Global Chart Review Tool

The group reviewed the latest iteration of the chart review tool. Here are a summary of the group's thoughts:

• Use cases

  • Help better understand a protracted hospital course by highlighting specific events within a series of inpatient progress notes and consults,
  • Identify the salient features of a discharge summary quickly,
  • Shorten chart review for a physician or consultant seeing the patient for the first time, and
  • Identify documents that should then be exported into the viewer's own electronic medical record (EMR).

• Display feedback

  • The overview display may be easier to read if the vertical axis only showed disease condition or symptoms. If a user clicked on a specific term, the additional information (note type, medications, procedures) could then appear on the next screen.
  • The note display is also difficult to interpret when first seen. It would help if terms from different categories were aggregated by disease process with options for the user to highlight or "un-highlight" based on what the user would like to see.

The Minimum Viable Product would be a chronological listing of notes that display the assessment and plan of each clinical document with an option to view the entire note. Some members argued that without the ability to send the information to the user's preferred medical record, the service would add more time than it saves. The group was amenable to having the records delivered to a DIRECT address or directly into the user's preferred electronic medical record.

Rich shared his experience with trying to move his physicians to using a similar tool in Epic. The Epic tool displays those medications and laboratory values explicitly linked with a specific diagnosis. The user enters a search term for the software to then search against. Adoption was very slow, even with focused education. Unless there are some ways to ensure the software will be widely adopted, he cautioned us against spending too much time and money on this project.

Radiology Decision Support

Anupam outlined the CMS requirements for decision support for all CTs, MRIs and PET scans for Medicare patients starting January 1, 2018. The rule will also apply to emergency departments. For the emergency department and other areas that do not require prior authorization, interrupting the ordering workflow with the decision support tool would be acceptable if the software could update the order within the ordering EMR. The group agreed that the decision support is less cumbersome than going through a prior authorization process. The different scenarios that need to be addressed include:

• Emergency room
  • Cerner (CareConnection)
  • Cerner (Sherman)
  • Meditech (BroMenn)
• Ambulatory provider
  • Allscripts (CliniCare) *Cerner (CareConnection Hospital Owned Outpatient Department)
  • Cerner (Sherman Hospital Owned Outpatient Department)
  • Epic (AMG West)
    
  • Meditech (BroMenn Hospital Owned Outpatient Department)
• Patient arrives from an independent ordering provider's office in the community with access to Advocate resources
• Patient arrives from an independent ordering provider's office in the community with no access to Advocate resources

The group was interested in learning more about the following:

• If the ordering user already knows what test to order, can the user bypass the clinical decision support window?
• Can the application also incorporate information about medications (e.g., metformin) and/or kidney function when making an imaging test recommendation?
• Imaging facilities at hospitals currently require the ambulatory ordering providers to
  • Fax the imaging order to the hospital radiology scheduling team
  • Place a radiology referral through ERMA
  • Obtain pre-authorization
  • Give the patient a signed copy of the requisition
• Could the vendor embed the radiology decision support within the eClinicalWorks application? Many ambulatory users rely on their ambulatory EMR to complete the advanced imaging required elements.

[ ] Anupam to follow-up with the radiology vendor to see what might be possible.

Sharing inpatient test results with outpatient providers

The group agreed that the following events were worthy of notification:
* Patient admission/discharge events
* Emergency room visit, discharge
* Hospital admission, discharge
* Specific abnormal test results (lab or radiology)
* Pending test results (lab or radiology)

These methods would be preferred for communication about these inpatient events:
* CareConnection Office
* DIRECT message to generic mailbox or directly to the physician's EMR inbox
* iConnect (only available for select practices)
* PerfectServe - only intended for notification for interested providers without the entire clinical content as it is challenging to forward a PerfectServe message into an ambulatory EMR for subsequent review or action. If any physician requested PerfectServe notification for inpatient events, we would request that the physician be prompted for a secure message destination to transmit reports and additional data to be stored in an ambulatory EMR.
* Unsecure email to remind user to look into CareConnection Office
(Fax is not a preferred method of communication)

The group believes that the workflows when the ordering provider is listed on the order requisition (for a lab request to ACL or a radiology request to Advocate's radiology facilities), the results usually get back to the ordering provider. There does not appear to be any reliable process to route inpatient test results to interested ambulatory providers (e.g., primary care provider, specific consultants).

Advocate's Information Technology team is working on developing a patient-provider relationship database that can be exposed to office managers and interested physicians to make sure they receive the relevant notifications about inpatient events. As this database becomes more robust, it may become the engine that drives additional inpatient event notification.

Anupam described a process where a DIRECT message could be generated from CareNet+ to an interested party. The group was interested in a PerfectServe notification that led the user to CareNet+. Within CareNet+, the user could then select the relevant documents or results and route them to their ambulatory EMR using DIRECT or some other transport protocol. The beauty of this approach is that the receiver would have the ability to select what message would come into their ambulatory EMR instead of a computer algorithm making that decision.

Questions from the group include:

• CliniCare physicians receive tasks about patients transferring from one floor to another rather than into and out of the hospital. Could this be remedied?
• Could PerfectServe conversations be stored within each party's EMR for later review?
• How will we handle physicians without DIRECT or PerfectServe (e.g., AMG West)?

Topics not addressed during the meeting due to time constraints

Discovery around the work required to create an Advocate-wide identifier for our patients
This initiative was recently included as part of Advocate's inpatient Revenue Cycle project.

Update on CareConnection's unified Provider Directory
This work is set to start sometime in the next 4-6 weeks. There may be some outreach to specific physicians over the summer as the cleanup occurs.

Next meeting May 2nd at 6 PM CST (Lync and teleconference)