Centers for Dialysis Care Electronic Medical Record

1. Centers for Dialysis CareElectronic Medical Record Clarity: Physician & APN Training Module

2. Introduction Comments and Notes Table of Contents

3. Introduction • You may view the slides in order, or pick a topic by double clicking the box on the table of contents. Return to the Table of Contents by double clicking the box next to page #. • The purpose of this presentation is to teach you • Login in at the CDC facility • Login remotely over the Internet using the Citrix Server • Basic navigation from the ClarityHome Page • The Message and Task Application • Signing Orders • Documenting face to face rounding “Real-Time Charting (RTC)” • Documenting an Office Visit (MD office visit – electronic) • Documenting an Office Lab review (MD office lab review – electronic) • Writing Progress Notes • Problem Lists • Medication Lists • Writing Orders other than orders in the Physician Tab of Real-Time Charting • The Clarity Reports • Built in ClarityHelp Functions • Frequently asked Questions from CDC MD users

4. Notes • You must have a CDC User ID and Password to use the CDC electronic medical record. • If you are new to the CDC information systems, or if your current DiProton User ID and Password do not work in Clarity, please call or email the Help Desk to set up a user account at (216) 229-6170 x149. • Claritydoes NOT support any browser BUT Internet Explorer. • The presentation assumes you know basic Windows and Internet Explorer navigation techniques. If these terms are foreign to you, please call the Help Desk for assistance. • If you view this presentation on a computer connected to the Internet, clicking on the URL links (ex: www.cdcare.org) on the slides will take you to the actual site on the Internet. • We will complete the roll out of Clarity to all of our facilities by the end of 2010. Some of the screens demonstrated in this presentation may be slightly different from the production application due to enhancements made as we go along. The essential functionality and navigation process will not change. • Throughout this presentation the text “NPOrganizationE-Signature” denotes a path to take from the Navigation Pane through the sub-menus. In this case to get to the E-Signature screens from the Navigation Pane (NP). • Clarityuses ‘drop down’ boxes for selection choices. Touching the down arrow reveals the choices. Scroll down and click your choice. Click ‘GO’ or ‘Search’ to finish.

5. Note to MacIntosh (Apple) Users While Clarity requires Internet Explorer, when you connect over the internet you are connected to CDC’s citrix server. When you launch the application you will be using the Internet Explorer application within CDC. The Problem for most Mac users is to launch the Citrix client successfully. When you connect to www.cdcare.org you will see the following window. If you try to start Clarity and you get a message about Citrix, download the “client” noted in the message window. Also, be sure you have the most recent version of Safari or Firefox.

6. Table of Contents cdc help desk

7. Connecting To the CDC EMR Login at the Facility Login over the Internet

8. General Comments about Login • You may use Clarity from any computer in a CDC facility. • You may use Clarity over the internet using the CDC Citrix Server. • In either case, the process will take you to the same Clarity Login screen and Home Page. • Clarity functions the same way irrespective of how you launch it. • You Login to the Home Page (Welcome Screen). If you navigate to other Clarity sections you may be asked if you wish to continue the Login Session (just say yes). If you are timed-out of the Login, you will not lose the work in your active window if you are doing a checklist or Real-Time Charting.

9. Login from CDC Facility Double click on ClarityLogin

10. Login from CDC Facility Note: Both User ID and Passwords fields are case sensitive Type in your User ID (Press TAB to go to password box) Type in your password Click the “I Accept” button or hit ENTER to complete login

11. Login from the Internet Type http://www.cdcare.org/ in your address bar in the browser Mouse Over either to “CDC Users” Double Click “CDC Citrix Login”

12. Login from the Internet Type your User name and Password as usual (case sensitive) You can expedite this process by going directly to  https://citrix.cdcare.org/ You can also “drag” this URL from the address window to your desktop creating a Desktop Short Cut

13. Choose this Clarity icon (NOT the desktop icon) Login from the Internet

14. Navigating through Clarity Home Page Window Control

15. YOUR NAME Clarity Home Page Physician USER Your Name and system notices You have 1 new message and 1 new task.. Welcome Screen and News area Navigation Pane Click for sub-menus Messages and Tasks Notification

16. YOUR NAME Clarity Home Page, Messages and Tasks USER, Physician Physician USER Clicking on the Message or Task Icon will open the indicated window in the Welcome Screen. Clicking on the date of the Task or Message will reveal the contents. Respond as you would to any email. CDC has not developed a procedure for these functions. Messages sent via this utility stay within Clarity. They do not go to the CDCare.org e-mail system.

