AHLTA Tips and Tricks: What You Need to Know Today!

1. AHLTA Tips and Tricks:What You Need to Know Today! USAFP Conference March 2007 Mark E. Stackle, MD AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

2. Outline • Creating and editing order sets from A/P module • Dx Prompt/Prompt • Default Templates • Consult Log (Time permitting) • Patient Handout AIM Form (Time permitting) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

3. Creating Order Sets In The A/P Module • Order sets can be huge time savers! • Enables you to select commonly used orders from pick list instead of having to search each time • Order sets can be created and edited from the A/P page within your normal workflow • You can easily modify orders in your order set to adjust for an individual patient (i.e. type impression for x-ray or consult order, change sig for medication orders) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

4. To edit the Order Set of an ENC template in the current encounterA/P module – 1) Select template you wish to modify in the drop down menu OR 2) If you don’t have a template yet, start one by following the steps on the next slides Selected Template AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

5. 1) Go to appropriate order module and search for the medication, lab or radiology study 2) Select appropriate order 3) Click on Save To Queue IMPORTANT: You must select Save To Queue, NOT Submit For example, order UA AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

6. You will know you are successful if the order appears here and is Underlined. Repeat previous steps to add as many orders as you would like. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

7. 1) Once you have completed entering your orders and saving them in the queue, go to the Order Sets tab 2) You should see the new orders you entered at the top and underlined (Any previous orders in the order set will be listed below) 3) Select Save As Order Set AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

8. 1) From this menu, select the template you wish to add the orders to. Make sure that the name appears below after Template Name 3) Once you have the correct name in place, select SAVE 2) If you are creating a brand new template, simply type in your desired template name. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

9. This menu will appear if you are editing an existing template, not if you are creating a new order set From this menu, Select ADD TO. If you select Replace, you will lose all your previous orders AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

10. 1) You have now successfully added an order to your Order Set without leaving the A/P module. (*You can finish ordering the tests/meds you had Saved To Queue by clicking SUBMIT ALL or you can Delete them.) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

11. 1) To access your newly modified Order Set on the next patient, simply select your template from drop down menu here and go to Order Set tab. 2) Select orders by clicking boxes, then click SUBMIT 3) To modify an order, pick select box on left and modify box on right—you will get prompts to make modifications. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

12. Additional Suggestions • Take a minute to list what orders you plan to add. The orders you add will appear in the sequence in which they were ordered so if you want to group orders by type (lab, xray, med), then group those together. • Note: Long term medications should be renewed from medication list to avoid adding duplicate meds to patient’s medication list. • Future: New enhancement will allow the building of order sets and full templates without being in an encounter (present in build 3.3) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

13. Default Template • This function allows you to set an encounter template to load automatically as soon as you open a patient’s encounter. • An encounter template can include an S/O template, diagnosis list, procedure list and order set • Can still load other templates if needed • Many of the new functions in future builds of AHLTA will greatly benefit users who have a default template AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

14. Start in Template Management with open encounter AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

15. Select and right click on the template that will be set as the default template. A drop-down list appears. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

16. Select Default Encounter Template on the drop down menu to set Default. (Can undo a Default Template by selecting Reset Encounter Template) **Important: A template must be saved as a personal template. To save as personal template, highlight desired template, then click Save As in top bar and rename. Then follow steps above to make template the default template. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

17. The selected template is designated as the Default Template. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

18. The Default Encounter Template is automatically loaded in the S/O and A/P module when either module is accessed. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

19. Prompt and Diagnosis (DX) Prompt • Prompt and DX Prompt are useful tools to populate your note with symptom or diagnosis relevant terms • Prompt works better for symptoms while Dx Prompt works best for formal diagnoses (Cough vs. Acute Bronchitis) • Prompt and Dx Prompt both bring up HPI, PMH, ROS and PE terms related to the desired symptom or diagnosis • Easy to filter number of terms to choose from using List Size button (3 levels = small, medium and large) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

20. Prompt and Dx Prompt can only be used from the Medcin Tree page For AIM Form users, the process to access Prompt or Dx Prompt is outlined on the next slide… AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

21. From an AIM form, you cannot access Prompt or Dx Prompt directly, but can access them by going to the Note View which will take you to the Medcin Tree page (see prior slide) To get to Prompt and Dx Prompt, Select NOTE VIEW AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

22. PROMPT FUNCTION 2) Select Prompt button 1) Highlight symptom you wish to expand (Could use Find Term to locate symptom if needed) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

23. Now select HPI, PMH, ROS and PE to yield related bullets List of bullet items can be increased/ decreased using List Size (up to 3 levels) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

24. Note relevant PMH items for cough AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

25. Note relevant Physical Exam bullets for cough AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

26. DX Prompt • Click on the Dx Prompt button at the top of S/O module. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

27. 2. Type ‘Acute Bronchitis’, and click ‘OK’ AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

28. 3. Select ‘Acute Bronchitis’ and click ‘OK’ AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

29. 4. Notice that HPI, PMH, ROS, and PE terms related to Acute Bronchitis come up. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

30. 5. Click on the ‘List Size’ button to increase/decrease number of terms shown. (3 levels) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

31. 6. Now, repeat steps for PMH, ROS, PE, and tests as necessary. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

32. If you wish to return to an AIM form that you were using after using Dx Prompt or Prompt, then select the Back Button Back Button AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

33. Questions? AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

34. Consult Log—How this Helps • Provides an easy to use menu to track status of consults to include being able to see: • Status of consult (has it been booked, has patient been seen, did patient no-show) • Access completed consult easily • Way to see all consults and pertinent info easily (reason for consult, location of consult) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

35. To access Consult Log, select from folder list AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

36. 2) From this box, select manner which you would like to track consults to include dates, status of consult 1) Click here to select parameters 3) If you always want to see consult display the same way, select this as default. 4) OK when finished. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

37. 1) Can sort by any of topics listed on this bar. (Status, Dx, Clinic, Appt Date, etc. . .) 2) Double click on consult and completed encounter will load if available. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

38. 1) Select HISTORY and you can track date/time of progress. (see box below) AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

39. Patient Handouts Template • A great tool to quickly access patient education materials directly through AHLTA! • Enables easy documentation into progress note that patient education occurred • Can be used by any member of the health care team (RN, LPN, Medic, Patient Educator, Provider) • Handouts available in English or Spanish • Many handouts have great pictures • Can link easily to other related handout information • Usage Directions: • Go to S/O Template Management from the S/O Module • Search for: all--patient handouts • Select and Add to Favorites for easy access in the future AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

40. General patient education topics across top of form AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

41. Selecting Left bullet will document that educational materials were given to patient AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

42. Documentation is added automatically under Counseling/Education AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

43. Selecting RIGHT “?” button will direct you to the Health Library patient handout that can be printed and given to patient. AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

44. Many are available in Spanish as well AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

45. *Information includes Causes, Risks Factors, Symptoms… *Blue text provides link to other related diagnoses or procedures *Some procedure topics also include short summary video of what the patient should expect with the procedure AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

46. *Also includes Diagnosis Methods and Treatment Options (both prescribed and OTC) and Prevention Strategies *Can be printed directly from site and handed to patient at the close of the visit or emailed to patient AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”

47. Questions? AMEDD AHLTA Program Office “Enhancing The Excellence Of Military Health Care”