Home Forums Discussions General Discussion Trying to make some sense out of "orders" and reconciliation

The orders section has been confusing and fairly useless to me. My approach has generally been to ignore it, or to use it to simply print an occasional order. I would like to report here how we are starting to use it in the hope that others can help to find a way to improve its utility. At the end of the post, I will also propose a (seemingly) simple change that AC could make to improve its functionality. It may be easier to understand what follows with the ?orders? window for a patient open as you read. To those of you who find this to be old news?feel free to skip it. I apologize for the length of the post.

If you have no interest in order reconciliation, and simply want to better understand how the order section functions, the first half of this post may be helpful to you.

When you write an order, you are given three choices:
Print, save (without sending), or save and send.

1. ?Print? gives you a printed copy, but as far as I can tell, does not record the order anywhere.

2. ?Save (without sending)? puts the order in the current note (in the plan section) and in the list of orders that you can see by going to "View...orders?. From there it can be reconciled.

3. ?Save and send? puts it in the current note, and in the list of orders to be reconciled, and also puts it in a message sent to a user.

So if you want AC to simply act like a printer and print the order (which saves time because the patient?s demos, insurance, and diagnosis are on it) then create an order and use ?print?. To record that order in any way in the chart, you must then re-type it into the note.

If you want the order to be automatically recorded in the plan section of the patient?s current note, use one of the two ?save? options. Realize that you will also be saving the order in a separate list to be reconciled at a later time. That is helpful if you plan to reconcile the order, but it creates a potential problem if you do not: apparently, accumulation of a large number of un-reconciled orders can eventually lead to slowing-down AC, so you should plan to remove these later.

(A note about removing these old orders: you can see the list of all un-reconciled orders by going to ?View?orders? on the main screen. You have two choices to clear an item from the list. They can be deleted, one by one. Or they can be marked ?completed?, and this you can do in large numbers, all at one time. This makes ?completing? much easier if you have a lot of old orders to clear out. The database does keep a record of which orders were ?deleted? and which were ?completed?.)


One would think that an electronic medical record would dramatically ease the process of order reconciliation. In practice, this is not easy to achieve. You need a list of all of your orders, and then sometime later you need to go back and cross-match that list with each patient?s chart to look for the result of each order and see if you can ?cross it off the list?. AC currently does a good job of creating the list of orders but does not make it easy to match it with results. Users tend to take an ?all or none? approach to this reconciliation process, which means ?none? for nearly all of us. What I propose, and what we are now instituting is to prioritize and decide which orders we choose to make the effort to reconcile. Here is how we do it:

First, decide which orders are sufficiently critical to require reconciliation. At the beginning, be very selective; after all, even reconciling a few orders is better than none at all. This will give you a chance to decide if the effort is worth it to reconcile a larger number of orders. It is your choice: mammograms, colonoscopies, cultures, x-rays, etc. Choose the things you most want to be sure are really done.
Then create a low level provider with the user name ?Reconcile?. Let everyone who will do reconciliation have that user?s password.
When the provider creates an order, he/she decides if it is one which will be reconciled or not (you can follow the rule you made above, or make exceptions). When the order is written, the provider chooses ?Save (without sending)? if the order is NOT to be reconciled. If you DO want it to be reconciled, click ?Save and send?; it is sent to the provider named ?Reconcile?.

One benefit of this system is that now orders which are to be reconciled are segregated and easily viewed in one place: the message box of the user named ?Reconcile?. Anyone (provider or staff) who has time can go through those messages and reconcile them. (It is a bit easier to do this from a message box rather than from the ?view?orders? box because when you double-click on the message, it opens a box which shows only that patient?s orders). You click on the button labeled ?Find imported items (not yet reconciled)? and it is generally pretty quick to find the result of the test. Double click it, and the order is reconciled. After going through this a few times, it doesn?t seem that laborious. When the ?Reconcile? user?s message box is empty?all of the orders are reconciled.

Another benefit of this system is that all of the orders that are NOT to be reconciled are kept elsewhere. You will periodically want to clear them out by going to ?View?orders? and deleting a large batch. Delete the old ones, and just be careful not to delete any recent ones that are still in the ?Reconcile? message box.

This may sound very complicated, but in practice it is not. We are finding that reconciliation of a fairly small number of key orders can be done without undue effort.

I am pretty sure my suggestion for AC has been made by others: create a ?reconcile? button which would become visible (like the one in the orders described above) when you sign-off AND when you import items (within the program and in Updox). That way, reconciliation could be done as the results come in which would be much more efficient than going back to check them off later. With that (fairly simple) change, I think ?orders? and ?order reconciliation? in AC could actually be very useful.

Maybe I am making this too complicated; if anyone has an easier way to utilize this aspect of AC, I would be happy to hear it.

After reading your detailed explanation, I think that you have developed a very viable work-around for the present AC "Orders" system. I hope that AC reads your suggestions.