17. Navigation: “Select a Patient” • All patient specific actions (write or review a note, checklist, order, or report) begin with the same patient selection screen shown on the next slide. • You need only select clinic, patient, and status if you are looking for one patient. If you are looking for groups of patients you can add more filters from the drop down menus. • If you get a “no record found” message, you may have chosen the wrong facility or status (choosing “All” under status will find patients currently in the hospital or pending transfer in). • If you are switching from patient to patient in different facilities, the program may revert to your default clinic. • A good way to find all your patients at a given facility is to specify the clinic, choose “All” in the status box, choose your name from the “Primary Nephrologist” drop down menu and click “Search.” This action will list your patients. You can use the printing function on your browser to print the displayed page from “print preview.”

18. YOUR NAME Navigation: “Select a Patient” Click “search” to find the patient Choosing yourself from the Primary Nephrologist drop down list and not specifying a patient, will generate a list of all your patients in the selected clinic Choose “ALL” unless you are sure your patient is not in the hospital or “pending” If your search returns “No records found,” check the Clinic choice, Status and spelling of name

19. YOUR NAME Navigating through Clarity • From the Home Page choose “Patient” on the navigation pane. • Choosing “Patient” will display a sub-menu of choices within the Patient specific applications. • In this case “immunizations” were selected. • Choosing any of the values in the Patient sub -menu will take you to a patient selection screen. Physician USER

20. Notes On the ClarityWindow Control • The page that shows the navigation pane and the Welcome message is the Home Page. • When you open a file from the navigation pane, some will open in the area of the welcome message, some will open as utility on their own page. • Those that open in their own page, will not have a navigation pane. • In this case, the Home Page (Navigation Pane) may be in a window behindthe new window. • You can appreciate the sequence by toggling the window size button on the Internet Explorer Title bar. • This perspective is demonstrated on the next few slides. • You LOGOUT of the home page. You merely close the other types of pages.

21. Toggling this icon will close the page. If you close the home page, it will log you off Clarity. Closing pages without the navigation pane will not log you off clarity. YOUR NAME ClarityWindow Control Clicking this icon will toggle between a full screen and scalable window. In the full screen mode, the other windows will be behind (not lost or closed). See next slide. Clicking this icon minimizes the window and puts it down on the “start” bar on your desktop. Bring it back by clicking on the title

22. In the scalable mode, you can resize the window by ‘click dragging’ this corner to change the vertical/horizontal dimensions. Clarity Window Control Both of these windows are in the scalable mode. Toggling these boxes will bring them to the full screen mode putting the other window behind.

23. Signing Verbal Orders E-Signature

24. YOUR NAME Clarity E-Signature (NPOrganizationE-Signature) Physician User Physician USER You have 1 new message and 1 new task.. You sign your verbal orders via this path to the screens shown next.

25. NPOrganizationE-Signature Select Clinic and Status Click Search Orders are displayed one page at a time Click reject if you did not give the order Clicking this box checks all the orders on the page, otherwise click one order at a time Navigate from page to page Review all the orders. Check one at a time or all by checking the box on the first row. Type your User Name and Password. If you wish a copy of your signed orders, click Show Report. Click “Sign Selected” (everything you checked will be signed, or the whole page if you checked the first box. Go on to the next page and repeat the process. If you ‘reject’ a medication order, it is placed on hold. Other rejected orders are cancelled. The facility runs a ‘rejected order’ report. If you see numerous orders that you did not give or do not recognize, please notify the Facility Manager.

