The Customization Potential The implementation of the EMR system can be customized to the requirements and needs of the user environment
The ifa EMR system offers compatible modules like the LEGO concept
The Customization Potential Introduction â€˘ Every eye care clinic/office is different (specialties, clinical pathways, terminology, equipment etc.). Therefore the customization potential and - process for the EMR system is an important key for the efficiency and ROI (Return on Investment). â€˘ User input is needed for the clinical and administrative workflow. The individual terms, codes and abbreviations have to be researched and implemented into the databases and user interface.
The Customization Potential Clinical Customization • The following databases have to be checked within the implementation process: – – – – –
Patient Encounter (Visit Type) Chief Complaint (Symptoms, reason for visits etc.) Diagnosis (frequently used ICD codes) Findings and Assessments Treatment Plan
• For each category the frequently used 24 terms are needed for customizing the SmartScreen user interface. Forms for the presetting process are available.
The Customization Potential Preparation Forms
The Customization Potential Administrative Customization • The adaptation for the administration (also for interfacing with the PMS/HIS) are more complex: – Physicians and staff (codes for documentation and access) – Referring physicians (data base for addresses/letters and reports) – Billing codes (if stored in the EMR system) – Prescription forms (medications, glasses, contact lenses) – Standard letters/standard reports (for referring colleagues)
(See separate document)
The Customization Potential Clinical Customization 1: Patient Encounter • The “Patient Encounter” defines the reason for the specific visit. The terms/codes depend on the individual service range e.g.: – – – – –
CCE CEX FU PO SU
Complete Eye Exam Cataract Exam Follow Up Exam Post OP Exam Surgery etc.
• See complete list for selecting the individual codes and terms
The Customization Potential Clinical Customization 2: Chief Complaint • The “Chief Complaints” are defined as the symptoms the patient reports to the medical staff and/or the doctor, e.g.: – – – – –
BIE BLUR DECVA FB HEA
Blood in the eye Blurred vision Decreased vision Foreign body Headache etc.
• See complete list for selecting the relevant codes and terms
The Customization Potential Clinical Customization 3: Diagnosis • The coding of the diagnosis depend on the national framework (e.g. ICD 9/ICD 10) and the billing requirements. Samples: – – – –
36251 36252 AMDDR AMDWT
Macular Degeneration Dry Macular Degeneration Wet Macular Degeneration Dry 362.51 Macular Degeneration Wet 362.52
• The 24 frequently used diagnosis codes should be used for the standard template (see complete list of diagnosis codes).
The Customization Potential Sample for Diagnosis Data Entry
80% Data Entry with just a mouse click 15% Data Entry with choosing from a comprehensive code list 5% Data Entry with text (individual by keyboard)
The Customization Potential Clinical Customization 4: Findings /Assessments • The system offers complete data bases for history and exam codes (following the concept of 8 part history and 8 part eye exam). Databases are offered e.g. for history: – PO Past Ocular History – AL Allergies – FH Family History • And for eye exams: – RT Retina – MA Macula – VF Visual Fields
The Customization Potential Clinical Customization 5: Treatment Plan • The treatment plan terms depend on the eye care services and the specialty/subspecialty. Samples: – – – –
SSC YAG NPOP PLAS
Schedule Surgery YAG Capsulotomy Need pre-op Photo Plan Lasik
• These codes should be customized (see list for further samples).
The Customization Potential Customization of clinical routines (1) â€˘ For a maximum of user comfort clinical routines can be represented by preset templates (sample of retina report):
The Customization Potential Customization of clinical routines (2) â€˘ Predefined clinical pathways (e.g. tech exam for specific patient encounters) can be easily programmed:
The Customization Potential Conclusion â€˘ The customization potential supports the high efficiency and productivity of the ifa EMR system. The preparation process is coordinated by the ifa team. â€˘ Changes of the data bases and SmartScreen templates can be easily managed by the user based on a professional documentation of the functions and features of the relevant tools.