Note that you’re not limited to using just one method. Entries entered both ways display on the SOAP tab.

32. Moving down the SOAP tab, you’ll next come to the Review of Systems. For an established patient, you may not need to do this at all, if you’ve covered everything in the HPI. (For a new patient, you’ll need to document a ROS, at least for coding purposes.) If you need to document the ROS, the best place to start is the age & gender specific one-screen option you find at the bottom of the list. Here we’ll click Primary Care ROS - Female.

33. From this screen you can make entries for multiple systems. And if you need to go into more detail, clicking the heading of each system will take you to the appropriate detailed ROS for that system. You can save & recall ROS presets. When done click Save and Close.

34. Continuing down the SOAP tab, you’ll see the Vital Signs and Physical Exam. Similar to the ROS, you have an age & gender-appropriate One Page Exam, with access to personalized preset exams. Also note this button. Click Office Diagnostics.

35. This is where you’ll find the results of any office tests the nurse has done for you earlier. When done click Close.

36. As you move to the bottom of the SOAP tab, you’re provided access to the Assessment/Plan section, the Order Module, & the Medication Module. One might tackle these in any order; for the sake of this demonstration we’ll start with Assessment/Plan. Click Add/Update.

37. Here you can select diagnoses in multiple ways: From the Diagnosis History, Active Chronic Problems, My List, or one of several ways to search for a diagnosis from scratch. Since we’re dealing with the patient’s chronic problems today, I’ve just clicked on them one at a time from the Active Chronic Problems list to add them to Today’s Assessments. When done click Save & Close.

38. You are taken to the “My Plan Suite,” a collection of popups that give you various ways to place orders and document plans. We’re currently on the My Plan tab, which can be useful, but let’s click Plan Details instead.

39. You can also use the Diagnostics or Referrals tabs to order imaging or referrals; we won’t do that here. The Plan Details tab gives you the chance to type instructions/plans for each problem. You can also use My Phrases to insert text that you use frequently. Use one or more of the boxes, or discuss several problems in one box—whatever is easiest & clearest. When done click Save & Close.

40. Your assessments & plans display on the bottom of the SOAP tab, though you may have to scroll up or down to see them all. Next, let’s refill the patient’s meds. The Med Module can be reached via any of the 3 methods you see circled.

41. For the purpose of this demonstration, we’ve renewed all meds as listed. You would next click the ERx button to transmit them to the pharmacy, then close the Med Module.

42. If we were going to order any labs, we could do that through the Order Module, which can be reached via either of the icons circled here. That is covered in other lessons, so for this exercise we’ll not order any labs.

43. Before the patient leaves, we need to generate a summary of today’s visit. Click Patient Plan.

44. Edit the note further if desired, then click the Printer icon. While there are several alternatives, often you would print this to the checkout desk for the staff to give to the patient as she leaves. When that is done, close the Patient Plan & return to the SOAP tab.

45. Now move to the Finalize tab to select the visit charge. You can do this by scrolling back to the top, or by clicking the EM Coding link here.

46. While you can manually select your visit code, let’s let the coding assistant help us. Click Moderate complexity, then the Calculate Code button.

47. Code 99214 is suggested, which is appropriate. Click Submit Code to accept this. On this screen residents will also need to select Submit to supervising physician, picking their attending in the ensuing popup, for review of the visit note.

48. In addition, a resident needs to view encounter properties to set the Supervising Physician for billing purposes. Right-click on the encounter folder and select Properties.

49. The resident doctor clicks the Supervisor dropdown arrow, and selects the attending. In this example, we’ll use Dr. Duffy.

50. Click OK to close the popup.