Good morning, I'm going to go ahead and get started in the interest of time here. My name is Max Starr, I'm from Georgia Hand Shield and Elbow in Atlanta, Georgia, and thanks for getting up early and joining us to dive into the electronic health record a little bit. I'm going to give you some tricks to make your life easier, we hope, by the end of this course. So a little background, the electronic health record, of course, has seen rapid advancements in the 21st century. The American Recovery and Reinvestment Act required health care providers to adopt and demonstrate meaningful use by January 1st of 2014, and of course the electronic health record has resulted in quality improvement, improved integration within health systems, researchable data, and expedited claims processing. Improvements in clinical efficiency often can be debated amongst providers, and hopefully today we can give you some tips on improving your clinical efficiency in your electronic health record. So the goals and objectives are to have a basic understanding of the capabilities and workflow of the presented systems, understand methods to enhance clinical efficiency within each system, understand pros and cons, and have a window into the future of the electronic health record and how it relates to practicing hand and upper extremity surgeons. So without further ado, I'm going to bring up Dr. Spencer Chambers, speaking in place of Dr. Michael Godchalk today. He is a fellow at Emory University currently and has many years of experience with Cerner. So, morning again. I don't have any disclosures, and just to commend everyone for showing up early to talk about EHRs. I came into residency the year before our whole system switched EMRs, so it's been pandemonium, and then just by virtue of my training, I think I've been trained on six now, and every single time the electronic training is watching paint dry, so hopefully we can cut out a bit of that pain and give you some of the highlights instead of going through all the details that we don't often use. Last time I started a new EMR, and starting in fellowship, we're trained on three additional ones, although it should be a simple task and you want to get things done, I still feel like this. I was actually just trained on Epic two months ago, which is a very nice system that I've been doing Athena, and when you just want to order some on Tylenol and there's three or four steps, that can be frustrating. But that being said, I think each of these are tools that you can use, and the effort time curve looks something like this. And I believe the main premise of this session, as Dr. Cocker will get to shortly, is we want to shorten the time you spend with this high effort and get to a process where things are much easier and run by themselves. And in thinking about what to present with regards to Cerner, you think about what an ideal EMR would be, and ideally it would be something that's simple, efficient, and intuitive. I don't think any of the EMRs we're going to present today hit all these marks, but I do think there's ways that you can modify their applications or use different parts of them to meet your needs efficiently. And that's what we'll be talking about today, and specifically with Cerner, I'll be talking about PowerChart. PowerChart can be very efficient and PowerChart can be very useful, but I do find that in order to make it work for you, there's some upfront work, and once you're established, it's something where you can make minor adjustments that are going to save you a lot of time. My goal, particularly in residency and fellowship, when you're doing a lot of the orders and you want the data to run well, is if I can do things in as few clicks as possible, have reproducible order sets and notes, and that's something where I can take time away from doing documentation and put it back to patient care. So in the early times, you have to spend time at home or if you have additional resources or a colleague to use, but once you've got your order sets available, you can do small modifications and feasibly do the majority of your orders and notes beforehand in a fraction of the time compared to doing paper notes or doing them from scratch. I thought the two parts to talk about that would be useful would be order sets in particular and then notes, and we'll talk about examples for this. When you look at a Cerner homepage, there's a couple of different places to start, and I have a pointer, so that's great. These are where I would start the majority of my orders, and if you've never had PowerChart or it's new to your system and you're creating something unique from scratch, I would recommend starting over here on the left panel. We will come back to a more efficient way to do order sets if you have someone else that's also done some order sets as well, but we'll do this first. And for the purpose of demonstration, let's assume that we're going to do an order set around shoulder surgery, and full disclosure, I am plastics trained, so shoulder surgery is very similar to me, so we'll talk about it in generics. But if I'm with Dr. Gottschalk and I want to set up his orders for the day, I would go to that order set and then I would search for orders. And regardless of the system you're with, the vast majority of PowerChart has different available libraries of orders, and they're somewhat intuitive to search for, whether that be through general surgery or, in this case, orthopedics. So naively, I would come in, I would search for orders, and I would say ortho shoulder, that sounds pretty good, so let's see what that looks like. There's different vernacular for each system. Whenever you see this yellow icon in the center of the screen, that's PowerChart's way of saying this is not a standalone order, such as a single dose of Tylenol, but rather a collection of order sets, and that can be useful and that can save you time, so you can order 10 things at once instead of one. So once you identify that this is a power plan, what happens on your screen is this single order is going to order these three or four things. This is a broad and flexible order set that you need to customize, because it covers everything and doesn't always make a lot of sense. And this is just going to be the starting point for what you're going to make for your own custom order sets that's going to save time later. I'll spare you the time of going through each of these, but you can imagine you click each of these subsets if you want to modify what side it is, change the type of fluid you give, or any particular things you like pre-op, you would do that, and similarly, pack you in post-op would be