There is a button already in the import area also to "reconcile to order" any item being imported at the time of importing. The button is however not functional. Nothing happens when it is clicked. We send all of our orders to labdoctor and then import them to labdoctor and then send them to me to sign off. I can easily tell in my mailbox which is a lab result from who the sender is. Either during the importing task or the sign off task would be ideal for me for reconciliation. For some reason the "reconcile to order" choice under importing doesn't work. It would be simple if it did. And it is already there. I wish it would be turned on. In the past, it has seemed that the consensus is that nobody cares about it anyway.

I think nobody cared because the system to reconcile was faulty. I'd like it to work as intended. EMRs already introduce all sorts of new burdens for the doctor. It would be nice to simplify one of them.

Jon, interesting work flow. Most of my orders are for "just prior to return". I do occasionally need to know as soon as something comes back (rely on message at present), I look into this.

I hate feeling stupid, esp. with HIT stuff, but I am having trouble setting a default "send to" for lab orders. Did it for f/u's imaging but can't get the lab orders to default to anything.

Am I missing something, doing something wrong?

Roger,
I think that once you send an order to a specific user, the user is "remembered" the next time you write an order. The user for each category of orders is remembered independently.

Jon,
OK, my problem was trying to use the built in Nursing (a group, right?). Never "stuck" to the drop down.
So I created a lab review user and, voila!
This user BB is one reason I decided on AC!
Thanks.

How do you do this? We're using version 5.0.29 and I cannot remove any order. Nor can I update the status of multiple orders at once to "complete." When I select more than 1 order, click the complete radio button, and click "update order," only the top order disappears from the list. When I click the remove button (next to the "find imported items.." button), nothing happens. Is there another way to delete orders?

Serene

Go to View...orders from the main AC page.
Select the top order, hit shift and then select the bottom one.
Hit the "completed" radio button, then "Update Order".
That deletes (actually "completes") the selected orders, at least in V6.09.

Maybe that is the my problem. I haven't upgraded to version 6. When I do exactly what you describe, only the first order gets changed to completed.

Brilliant! This is why I love the message board. Jon your RECONCILE username is a great workaround for something that I've wanted to do. We are required to track referrals, etc from one of the medicaid groups. Having a reconcile user would accomplish all that without having to worry about it sitting in one persons inbox.. That's something my front office staff all does.

One of the problems I figured with orders was not knowing which person was going to be in our lab on a particular day. We have three different people who draw blood back there at any given moment. So now I'll create a LABORATORY username, we can send all the orders for labs to there. By going to the orders window, I can then select and print all the orders sent to LABORATORY to UPDOX and save them as a PDF file (There's my copies of my requisitions I needed in the previous thread.

This message board is awesome!

Thanks

I can't seem to find that button; can you describe it's location in more detail, please?

It is gone. Must have been removed in one of the updates. It wasn't actually a button but an item for selection in the drop down when one was importing items or again an item in the drop down menu when signing off. I just went to look at it and it's gone. It never worked. You could click that selection all day and nothing would happen. It would have be the ideal time/place for reconciliation in my practice work flow. Could have easily been done at either the time of import without difficulty or many steps or again at the time of signing off. too bad.

Too bad after you reconcile the order it doesn't delete the message from the message inbox automatically.

I am trying to decide if I want to use Orders in AC. My present workflow is that orders (whether in office or going out) are ordered on encounter form and then acted on by MA. I plan to continue using the (paper) encounter form for now with AC. My question is: doe using 'orders' in AC have any MU significance? If I don't use orders but just use simple templates in the Plan section, will that ding me when it comes time to attest MU?
Thanks for all replies in advance.

No, I don't think they do. You can meet the requirements without utilizing orders at all. (We got the MU incentive money, and were not using the orders section at all at that point).

I think orders and reconciliation of orders comes with stage 2 of meaningful use. The lab connection, xray connection, and referrals going back and forth are part of stage 2. I think that's why the "reconcile to order" function in the import area was removed. It will all be done digitally eventually through RHIOs or something like that.

We just discovered the "View" "Orders" box, and it looks like it will be fairly easy to use. My MA gets orders that are generally arranged with the patient in the office (such as lab, imaging and other tests), while my receptionist gets those that are more likely to be handled by phone/mail (such as referrals; records, etc.). I don't think a special mail box is necessary, as orders can be specified as "pending" or "complete", and it looks like anyone can access these lists (and see ALL orders) from his own box. We'll be able to retire all our old logs (for lab, referrals, etc.) when we start using this feature. I'm sure we'll learn more once we start playing with it. Has anyone else had any experience with this? Please share!

Using Jon's idea, we created a username FOLLOWUP. Now any referrals (or anything that needs to be followed up closely) are sent to the FOLLOWUP user. Everyone has access to this account and all three front office girls go in there periodically and process & update the orders. We used to keep a paper referral log with demographics, tracking #, date processed, date received, pt notified date etc. Now it's all documented nicely in the chart as messages when the referrals are complete.

