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AHLTA
Documentation Tips and
Efficiencies
1
AGENDA
 Optimal Settings
 Templates
 Team Documentation
 AHLTA tools
 Time saving strategies
 Cross Product/Cross Environment Access
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NOT......
 Teach you how to code
 How to get a 9921x with every encounter
 Decide what AHLTA really stands for
 Reveal the new EHR solution
 Provide System Admin training
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Disclaimer
Patient names shown in the slides are certified as
fictional, are created only for training, and without
intended correlation to real people.
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Optimal Settings


Computer
 At least 2 GB RAM (4G recommended)
 Virtual Memory at least 1.5x total RAM
(Windows 7: Control Panel>System>Advanced system
settings>Advanced>Performance>Advanced>Virtual Memory)
 Display color resolution set to 16 bit (CITRIX: 16 bit color setting)
AHLTA
 Release Version 3.3.6 SP1C (pending 3.3.7 release)
 MEDCIN Knowledgebase Version: 4th QTR 2012 R1 (14 NOV 12)
(AHLTA>Help>About)
 Encounter Summary Properties
(Turn off Auto-print unless clinic policy)
(Set “Auto-save S/O every” to “0” Min)
 Health History Tab; Do Not Retrieve Vital Signs (see screenshots)
Optimal Settings (Health History)
1. Access Health History from Folders List
2. Select Options to open Health History
Configuration window
Optimal Settings (Health History)
1. Select Vital Signs
Review from drop down
menu
2. Uncheck “Do Not
Retrieve”
AHLTA Customizations
With opened encounter, click
Options to reveal Encounter
Summary Properties and
customize your AHLTA Settings.
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AHLTA Customizations
 Suggested AHLTA Customizations
 Signature Block (job title, Co-Signer)
 Minimize AutoCite preferences
 Convert (+) ROS to HPI if using a Medcin Template
 E&M Calculator Defaults (check with your coder Re: Service and
Exam Type settings)
 Sensitive Default (Mental Health Providers)
 Include ICD9/CPT/HCPCS codes in encounter note
 Don’t default TSWF or Usability AIM Forms
 Don’t use Merge Dx Prompt/Prompt with Default Template
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AHLTA Customizations: Setting Order of Columns
Drag and drop Column headings to configure the order
of columns in Appointments and Telephone Consults
Modules
Click on Column headings to re-order lists based on
that column data
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AHLTA Customizations: Appointments Module
From the Appointments Module,
click on Options to customize
Appointment Module settings.
11
AHLTA Customizations: Telephone Consults Module
From the Telephone Consult
Module, click on Options to
configure Telephone Consult
Module Settings
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Templates
 The best time saver
 Default template (except TSWF, Usability AIM)
 TSWF
 Usability AIM Form
 Generic example
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Templates: Advantages
 Most efficient documentation process
 Minimizes duplicative efforts
 Standardizes documentation process
 Configure readable notes
 Familiarity facilitates efficiency
 Promotes patient safety
 Improved coding compliance
14
Template Management
Purge unnecessary Templates
From Template Management:
Select ‘Default Encounter Template to set a
Default Encounter
Right click to remove the template from
your favorites
15
Template Management
Make the most of improved Template
Management:
Use Edit to modify existing templates
Add Order sets
Use “Add To Default Template” to modify your
default template while documenting an encounter.
16
Templates: Approved templates
Borrow don’t build templates. Look for
“approved” templates in the Enterprise Folders
based on specialty.
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The TSWF
The Tri Service Workflow (TSWF)
 Workflow concept built around a core AIM form
 Team documentation effort
 “Live” Document
 Takes advantage of effective AHLTA features, overcomes
AHLTA challenges to create:
 “One form fits all” concept
 Manageable Problem List, Medication List, Family History
 Readable notes
 AHLTA down-time solution
 CPG compliance
 Coding guidelines
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AHLTA Tri-Service Workflow
Tri-Service AIM
Form
Provider takes
over note
Provider reviews
tech input
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Usability AIM Form
 Alternative to the TSWF
 “One form fits all” concept
 Presents data in easy to select format
 Includes care guidelines
 Does not include team documentation concept
 Not Tri-Service approved content
 No longer updated
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Usability AIM Form
Usability AIM form: “One template fits all”
Do not Default.
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Usability AIM Form
Usability AIM Form: Presents data in
easy to select formats
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Usability AIM Form
It even includes care guidelines
23
Generic Template
Generic template example. Based on Medcin
terms. Advantages vs Disadvantages.
24
Team Documentation
 Procedures, lists, med recon, questionnaires, etc
 Use a common template
 Make sure you take over note correctly
 Support staff can document all but the HPI
25
Take Over the Note
To assume ownership of the
support staff encounter note,
click the ‘Edit This Note…’
button.
“Add Additional S/O Note…..”
creates a duplicate note under
the support staff note.
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Take Over the Note
The Provider can edit the support
staff’s note accordingly.
27
Take Over the Note
The Provider has taken ownership of the note and
the note output is not duplicated.
The support staff’s documentation goes to the
“Change History” portion of the note (next screen
shot)
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Take Over the Note
Staff portion of the note goes to “CHANGE HISTORY” in small
font for audit purposes but is also retained within the provider’s
documentation.
Support staff and providers should work off the same template
when possible and practical so the provider can see during
documentation what has already been documented by the
corpsman.
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AHLTA Tools
 Check-out
 Favorites List
 Copy forward
 Dx prompt
 Spell Checker Macros
 Voice dictation
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Check-Out
From the Appointments Module, select Check
Out.