self-explanatory. Once you've done that, you're going to save this as a favorite order set, and this would be one of my particular complaints of PowerPoint as well, is the organization of your custom order sets isn't done particularly well. There is file tree systems that you can use to save favorites on a desktop, but I've never actually had the functionality to work at any of the sites I've been at, and that's been three or four systems. So if you know how to do that, maybe you can give me a tip or trick on that. Instead what I've done is I think if you categorize these in a meaningful way, once again being in training, I usually use attending as my search word, and then I'll specify whatever procedure it is, because I don't have preferences yet, as you may remember. Once you do that and save, next time you go to your order sets, instead of doing that generic orthopedic shoulder surgery, you can have all these different preferences. And again, maybe you all remember, one of the hardest things about being a fellow is not remembering how to do the surgery, but remembering how your attending likes to do the surgery, because there's only one right way that day. So eventually you can build a folder that looks like this, so instead of having to change and do all those clicks, I can go in the night before, know I'm with Dr. Gottschalk first in the morning doing a rotator cuff and click rotator cuff right, and then I'm with Wagner in the afternoon, and in this way I can do all my orders in about six clicks, which is very efficient, especially when you read and get to the real meat and details of the surgery. That's a good starting point. What's even better is if someone's already started for you and found you halfway along the way. And I think Dr. Kalkar is going to get into how ASSH is going to help you with Epic with that regard, but there's always someone who's more savvy at EMRs than me in the group, so I usually like to start with their work. If you recall where we started, there was two options to start your orders. The left one is the most generalizable one. The second one for new order entry is harder to find on your homepage, but once you have it, what it allows you to do is you can search a collective shared group of order sets. So anyone who's gone on and made these modifications previously, you can access their favorites folder and just copy them verbatim into yours. So once again, if it's my first day with a new attending, and in this case it would be with Dr. Gottschalk, I would search his name, it's going to come up with his favorites, and this gives me a centralized shared power plan folder. So I already know all of his preference, and then in that way I can prepare for that, and if you work with a partner that you like the order sets or it makes sense to you, that would be the analogous thing that you can do. And you can see he's gone ahead and organized all of his order sets, and it's very easy and intuitive to navigate. Other places I think that pre-ordering can save you a lot of time, or pardon me, so that kind of discusses how you're going to use order sets and have your starting point. Once you have that, obviously we make decisions and we change plans, and it's important not only to have a good basis, but be able to modify it quickly. So as an example, let's say that order set for a right shoulder or a total shoulder arthroplasty, for whatever reason he has a new fellow on service, we're getting different infections, couldn't figure out why, and instead of starting all of his patients on ANSEF, we want to move towards something like vancomycin. Instead of rewriting the whole order set, what you can do is you open it as if you're going to order it anyway, you change your selection, so in this case we'd be changing from ANSEF to vancomycin, and essentially just resaving your same order set. You're going to save it as my favorite, it's going to ask you to overwrite, and that's the way to update orders in PowerChart. So unfortunately you can't open them in a dummy mode, you have to open them on a patient, but instead of ordering it and saving it, you would just save this, cancel this order set, then reorder your new modified order set, and you can do that for any sorts of changes, whether that be laterality or otherwise. Other places I think you can save a lot of time with pre-made order sets is in terms of patient education, prescriptions, common imaging, et cetera, things like that. So as a resident, we would have order sets that had all our common discharge medications instructions in one click. So instead of going through, typing that out, or having to rewrite every time you did a new prescription, you ordered your PowerPlan, did three clicks, you sign, and then everything gets printed in the PACU. So that would save a lot of time, and then you've given written information to the patient that's reproducible, and you know you did, and there's an electronic record of it. Common imaging I think makes sense if you're always seeing similar problems, and similarly if you're getting called about the same problem in eMERGE, you can have a PowerPlan built for that, whether that be a distal radius set, and the follow-up is all built in as well. So that would be how you save time beforehand. The other thing that I found a little bit intrusive to workflow is having to write brief op notes and operative notes on the fly, and that's something that's unique to centers I've worked at here versus where I trained. And you think about what the ideal note-taking system is. I hope this makes sense. I haven't found a Jonathan yet in America, but that would be the goal. But a note system where you can have templates, incorporate existing info, so rewriting something that's already exist in the EMR is incredibly frustrating. So it's something where if it can incorporate as much intuitive data and save time, and be flexible, I think that would be a great thing. Similar to our homepage, so going through how to make a note, and we'll talk about how to make a brief op note quickly just for the purpose of demonstration. So this is the same panel, instead of orders over here, we're going to click clinical notes, and this is how you make a new clinical note in PowerChart. From that, this is the most basic thing you can do. You could rewrite this every single time. So whatever you're going to write, this is like a text box modification, and if you assign this, this is going to go into the patient's chart. You can do that every single time, and that's particularly onerous, but once again, regardless of the PowerChart you have, most of them have templates that are pretty basic built in. So that's what this