BASIC ELECTRONIC HEALTH RECORD (EHR) SETUP

Learning Objectives• Compare and Contrast the Various

Resource and Patient Management System (RPMS) Packages Utilized for RPMS EHR

• Delineate Functionality of Each Package• Review Basic EHR Setup

RPMS-EHR SetupComponents needed for RPMS-EHR to

function properly:• Text Integration Utility (TIU)• Health Summaries (IHS and VA)• Orders (OE/RR)• Consults• Graphical Patient Care Component (PCC)

Components• EHR Components (BEH)

Text Integration Utilities• Progress Notes and Discharge

Summaries• Package is both RPMS and EHR• Character-based (No Pictures, Italics,

Bold, Underline)• Individuals are set up by User Class• Controlled by a set of business rules

– Document Class– User Class

Indian Health Service (IHS) Health Summary (APCHS)

• Displays data stored in files• Retrieval only (No data is stored into health

summary)• Sites may customize and create their own

health summary types• Originally intended for printing

VA Health Summary (GMTS)

• Veterans Administration’s (VA’s) version• Ad hoc component to create “on-the-fly

health summaries”• May create “TIU Objects” from VA Health

Summaries

Order Entry/Computerized Patient Record System (OR namespace, OE/RR, ORD)

• Order Entry/ORD • Quick Orders• Order Checks• Printing of Orders• Delay Orders• Keys Management

Notification (NOT)• Configure all notification dealing with

orders• Notification dealing with TIU are hard

coded and can not be edited• All notification are alerts but not all alerts

are notifications• CAC can activate or de-activate

notifications

Patient list (PAT)• Set consult team list• Create patient list that are auto populated

according to the ADT movements.• CAC needs to assign or is responsible for

editing these team list when providers are hired or leave the facility

• Teams may be setup as a subscribe list, meaning that providers can either add or take themselves out of these list within EHR.

Consults (GMRC)• Setting up Consults (Internal)• Not to be Confused with Referred Care

Information System (RCIS) (External)• Tracking and Reporting Options• Can be used for Requests for Service or

Procedure as well “Consults”

Graphical Components for V Files (BGO)

• Setup of Pick Lists and Super Bills• Current Procedural Terminology (CPT) Codes

(Super Bill)

• International Classification for Diseases, Ninth Edition (ICD9) Codes (Pick List)

• Patient Education Codes (Pick Lists)

• Includes transaction codes and CPT Modifiers

• Associations may be created for CPT Codes

EHR Components (BEH)• BEH = Parts of EHR that are not “OR”• Most “OR” parameters are available on the

“BEH Menu” for Clinical Application Coordinator (CAC) configuration.

• Some parameters created specifically for the flexibility of the EHR

• Vital measurements, patient and encounter data

Clinical Reminders (PXRM)• Only used at EHR sites• National reminders• Sites must configure local tests to national• Reminder dialogs allow users to enter data

into progress notes and PCC simultaneously

• Reminders implemented separately from RPMS-EHR

CAC Setup• Make sure Medical Records staff and CACs

have necessary keys– TIU Keys = TIUZMGR and TIUZHIS

– BEH Keys = BEHOZMENU

– CIA Keys = CIAV COMPOSE and CIA DESIGN

– BGO Keys = BGOZCAC

– BIZ Keys = BIZ MANAGER

CAC Setup• Health Summary Keys = APCHZMGR and

GMTSMGR• Allergy Keys = GMRA VERIFIER and

GMRA USER

Special TIU CAC Setup• Three TIU User Classes

– CLINICAL COORDINATOR– CHIEF, MANAGEMENT INFORMATION

SYSTEM (MIS)– PROVIDER

Questions and Discussion