26. Patient Progress Notes Reviewing Patient Notes Writing Patient Notes

27. Clarity: Patient notes • There are 2 ways to write a note in Clarity: • A ‘free text’ note (NPPatientNotes) A typed text note with a “TYPE” drop down choice list, a summary line and a text insertion window. Starts, as do all Patient choices at the “Select Patient” screen. • A ‘Check List’ (NPPatientPatient Checklists) An “interactive” note that incorporates formatted text, current data from the dialysis and laboratory results and free text insertion windows. Once completed, it remains in its list form or can be printed as a report. While their content is different, they all work the same way. • We will discuss the Office Lab Review, Office Visit, and Real Time Charting Physician Note in this presentation.

28. Clarity: Free text patient notes. • You can review, print and write patient notes from NPPatientNotes. • You can ‘import’ text notes from the computer clipboard into these notes. • You can review notes written from checklists. • Orders written from NPPatientPhysician Orders are reviewable here. • This path will take you to “Select a Patient” if you are not already working with a patient. • The next slide shows index screen after you have selected a patient.

29. Clarity: Reviewing Patient Notes You can change patients by clicking here. By using “type” and/or “date” filters you can look at specific notes. In this case all the MD Office Lab Reviews for this patient are listed. Clicking “Notes Report” displays the content of all the progress notes in chronological order. Clicking on the column heading (in any table like this in Clarity) will sort the rows by that column. Review an individual note by clicking on the date.

30. Clarity:WritingPatient Notes By clicking on “Add New” you can write a note on the patient listed at the top of the page.

31. Date and Time stamps are supplied. Choose a type from the drop down list. In this case “Hospital Progress Note” is chosen. Clarity:Writing Progress Notes The note can be attached to a dialysis treatment by clicking here. ‘Grayed’ out fields are not active in the note writing screen. Patient undergoing evaluation for GI bleeding …etc. Type a summary of the note. Then type your note in the note entry box. When finished click “Add.” Any text that is on the computer ‘s clipboard can be pasted [Ctrl-V] into this space such as discharge summaries, op notes, x-ray reports etc.

32. Problem Lists Multidisciplinary Problem and Diagnosis List

33. Clarity: Problem List (NPPatientProblem List) • Problems can be medical diagnoses, or active care plan issues. • The completeness of this list will support co-morbidity documentation under the new bundled payment system. • All disciplines can enter and modify problems. • Problem List report: NPPatient ReportsProblem List • The problems are printed on the Problem List Report. • The following slide shows how to add, modify (update), or delete a problem.

34. Clarity:Problem List Maintenance NPPatientProblem List NPPatientReportProblem List • “Add New” or Update (by clicking on) problem • Choose (or change) the category (organ system) • Indicate whether active or not • Free text comment or explanation • Put ICD9 code (search via “Select” ICD-9). Text Automatically displayed. • Indicate if you wish the problem displayed • Place a start (or supply stop) date on reports • ”Add,” “Submit,” or “Delete” • Problem List Report Looks like this

35. Medications & Allergies Medication List Medication Report Patient Allergies

36. Clarity: Medication List (NPPatientMedications) • Staff enters orders for medication starts, stops, or changes at NPPatient Medications • Either MD’s, or APN’s, or Staff can enter Medication Allergies. • Allergies (NPPatientMedication Allergies) are displayed both on the List and the Report • MD’s and APN’s should place medication orders in NPPatientPhysician Orders (or RTC orders) • Once the staff enters the order, it will display on the Medication List Report (NPReportsPatient Reports  Medications)

37. Clarity:Medication List and Report NPPatientMedications NPReportsPatient Report Medications • Displays Allergies • Choices for Status of Medication • Click on Med for order details and history • Not formatted for printing and filing in office record. • Printed version suitable to file in office chart • Run for a defined date range • Allergies and date of last med review displayed • Dose history of meds given during dialysis listed (for date range)

38. Clarity:Medication Allergies • Add or update a medication allergy • Find medication in “Select Medication” • Specify the type of reaction • “Add” or “Submit” to display on medication list and report • Clicking “Update Allergy etc…” will return an “Access Denied” error message (don’t do it).

