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| CCHIT Related |
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| Order Entry Management System |
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| Abstract: An Introduction to Order Entry Management System in a Practice / Hospital settings and making Electronic Medical Records a better companion to the Physician community. |
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| Introduction |
| The article mainly covers an introduction to current manual process of placing the orders for the patient, usually by the Physicians in an Ambulatory settings and the challenges encountered during the change of the order status from “Ordered” – “Completed”, along with the various tasks involved with any deviation from primary workflow to alternate workflow’s – “Cancelled”, “Rejected” as there exists a dependency between the departments, external faculties, physicians, specialties (sub-specialties) etc. |
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| The article is prepared in order to address the time-consuming areas in a patient care setting, especially with the Orders which plays a key role in treating as well – as financial dependency (Insurance or Self-Pay), preparation by the Pharmacy, Lab, Radiology departments etc. |
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| The topic introduces the use of Healthcare IT product “CareEMR” and the key aspects to its effective usage leading to the quality patient care. |
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| The requirements underlies the usage of Physician Order Entry as well-as Non-Physician Order Entry electronically and the fitment of CareEMR in achieving the desired outcome. |
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| Order Entry |
| Patients often establish a relationship with the physician either through an Encounter / New Visit. One of the activities that occur during the encounter is placing of orders for the patients. These order types, might be - Medication orders, Lab orders, Radiology orders which categorizes into Physician Order entries as individual billable components. Referrals, Pre-Admit orders etc. will not be billable for the patients & categorized as - 'Non Physician Orders'. The orders can vary ranging from a single department to many departments within the same facility or other facilities depending on the type. |
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| Often, the co-ordination between the staffs or the interaction for request’s & receiving the results in a timely manner poses a great challenge for the Physician community for immediate continuity of treatment, leading to patient's concern, physician's non-availability etc. |
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| In order to minimize & eliminate the impact, the use of Electronic Medical Records within the Outpatient settings - Physician office, Satellite centers, Day Care Surgery centers etc... can support & aid with the busy day schedules, along with providing an opportunity for spending more time with the patients for quality care. |
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| Order entry provides easy recording of the Superbill, generating the bill for the patients, as well as submitting to the Insurance companies – manually or electronically with the applicable standards. |
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| Recommendation |
| CareEMR - Electronic Medical Record with Role Based access control (RBAC) adhering with the HIPAA regulations is designed for the Outpatient/Ambulatory settings, comprising "Plan" module that consists of Physician Order Entry features as well-as Non Physician Order entries features. This helps the Practices / Physicians with easy routing of lab orders to diagnostic centers, receiving lab or radiology results in a timely manner through HL7 messaging, proper billing with the ability to capture - CPT-4 code along with the association of Diagnosis code (ICD-9) sets for regulatory compliance's, Medication orders - Formulary checking, Fax routing, Decision Support systems provided by New Crop Inc, Integration across the departments through Alerts within the individual or staff Dashboard. |
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| Author: Vinay Kumar.K |
| Designation: Product Specialist – Healthcare IT |