Note: The Patient’s appointment status must
be ‘InProgress,’ ‘Completed,’ or ‘Updated’ for
the Check Out icon to activate.
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Check-Out
Use Check Out to configure a Check Out Date
and Time and select the type of handout to print
for the patient. Use Print Preview to view
form(s) prior to printing.
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Check-Out : Update Check-out Data
From the Tools Menu, select Update
Check-out Data to configure the Print
Orders (Instructions) template.
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Favorites Lists
Use List Management to populate Favorites
Lists for Diagnosis and Procedures.
Suggest populating your templates with
common procedures and your Favorites
with uncommon or hard to find procedures.
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Copy Forward
To use the Copy Forward function,
open a current encounter.
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Copy Forward
Go to Previous Encounters, open the desired
encounter and click Copy Forward.
(The S/O, A/P Diagnoses, Procedures, and
Orders will be available for selection.)
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Copy Forward
You are returned to the current encounter.
Click the S/O or A/P button.
37
Copy Forward
Positive and normal findings in the
Medcin tree in the left pane copied
from the previous encounter display
in yellow.
Findings copied from the previous
encounter do not populate the current
encounter note until you select them.
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Copy Forward
The A/P information associated with
the previous encounter will display on
the appropriate tabs. (i.e. Diagnosis)
39
Copy Forward
The A/P orders associated with the
previous encounter will display in the order
set tab.
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Dx Prompt
This is the Dx Prompt tool that can help
with finding appropriate Hx and PE
terms to include in the encounter note.
Creates a template “on the fly.”
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Dx Prompt
Dx Prompt will present added terms consistent with the
Search or listed selection diagnosis. You can return to
your template by using the template drop down menu.
Click on the List Size to expand the terms up to List Size 3.
Suggest not selecting the Merge DxPrompt option.
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Spell Checker
 Built into AHLTA SP1 (in case you didn’t notice)
 Can create some conflicts if using As U Type
 Macros capability
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Creating Macros
1. With an opened encounter, right
click inside a text box (S/O or
A/P)
2. Select “Autocorrect Options”
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Creating Macros
3. Make sure “Replace text as you type”
is selected from AutoCorrect Options
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Creating Macros
4. Type in the name of your macro in the
“Replace:” box
5. Type in the macro phrase in the
“With:” box
6. Click on “Replace” to store your
macro phrase in the Dictionary
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Creating Macros
Type in the title of your macro from an
AHLTA Text box, hit space bar to
reveal your phrase. Click “OK” to add
to your encounter note.
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Voice Dictation
©
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Time Saving Strategies
 Minimize size of Template Favorites
 Complete A/P first
 Standardize processes and training
 Be prepared for catastrophes
 Avoid temptations to postpone documentation
 Don’t let providers do all the documentation
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BHIE Share
BHIE Share
DoD
FHIE/BHIE Framework
VA
CHCS
BHIE
CPRS
or
VistAWeb
SHARE GUI
FHIE/BHIE
Framework/
DoD MPI
CDR
BHIE-AHLTA
VA
VistA
VA
Master
Patient
Index
BHIE Viewer
Essentris
BHIE-Essentris
TMDS
BHIE-T
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BHIE Share: Web Link Access
AHLTA Links Folder
Essentris Web Links
THIS !
NOT THIS!
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BHIE Share
Select the Site Link that
corresponds to your MTF and
save to your Internet Favorites
Type in your CHCS Credentials
to Logon
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BHIE-Share vs BHIE-AHLTA




More robust data
Faster retrieval
Local and remote data retrieval
User Preferences
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BHIE Share: Patient Summary
The Patient Summary Page loads when
a patient is selected
•View details of results by selecting
hyperlinks
•Page may be configured to user
preferences
•Patient Data Categories: Select
Documentation to retrieve Essentris notes
BHIE Share: Remote Data
The Patient Summary Page loads when
a patient is selected
•Remote data auto loads by Health Data
category if available
•Date range defaults and display may be
set in preferences, dates may be changed
on the Summary Page
BHIE Share: Essentris Notes
Sample Essentris Note:
•Available in Documentation Patient Health
Data category
•View by clicking hyperlink in
Documentation box of Patient Summary
Page
•Requires Essentris configuration (LOINC
code) to be viewable in BHIE-Share
VLER
Virtual Lifetime Electronic Record
(VLER) Health Enterprise
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VLER: Virtual Lifetime Electronic Record
VLER Health Enterprise External Health Data Sharing
provides the ability to:
Find and retrieve healthcare information within and
between health information exchanges and other
organizations.
Deliver a summarized patient record to support
patient care and the patient’s health.
Support consumer preferences regarding the
exchange of personal information, including the ability
to choose not to participate in External Health Data
Sharing.
Match patients to their data without a national patient
identifier.
Exchange information securely.
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External Health Data Viewer: Patient Summaries
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VLER: Patient Summary Document
Patient Summary Data Categories
• Patient Demographics
• Allergies
• Medications
• Problems
• Diagnostic and Lab results
• Next-of-kin/Emergency Contacts
• Vital Signs
• Immunizations
• Procedures/Surgeries
• Appointments/Admissions
• Insurance Provider/Payer
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VLER: Patient Summary Document
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References
All reference materials will be loaded on the DHIMS
Knowledge Sharing Site (KSS). For more information, please
visit:
https://www.ehrknowex.com/welcome
 Follow onscreen instructions to create an account
 Request to join desired content groups
 Type in desired topic in Search window (do not hit Enter)
 Select from created drop-down list
 Download and/or review desired content
62
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