Once I get the message that the order was completed. I then use the letter writer to write up a quick note to the specialist, attach chart notes, labs etc and print to Updox. Then it's faxed & everything is saved to AC.

I wouldn't want to do this for each individual test and/or lab. I'd be there forever working on my inbox.

I discussed with my staff adding another user name that everyone has access to and into whose box follow ups, etc could be placed. They pooh-poohed the idea immediately..."Just another place we need to remember to look". So, I guess we will go on as is for now.

There is no question that what I describe above adds some time and complexity to our current workflow. The goal was to allow us to track certain key orders. The current set up in AC is so clunky that I don't know of anyone who uses it effectively (though perhaps some do).

Sujay, if it works for you to send all orders and have staff find them in their own message boxes, then go for it! That is how AC apparently intended for it to work.

Leslie, are you currently tracking and reconciling any orders? If so, and your current system is working, then why change it? On the other hand, reconciling by its very nature requires some additional work. So if you are not currently doing it, it is no surprise that your staff sees this system as an added burden and is less than enthusiastic.

One of the things we like is that it allows us to reconcile SELECTED orders fairly easily.

I use orders quite a bit but I am not reconciling them, although, if it were easier to do I might. I have a part-time person right now that goes through all the pending orders once a week and marks them "Complete" just to get them out of there.

Leslie, you do realize that if you "print without sending" those orders you won't need to have them all "completed".

Yes, but I do send many of them to the staff so that they can be making arrangements before the patient gets to the front desk, e.g. scheduling CTs, referrals, etc.

I do that too Leslie.
pt's are pleasantly freaked out when they leave the exam room and my staff has an apt date all set up for their bone-dens and mammo. They are like "we were just talking about that a few minutes ago, and you have it all set up? Wow!!"

what's even more freaky to them is when I use the IPMessenger application to request my staff to get me something. Let's say the pt and I are discussing a CT report which I don't yet have. I message the staff to obtain it asap. A few minutes later, my staffer walks into the exam room with that report in hand. The pt looks at the staff, looks at me incredrulously, then looks at my staffer again and says "how did you know to get that?" We smile and say "magic..."

IPMessenger is a neat little program Bert told me about and has been using himself for quite a long time. We use it all the time and every day in my office. It really improves my efficiency. I can get staff members to help me multitask, and I never have to interrupt the flow of the office visit by leaving the room to ask for stuff.
Likewise they can ask me things without interrupting the flow with that horrible "Knock knock knock..." on the exam room door.........one of my biggest pet-peeves. The knock would always come at the worst time, like when a pt says "did you hear that my mother passed away last week and I'm feeling really distraught"....KNOCK KNOCK KNOCK. uhhhhh, hold that thought I'll be right back

Instead of IPMessenger, I am still using the FREE Yahoo Messenger. I do the same as you, Adam and it freaks the patients out. We never give any patient's last name. I can message a staff to see when a patient's last colonoscopy was and then while I am moved onto something else, the staff can call, find out, request the report and message me back all within a matter of minutes. And usually the fax is also there before I am finished with the patient.

Even better, if a patient is going on and on and on about their second cousin's bunionectomy I can message the staff "GET ME OUT OF HERE!" and within seconds, there is a knock on the door telling me the ER is on the phone. Whew! I have also had to use that ploy when my second cup of coffee kicks in at a disadvantageous time.

I totally agree with the value of an in-office messaging system for all of the uses above. We use Google chat which is also free. And no, these things are not HIPAA compliant so we are sure never to discuss private or identifiable patient information.
E.g. I send a message "we need the CT on this patient". They call and have the radiology report faxed, and it is in the chart (or in Updox) quickly.

IPMessenger is a free application.
The thing I really like about it is that is sends the message through our local network, so it really is HIPAA compliant. It is not sending anything through the outside internet. Also it doesn't require my staff to be logged into any internet based messaging system (which I could see their friends messaging them during work hours, making me mad at them). And keeps my friends from trying to message me while seeing patients.

IP Messenger is great - there should be a post of famous 'Bert Recommendations' as that is wonderful - I can send message to the front desk, the file desk, etc and it does not allow them off the network.

I use it all the time - seeing a pt. and decide I want a b12 shot - send message and a minute or two later the door knocks and hands in the shot - pt. love it and I also use it for phone calls, etc.

Exactly Steven. It's a great program.
And I agree, we should make a thread of Famous Bert Recommendations.

Very good write up for someone just starting out with AC.
You are correct, you should be able to reconcile from the import area.
Also when you try to find imported items not yet reconciled, the list does not give you the patient's name. Impossible to know who the item belongs.
How does everyone track items that are complete and results such as "normal" urine? Would be great to pull up chart and see all results quickly.
Only way I see that we can be sure the results and tests are all completed so we can write the patient a letter is to print the assessment and plan and manually cross off the items.
Any other solutions?