Streamlining Eye Care Orders and Workflow in the Clinic

1. IHE & YOU—How Does it Work in the Clinic? Linda Wedemeyer, MD, MS--Ophthalmologist Veterans Health Administration Los Angeles, CA

2. Mrs. Smith Arrives for Appointment • The clerk checks her in, providing demographic information to the ADT actor • ADT actor: possibly practice management system or hospital information system • ADT actor sends demographic information to the order filler or order placer • Order filler: possibly EMR • Order placer: possibly practice management system

3. Generic Eye Care Orders Created • Order Filler (possibly EMR) creates automatic orders for lensometry and autorefraction.

4. Why do we need Generic Eye Care Orders? • Have you ever heard of a physician writing an order every time a pair of glasses gets measured? • Can you guess what he would say if you asked him to?

5. So Why Do We Need Orders at All? • For Data Integrity • Right patient, right image, right data

6. How do we solve the dilemma? • Generic eye care orders • Automatic creation of orders when a patient is registered • Some of the orders will be performed, and some won’t • The tech decides which ones, as he would normally

7. What is different about a generic order? • It may or may not be executed, as decided by the technician or by some other informal process • Generic orders that are not executed will probably expire in a shorter time frame than more specific orders

8. Generic Eye Care Orders—Mrs. Smith • Again, recall that automatic orders were created for lensometry and auto-refraction for Mrs. Smith • Triggered when Mrs. Smith was registered in the clinic

9. Information Flows to Modality Worklist • Generic eye care orders cause Mrs. Smith’s demographic information to be listed on the lensometer and auto-refractor • Both instruments are acqusition modalities • This list is the Modality Worklist

10. The eye tech calls for Mrs. Smith • He brings her to an exam room, takes a history, then measures her glasses. • The tech arrives at the lensometer with Mrs. Smith’s glasses. • On the lensometer, he selects Mrs. Smith’s name on the Modality Worklist • This confirms what procedure was actually done • He measures the glasses • Measurements are uploaded by the image manager to the storage server

11. Tech decides not to perform auto-refraction • Mrs. Smith’s vision is 20/20 and she is happy with her glasses

12. What happens to the order for auto-refraction? • It expires • At whatever time the clinic determines • Time for expiration is set in the Order Filler (possibly EMR) • Expiration could be triggered by time of day, or perhaps by an event such as completion of physician documentation

13. Tech completes appropriate workup • Mrs. Smith is ready for the physician

14. Physician Sees Mrs. Smith • Takes a history • Performs an exam using multiple instruments--slit lamp, indirect ophthalmoscope, tonometer… • Some of these instruments may produce digital images—generic orders might be used as described above

15. Physician Elects Further Workup • Decides that a fundus photo and visual field are indicated • Orders these procedures • Uses either the order placer (possibly practice management system or hospital information system) • Or the order filler (possibly eye clinic EMR)

16. Specific Orders This Time • This is a physician generated order, where a specific procedure is ordered for a patient • The expectation is that these orders will be executed • They may or may not be set to expire automatically

17. Orders Created by physician

18. Orders Transmitted to Instruments • The visual field machine and the camera query the order filler (probably EMR) for the patient’s demographic information • This creates the Modality Worklists on those devices (acquisition modalities)

19. Technician Notified • Yelling down the hall • Or tech looks at orders in EMR

21. Mrs. Smith is sent to camera--Imager Selects name/demographics

22. Photos Taken—any IHE Compliant Camera

23. Images uploaded to storage server

24. With a couple mouse clicks…

25. Charge Posting—Procedure Codes • The instrument passes procedure codes to the order filler (optional feature) • The order filler maps to CPT codes • The order filler notifies the billing system (charger processor or charge poster) that a billable procedure has been completed

26. Charge Posting—Diagnosis Codes • Diagnosis codes added manually using charge processor • By physician or billing personnel • Some day we’ll automate this too!

27. What happens to studies to be read? • After the modality performed procedure step • The order filler can be configured to notify the physician that there are results to be read

28. Physician notified

29. Images now viewable

30. Image Display Actor • Desktop computer • Retrieves images from a storage server

31. Physician reviews the photos

32. And writes a report • In the future, report creation will be standardized in IHE • Once report creation is addressed in IHE eye care, automatic charge posting for the physician’s report can occur

34. Tech Calls Mrs. Smith • And brings her in to the visual field machine • Selects Mrs. Smith’s name on the visual field machine and then performs the procedure • Data is uploaded to the storage server

35. Charge Posting—Procedure Codes • The instrument passes procedure codes to the order filler (optional feature) • The order filler maps to CPT codes • The order filler Notifies the billing system (charger processor or charge poster) that a billable procedure has been completed

36. Charge Posting—Diagnosis Codes • Diagnosis codes added manually using charge processor • By physician or billing personnel • Some day we’ll automate this too!

37. The physician is notified • He retrieves the visual field from the storage server (image archive) • While sitting at his desktop computer (image display actor) • Reviews the study

39. And writes a report • Some day this will generate a charge

40. Diabetic Teleretinal Screening • Perfect example for generic orders • Every patient gets the same thing • Every scheduled patient is automatically on the Modality Worklist of the camera

41. Integrating the Healthcare Environment (IHE) Eye Care • Patient Data Anytime, Anywhere… • Standards make it happen!

42. More information…. • IHE Web site: www.ihe.net • Technical Frameworks • ihe_eyecare_tf_TI_vol1_2006_06_01 (Trial Implementation version) • ihe_eyecare_tf_TI_vol2_2006_06_01 (Trial Implementation version) • ihe_tf_rev6.0ft_vol1_2005-05-18-FINAL (Radiology) • ihe_tf_rev6.0ft_vol2_2005-05-18-FINAL (Radiology) • ihe_CARD_tf_vol2_2.1_FT (Cardiology) • Standards used by IHE Eye Care • DICOM Standardwww.nema.medical.org • HL7 Standardwww.hl7.org • IHEConnectathon Oct. 2006 at RSNA HQ • IHEShowcase at Nov. 2006 AAO Conference • Vendor Products Integration Statements