POP305 Flashcards
(23 cards)
Population health
Population health management involves providing comprehensive and ongoing care for patients in a given population with the ultimate goal of improving outcomes and the overall health of patients within the population. It focuses on patients’ overall well-being, including chronic disease management and preventive care, coordination of care, and support for self-management.
The episode type (HBD) record
The episode type (HBD) record is where you specify the default settings for the program, such as default status, default targets, the SDOH domains most closely associated with the program, case team settings, and more. Each program at your organization will require a new episode type. Each episode type available to a user will appear as an option when they add a new program from the Programs navigator section, or using bulk creation from reporting workbench.
Outreach Task
Outreach tasks are best when you need to prompt users to contact the patient on a recurring basis. For example, a care manager might have an Outreach task to call the patient on a monthly basis as part of a High-Risk Care Management program.
When the user is able to contact the patient, they open a Patient Outreach encounter or a Telephone encounter to document the call. Within the encounter, they use the Reason for Outreach navigator section to link the Outreach task to the encounter.
Linking an Outreach task to the encounter:
Pulls the appropriate assessments into the Outreach Assessment section.
Links the encounter to the appropriate Compass Rose program.
The completion of the task generates the due date for subsequent tasks.
New Program Target
Targets are used to document the progress of a patient’s care. Target and target template records define what documentation and decision milestones are required for a given program, as well as the due dates for these milestones to be completed.
Targets are a specific kind of task record created in the Task Editor. Targets are associated with program episodes and track information about the progress of a patient’s care, often related to regulatory requirements about the number of days or weeks it takes to complete a given task. You should build targets to track the most important milestones, or time-sensitive requirements, for your organization’s programs. You need to group the targets you create into templates so they can be automatically added to episodes. Note that you need to create a template even if you created only one target.
Auto-Completion
Compass Rose checklist tasks and targets can automatically advance to a status of complete when patients check in for appointments or when they have procedures, scanned documents, letters, or signed notes that satisfy the specified criteria. Automatic completion of checklist tasks and targets makes it easier for case managers to keep the checklist up to date and concentrate on outstanding tasks for patients.
Healthy Planet build uses orders in several ways, What are some?:
SmartSets to help care managers, physicians, and other providers close care gaps
Health Maintenance build defines which procedures satisfy a Health Maintenance topic (i.e., close a care gap)
Preference lists for placing bulk orders
Registry metrics track when patients had procedures performed or what medications were prescribed
Groupers define reusable sets of records, for example a list of statin medications or colonoscopy procedures
Ordering-Related Master Files:
When a user looks up an order, the system looks to records in either the Medications (ERX) or Procedures (EAP) master file. Put simply:
All medications have Medication Record (ERX) records, and each strength and form (tablet, suspension, etc.) combination requires its own unique medication record.
Anything you order that is not medication-related has a record in Procedures masterfile (EAP).
Order Records(ORD)
While placing orders for a patient, you spend time configuring those orders in the Order Composer. When you’ve finished modifying a patient’s order, clicking the Sign Orders saves those details in new record in a third master file: the Orders (ORD) master file.
Every signed order has at least one ORD record. In other words, the ORD master file contains all of the orders that have ever been placed in your organization. You do not build ORD records. Rather, ORD is a master file of records created dynamically by the system.
Whereas a procedure or medication record contains the default configuration for a type of order (like a Lipid Panel), ORD records contain the details about a specific order placed for a specific patient. For example, the ORD record contains information about:
- The patient for whom the order was placed
- The provider who authorized the order
- The user who typed the order into the system
- The frequency, start time, end time, and number of times the order should happen
Result Component Records (LRR)for Lab Orders
After a lab order is signed, either clinic staff (for point of care tests) or lab staff document the results. To accurately document results, we need to define what the result is, the reference range, measurement units, and other details. This information is built into result component records (LRR). For point of care tests, these result components are linked to the procedure record.
