Using Epic for Patient Chart Review
Epic is the application physicians at VUMC use to take care of patients, which has customized views based on department and login profiles. In the video below using Epic's playground environment, Dr. Aileen Wright demonstrates how to use Epic’s interface to view the various components of a patient’s record, as well as how to generate documentation notes, create orders, and graph a patient’s lab result values over time (no real patient data shown). Along the way she also explains the difference between problem lists and visit diagnoses, and highlights some of the ways the interface can be customized to streamline tasks and support user preferences. From this video, it’s clear that interacting with the EHR can be a time-consuming but necessary part of a provider’s job, especially for complex patients with many co-occurring conditions! This also highlights the value of clinical informatics to identify opportunities to improve workflow so providers can take better care of their patients more efficiently.
Intro to eStar: Outpatient Workflow Exercise Part 1
Using Epic During Patient Visits
In the video below using Epic's playground environment, Dr. Wright demonstrates how she would use Epic during an interaction with a new patient, including reviewing their current problem list and medications with them, addressing any medical concerns they may have, ordering lab tests and procedures to be completed, and sending new prescriptions to their pharmacy (no real patient data shown). The interaction also shows how clinical decision alerts appear during the visit to indicate a medication being prescribed is actually contraindicated for the patient due to a medical condition and other medications. Dr. Wright demonstrates how she takes notes within Epic throughout the visit and ensures they are complete before signing.
Intro to eStar - Outpatient Workflow Exercise Part 2
For this exercise, you will view a video of a typical outpatient encounter and document it in Epic.
Start by logging in to the PLY environment (see Confluence for username and password). Create a new “Office Visit” encounter for one of your test patients, using OPMED15 as the encounter provider.
View the video below (you may need to pause or rewind several times), and document everything you observe. Make sure to capture, at least, any:
- Medications the patient is already taking
- Allergies
- Vital signs
- Chief complaint
- Past medical history
- Past surgical history
- Review of systems
- Physical exam findings
- Point of care test orders and results
- Assessment
- Plan
- Encounter diagnosis
- New medications or other orders
Items in bold should be entered as structured data in Epic, but also make sure to write a coherent note. During the visit, the physician will verbalize three orders (a test, a medication and a referral). Place (and sign) these orders in Epic - don’t just enter them in the note. You are welcome to use Notewriter, or write the note yourself (from scratch or using a template).
If you don’t know where or how to document something, check out WeLearning or Confluence to see if you can figure it out. You can make reasonable assumptions about any data not stated during the video.
Please note that the PLY environment resets nightly, so try to avoid doing the exercise between midnight and 6:00 AM, and make sure to complete it in one sitting -- if your visit spans midnight you will need to start over
Introduction to BPAs
Best Practice Advisories (BPAs) are a form of clinical decision support that provide clinicians with warnings or reminders based on patient data.
Building BPA Alerts in Epic
Within Epic, BPAs are built from criteria records, which contain the information that will trigger the BPA, and base records, which contain the display text and follow-up suggestions shown to users. In the video below, Dr. Allison McCoy walks through the process of creating a BPA to suggest metoprolol for patients with coronary artery disease (CAD) who aren’t already on a beta blocker. This example requires the creation of two criteria records (one that checks for patients with a diagnosis of CAD and another that checks for whether the patient is taking any beta blocker medication) and one base record that links to the criteria records with the appropriate logic. Dr. McCoy explains how to set encounter and gender restrictions, how to select a trigger action to cause the BPA to appear, and how to link the alert to a provider response action, such as ordering a beta-blocker or providing an acknowledge reason to decline the suggestion.
Creating Groupers, Preference Lists, SmartLinks, and SmartText
Value sets, or groupers in Epic, contain lists of related records like diagnoses or medications and they can be used in different applications within Epic, not just BPAs. Creating a grouper is a good way to define a group once so it can be used consistently. In the video below, Dr. McCoy walks through the process of creating groupers within Epic’s grouper editor. Sometimes using concepts like SNOMED clinical terms or pharmaceutical classes can still leave out important records or include ones you aren’t interested in, so it’s important to check what’s including using Epic’s grouper review. In the video below, Dr. McCoy also shows how to create preference lists using Epic’s preference list composer, which can be used in the example from the last video allowing a medication to be ordered from within a BPA. The video also shows how to use SmartLinks and SmartText to allow your BPAs to display more useful information.
Epic Build Exercise
For this exercise, you will create a a new BestPractice Advisory (BPA) in Epic.
Start by logging in to the PLY environment, (See Confluence for username and password)
Please note that the PLY environment resets nightly, so try to avoid doing the exercise between midnight and 6:00 AM, and make sure to complete it in one sitting -- if your build spans midnight you will need to start over.
Imagine that you have received a request from your primary care leadership. They have reviewed research on the APOL1 gene and have submitted a new CDS request:
Please create a BestPractice Advisory that fires for patients who 1) have hypertension on their problem list, or whose last systolic blood pressure is above 140 and 2) have the "APOL1 High Risk" genomic risk indicator and 3) are not currently taking an ACE inhibitor. The BPA should clearly state why it fired, and allow the user to order lisinopril 10mg once daily.
For the exercise, please:
- Analyze the request through the lens of the CDS Five Rights. Prepare a brief (<1 page) written design document describing the results of your analysis and your planned approach.
- Build the BPA in the Epic PLY environment. Submit screenshots of your base and criteria records, as well as a preview of your BPA. (Username: ipadm)
- Design an evaluation plan (0.5-1 page) that describes how you will evaluate the effectiveness of your alert.
If you don’t know how to build something, check out WeLearning or Confluence to see if you can figure it out.