1 creating specialty-specific hpi content using ccc text file editor michael zaroukian, md, phd...

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Creating Specialty-Specific HPI Creating Specialty-Specific HPI Content Using CCC Text File Content Using CCC Text File

EditorEditor

Michael Zaroukian, MD, PhD

Michigan State University

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This session is for those who This session is for those who want to…want to…

• Create custom HPI content for any problem or symptom

• Customize HPI content by specialty or location of care

• Get HPI forms you need fast• Organize and speed HPI documentation• Automate counting of HPI elements for

E&M coding• Get automatic prose text translation

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ObjectivesObjectives

• Overview of HPI-CCC Specialty-Specific Tab– What it looks like– How it works

• Customizing CCC HPI content for your needs– Creating content– What the finished product looks like

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Specialty-specific HPI: Specialty-specific HPI: HPI-CCC FormHPI-CCC Form

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Spec-specific HPI: Spec-specific HPI: Text Translation / Flowsheet Text Translation / Flowsheet

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Spec-specific HPISpec-specific HPI

• Categories you can use– Onset– Intensity– Complains of / Denies– Up to 6 more categories of historical data

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Spec-specific HPI:Spec-specific HPI: HPI-Spec-Specific Editor-CCCHPI-Spec-Specific Editor-CCC

• Examples of other categories you can use– location– radiation– aggregating / relieving factors– therapy (effective, ineffective)– associated symptoms– risk factors– prior evaluation– PMH / SH / FH– psychosocial factors– problem-specific ROS

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Additional Features of the HPI Additional Features of the HPI Specialty Specific TabSpecialty Specific Tab

• View/Insert Prior HPI (can be specialty-specific)

• All values can be linked to Obs Terms (structured – can drive decision support)

• Even if not linked to Obs Term, will automatically calculate and check the appropriate history for E&M Advisor– brief = 1-3 elements– extended = 4 or more

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Before You Request a Before You Request a New SS-HPI FormNew SS-HPI Form

• Check the catalog for an existing HPI problem or symptom

• May be one in more than one specialty

• If you see one you like, ask to have it put in your specialty drop-down list

• If you see one you want to edit, start with the existing one and make your edits

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Building SS-HPI Clinical ContentBuilding SS-HPI Clinical ContentStarting with a WorksheetStarting with a Worksheet

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Building SS-HPI Clinical ContentBuilding SS-HPI Clinical ContentCompleting the WorksheetCompleting the Worksheet

• Start with the desired HPI end result– Hypothesis-driven questioning?– Evidence-based history?– Inform decision support?– Relevant PMH, FH/SH, ROS– Facilitate E&M coding and compliance?

• List the diagnoses to be considered • Decide what questions to ask

– Clinician input ± knowledge source needed

• Organize into historical categories (Onset + Intensity + 8 other categories)

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Categories and Number of Required Categories and Number of Required Elements for E&M CodingElements for E&M Coding

• Timing• Severity• Signs and symptoms • Quality• Location• Duration• Modifying factors• Context

*Listing status of 3 chronic problems counts as comprehensive HPI

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SS-HPI Use Case Example:SS-HPI Use Case Example:DiarrheaDiarrhea

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Building SS-HPI Clinical ContentBuilding SS-HPI Clinical ContentDiarrhea Worksheet - DraftDiarrhea Worksheet - Draft

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Building SS-HPI Clinical ContentBuilding SS-HPI Clinical ContentWinnowing List to 8 (if Needed)Winnowing List to 8 (if Needed)

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Testing Your New SS-HPI: Testing Your New SS-HPI: Step-by-stepStep-by-step

• Log in to EMRLog in to EMR• Select a Select a

patientpatient• Start Start Chart Chart

UpdateUpdate– *1-CCC-V8*1-CCC-V8

• Select Select Specialty-Specialty-SpecificSpecific Tab Tab

• Look for your Look for your new problemnew problem

• SelectSelect categoriescategories• Click Click RefreshRefresh

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SS-HPI Test DriveSS-HPI Test Drive

• Select Select OnsetOnset, , IntensityIntensity and 1+ and 1+ items from items from each each categorycategory

• Click to Click to Insert TextInsert Text

• Inspect Inspect Final TextFinal Text for accuracyfor accuracy

• Inspect Inspect elementselements

• View noteView note

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Questions and CommentsQuestions and Comments