Immunization Records (LIM) for Immunization Orders
Immunizations are ordered using a medication Record (ERX).
After a provider orders an immunization, a medical assistant or nurse administers it and documents the administration details. Additionally, medical assistants and nurses need to document patient-reported immunizations, which don’t get ordered. Immunization records are used to document the administration details. For the immunization administration workflow, immunization records are linked to the procedure records used to place the order.
Configuration for Bulk Orders and Communication
When clinicians perform outreach activities from Reporting Workbench, they are using two activities that require some setup: Bulk Orders and Bulk Communication. You need to make decisions about what orders are appropriate to place using these activities and make them available to the appropriate users. You also need to define which letter templates are available for communication and make sure the two can be performed together to streamline workflows.
To further streamline bulk ordering, you can build order filter rules to ensure patients only get the orders for which they are due, and diagnosis association rules, to ensure orders placed in bulk can still be associated with patient-specific diagnoses.
Before users can complete bulk outreach workflows, you need to configure:
- Bulk ordering preference lists
- Diagnosis association rule
- Bulk order filter rules
- Specify bulk order preference list in a profile
Bulk Ordering Preference Lists:
When a clinician clicks the Place Orders button from a Reporting Workbench report, a preference list browser appears. If you want clinicians to be able to place bulk orders, you must link the desired preference list in System Definitions or in a profile if you want different preference lists for different groups of users.
A Bulk Order Preference List
If diagnosis codes should be associated with the orders placed through bulk ordering, builders need to set up the association in the Preference List Composer using a diagnosis association rule, or a default diagnosis. Those diagnoses are automatically added to the bulk ordering encounter that the system creates for each patient. However, clinicians cannot add or change diagnoses while placing bulk orders.
To set up patient-specific automatic diagnosis association with bulk orders, there are three tasks you need to complete:
- Build a diagnosis grouper, or validate an existing diagnosis grouper (VCG).
- Build a CER rule that checks whether a patient has a diagnosis in the grouper.
- Add the CER rule to the order in a bulk orders preference list.
In class, you will build a CER rule to automatically associate patient-specific diagnoses during a bulk ordering workflow.
Placing Orders Based on Patient Criteria
Patient-specific order filtering with bulk orders uses Health Maintenance to determine whether a patient is overdue for an order. Assuming you have Health Maintenance configured, there are three tasks you need to complete to use patient-specific order filtering with bulk orders.
- Build a Health Maintenance topic grouper (VCG)
- Build a Rule Editor (CER) rule that checks whether a patient is overdue for the HM topic.
- Add the rule to the order in a bulk orders preference list.
System Settings for Bulk Ordering Encounters
The system automatically creates a new encounter for each patient included in a bulk ordering session. You can determine what type of encounter the system creates, such as Orders Only. You can configure this option in System Definitions.
How Bulk Ordering & Communication Encounters Are Created
When encounters are created for bulk orders, the system uses the authorizing provider as the encounter provider. The department that is listed for the encounter is the user’s login department.
While there is a setting in System Definitions (LSD) for a default bulk ordering encounter type, the system will create different types of encounters depending on the exact bulk ordering workflow.
Bulk Ordering without Bulk Communication: If an existing encounter of the correct type is found, on the current day, in the correct department it will be re-used. If not, we always create the default encounter type.
Bulk Communication without Bulk Ordering: When patients have a communication preference of phone, a Patient Outreach encounter is created when a person clicks the Initiate Calls button from In Basket.
Bulk Ordering with Bulk Communication: When patients have a communication preference of phone, a Patient Outreach encounter is created right away and is used for the bulk orders. This encounter is left open in order for clinicians to use when calling the patient. The clinician should select the Patient Outreach encounter already created for the patient when clicking Initiate Calls from In Basket.