39. Writing Notes Using Checklists Checklists Office Lab Review: Checklists: Office Visit

40. Clarity: Checklist (NPPatientPatient Checklists) • From the Navigation Pane chose Patient • From the Patient Sub Menu choose Patient Checklists • On the next screen you will chose what checklist you wish to use

41. Clarity: Checklists, Office Lab Review Choose “MD OFFICE LAB REVIEW (ELECTRONIC) & click “GO.” The next slide shows the OFFICE LAB REVIEW check list. Note that the Check List opens in its own window. There is no Navigation Pane on this window. Clicking the “X” box in the upper right hand corner will close this window only. The Claritynavigation pane may be behind this window if you have not toggled the scalable option. You can print this checklist to document your review in your office record. YOU CANNOT PUT ORDERS ON THIS CHECKLIST. That functionality is in development. To write orders you must go “NPPatientPhysician Orders”

42. Clarity: Checklists, Office Lab Review After you have signed the note, you can print it for your records. Select the appropriate Clinic and Patient from the drop down boxes. Select your name from the Physician UPIN drop down box. Type month of the data reviewed. You may review previous notes by using the History drop down menu. Go through the list responding to the prompts. Clicking on text like “View BP trends report” will display the most recent BP data in a PDF page. Close the page after you review it. Enter free text as you wish in the adjacent “Notes” column. Indicate whether the patient is stable or unstable (and the reason for the unstable status). Sign the note with your User Name and Password. If you wish to write orders, go to “NP  Patient  Physician Orders.” Go on to the next patient by changing the Name and Clinic in the selection boxes.

43. Clarity: Checklists, MD Office Visit • From “NPPatientPatient Checklists” • Choose “MD Office Visit (electronic)” • Choose the patient from the “Select Patient” screen. • Complete the check list as noted in the next screen. You may document your H & P on this check list. You can review dialysis, BP, medications, and cumulative laboratory results. You can print this report to place in your office record. As of yet, you CANNOT write orders in this checklist. You can write orders by “NP  Patient Physician Orders.

44. Clarity: Checklists, MD Office Visit Choose the Clinic and Patient. Choose your name from the MD list. Record the CC, PI etc. in either of the text entry boxes (Value or Notes). View the Linked Reports. Comment in the adjacent Notes column. Record your Exam by clicking the organ system and adding the observations in the adjacent Notes column. Complete your assessment and plans. Sign with your User Name and Password. Print the report for your office records. To write orders you must go “NPPatientPhysician Orders

45. Writing Orders Orders not Associated with Dialysis Real-Time Charting

46. Clarity Writing Orders (NPPatient Physician Orders) • From the navigation pane chose “Patient” • From the Patient Sub-Menu chose “Physician Orders” • Select Patient from the “Select Patient” screen • The next screen is the physician order panel.

47. Clarity Writing Orders (NPPatient Physician Orders) You can review existing orders by clicking on the order’s date. You can change patients by clicking the “Change” box to bring up the “Select Patient” screen. You can add a new order for the patient listed by clicking “Add New” Clicking “Add New” brings up the screen shown in the panel to the right. The date and time stamp are supplied Write a summary of the order in the “Summary” box. Write the order(s) in the text entry window. You may write as many orders as you wish. Please put each order on its own line. Please use the standard hospital order writing conventions. No abbreviations. “Increase Dry Weight to 68 KG” NOT “ dw to 68.” Click “Add”. If the “Add” button is not displayed, you cannot enter the order. You are likely in an some other user’s login. These orders are checked twice a day. You should call the facility if the order you wrote is urgent or if it pertains to today’s dialysis.

48. Dialysis Rounds The Treatment Menu Rounding Physician Dashboard Real-Time Charting

49. Clarity:The Treatment Menu • Treatment History lists an individual patient’s treatments. You can click on the date to see the treatment. • Rounding Physician Dashboard (see next slide) lists your patients for that day. This is useful place to plan your rounds. • RTC Status states the current status of dialyzing patients. • Real-Time Charting (RTC) is where you do and document your face to face rounding. • These as table format reports. Clicking underlined text opens the treatment or patient dialysis RTC record.

50. Clarity:Rounding Physician Dashboard One, Patient Two, Patient Three, Patient Pick your name and today’s date. “Search” will list all patients assigned to you. Clicking on the patient’s name will open their RTC record. The table lists the scheduled time and treatment station. Any requests from the RN staff are listed in the last two columns. You can get a list of your rounding patients by printing this table using the printer function of your browser through print preview. There should be a list of your patients in your CDC mailbox.