Health Maintenance Basics
Health Maintenance is one of Epic’s tools for monitoring and addressing patient care gaps. Using Health Maintenance, you can set up warnings to help clinicians track immunizations and routine screening tests or manage patients with chronic diseases. The system can also generate a reminder letter to be printed and mailed or sent to the patient through MyChart, or generate an In Basket message reminding staff to call the patient with the reminder.
Health Maintenance is one of Epic’s tools for monitoring and addressing patient care gaps. Using Health Maintenance, you can set up warnings to help clinicians track immunizations and routine screening tests or manage patients with chronic diseases. The system can also generate a reminder letter to be printed and mailed or sent to the patient through MyChart, or generate an In Basket message reminding staff to call the patient with the reminder.
Overdue Health Maintenance topics can also appear as Care Gaps in Healthy Planet Link, and your organization can decide which topics can be satisfied by other healthcare providers using Healthy Planet Link.
Health Maintenance is used primarily as a preventative health tool. Unlike most clinical decision support (CDS) tools, which are intended for clinicians only, the goal of Health Maintenance is to remind both clinicians and patients of their preventative health care needs. Health Maintenance works in conjunction with other CDS tools, such BestPractice Advisories and SmartSets, to provide a means to quickly perform actions relevant to addressing patient care gaps.
Setting up Health Maintenance(HM) involves creating HM topic records (HMT) and HM plan records (HMP).
Topics define the HM-related information that clinicians see in the system. Topics include configuration such as frequency for the routine care, diagnoses and procedures that satisfy the topic, and the reminder letter to send to the patient.
Health Maintenance topics (HMT) define the HM-related information that clinicians see in the system. In each topic, you can specify details such as:
*Frequency (how often the topic is due)
*Time Before Due Date to Show as Due Soon
*Time After Due Date to Show as Overdue
*Patient Outreach settings (whether to send patient reminders, how to send them, and when)
*Completing Actions (Procedures, diagnoses, and other documentation that will satisfy the topic)
There are four types of Health Maintenance topics:
- Normal
Regularly repeated (such as annually), or once in a lifetime - Sequential
A series must be completed - Seasonal
Recurs based on the time of year, rather than a regularly recurring schedule (Normal) or sequence (Sequential). - Combination
This type combines multiple topics into a single topic when multiple screenings are used to address the same preventive care gap.
Plans determine the patient populations to which Health Maintenance topics apply. HM Plans can define a patient population either by using Classic Criteria, such as Age, Sex, PCP, Modifiers, or by using Rule-Based Criteria.
Health Maintenance Plan Rule
CER rules are used widely in Epic, in many different contexts. Rules are sets of logical expressions that identify records that meet (or do not meet) criteria that you configure. You can use rule-based configuration for Health Maintenance plans to help you get the right patients on the right plans.
Rules used for Health Maintenance have a context of “Health Maintenance Plan Rule.”
Health Maintenance (HM) Modifier
A Health Maintenance Modifier is a discrete value that can be assigned to a patient. The modifier value(s) assigned to a patient can be evaluated in HM Plan classic criteria or rule-based criteria to include or exclude the patient from a Health Maintenance population.
Modifiers are nothing more than a value in an editable category list:
Category list address: EPT 18675
Building Health Maintenance
The ability to identify patient populations using criteria such as age, sex, and modifiers has existed in HM for a long time and is referred to in the HM Plan as “classic criteria.”
Using rule-based criteria allows you to use additional criteria to define patient populations and to add patients to a plan automatically. When you use Epic’s analytics registries, you can use the registry population and registry metric data to define the population for a Health Maintenance plan.
Flowsheets Activity
The Flowsheets activity has been traditionally used for documentation on admitted patients, where multiple readings and values are common during a multi-day admission. However, flowsheets are also used in outpatient workflows, especially when embedded into Navigator sections.
Flowsheet groups and rows are both built in the Flowsheet Groups/Rows (FLO) master file. They are assigned a type that dictates what information can be entered. Because of this, be sure to create records with clear naming conventions.