stamp is up here. So instead of just typing out my brief op note, where I have the date of procedure, et cetera, I click this template, and it's going to pre-populate all of these things. That's a small step, because it's a bit annoying to still have to fill in all this information. That's not going to change really that much. The primary surgeon might have some variance, but in general, you can have brief op notes for your common diagnosis and common surgeries. So to go one step further, if I know I'm with Dr. Goschek for a whole week, a whole month, I might go on and pre-fill all of this information, that I'm always going to be the assist. He's always going to be the staff attending, and we're always going to use minimal blood loss, of course. But if I wanted to make a more flexible template that's quick to use for all of my attendings, instead of just saving this as a simple dot phrase, what I would do is I would save this as auto-text, so it would highlight everything I want to keep. It's going to open this documentation, and this would be the abbreviation I would use up here. So any time I'm in that notes, instead of typing the whole thing or using the template, I could put dot brief op GOTS, and it's going to insert this text box. PowerChart also has some built-in tools that can be very useful to make this more flexible and quick, because if I'm always working with Dr. Goschek, that's great, but if there's variability, I'm still stuck re-typing a lot of things. And that's what these tools are up here. The two concepts are something called smart tokens and drop-down lists, and other AMRs have a similar implication of this. In terms of this, so I would take this, don't modify it, and if you click up to drop-down lists, I can add a scrollable wheel or a findable field here where I can make primary surgeon searchable. So if I'm working with a number of attendings, I add this all in. And similarly, things that have only a few options, whether it be anesthesia or the amount of blood loss or complications, I can pre-populate that. So instead of typing every answer, I'm going to end up clicking it. And similarly, there's a number of ways to work the smart tokens, but one of the intuitive easy ones is looking at date tokens. So there's information that exists in PowerChart that's categorized as metadata that you can pull into your notes automatically. It's a bit frustrating at times to search exactly what this means, but with a little bit of time and effort, you can fill in a number of things, whether it be patient name, patient contact information, or for the purpose of this presentation, just date. So now, when I go to do an off-note with Dr. Gottschek, instead of typing all this from scratch, I put .gotscuff, and it pre-populates all of this. So I have to do three selections. If there's any unique findings, I can add those, and in that way, my brief off-note, instead of taking me three or four minutes to type up, is done in about 15 seconds, which adds a lot over the course of a day and makes things a lot more straightforward. So I guess in summary, I do think each of these emerges has pros and cons, and PowerChart, once you're set up, can work quite well. I think that initial setup can be very frustrating, and if you have someone to work with or if there is an organization that can supply some foundation, I think that's extremely helpful. But once you have your established notes in PowerCharts, it's flexible and easy for modifications. Thanks again for your attention, and I think we're saving questions for the end, but feel free to contact me. Thanks, Spencer, that was excellent. I'd like to next introduce Dr. Sanj Kakkar from the Mayo Clinic. He's going to talk to us about the EPIC experience, and specifically some of the work he's done through the Hand Society with EPIC. Thanks, Mac. Morning, everybody. It's nice to see everybody. Nice job, Spencer. Okay, so my role is to talk a little bit about how the Hand Society has tried to sort of work with EPIC. Now, just as a disclosure, the Hand Society does not endorse EPIC. The reason why EPIC was chosen, because it's probably the most pertinent EMR that most people are using, so I think that's important to know. Just a quick show of hands in the room, how many people use EPIC? Okay. All right. So hopefully, I'm not going to show you how to use EPIC. I'm going to try and give you some tips of how to try to make it hopefully easier. So during Jim Chang's presidential year, physician burnout, if you remember his presidential address, was a big, big deal. And every year, the Hand Society convenes with council in December with the young leaders, and they're split into groups, and they tackle a sort of a mega-task. And the mega-task for these young leaders on the screen, and certainly a big shout-out to all of them, and Olivia Williams of ASH staff, was to address physician burnout. So we partnered with the AMA, you may have remembered, receiving a survey a few years ago in 2000, so over four years ago. And just a quick summary in that, basically, the biggest problem in terms of burnout was EMR and EHR frustrations, so clearly that was a problem that resonated with the majority of us. And a lot of the nuances of that survey is published in the Journal of Hand Surgery. Again, Hand Society doesn't endorse EPIC, but realize that of the EHRs, EPIC was probably the one that the membership was using the most. And so really, then, there was a big team of ASH staff and central leaders, and then Dr. Boyer came in, as you remember, his presidential initiative was to take the baton from Dr. Chang and say, if we're going to increase the joy of practice, and one of the biggest burnouts was the EMR, how can we work together to try and make something better for you? And so this was a team of many people coming together, and so we reached out to EPIC and said, hey, listen, what can you do to help us to help you? And so we basically had this EPIC working group in action to look at all the templates from clinical notes to operative notes to order sets, and partner with EPIC to say, can we use them and categorize them in a better way? So as you know, the Hand Society has this thing called the SHU, which is the Surgery of the Hand and Upper Extremity Curriculum. So all the lectures on Handy are geared along SHU. So can we use those SHU topics like, for example, forearm, shoulder, elbow, wrist, finger, etc., and break those down to get order sets, templates in those categories for you? And so we reached out with EPIC, and we wanted to do that, but we also wanted to have a platform which was real-time, where members can go in and interface with the EPIC staff if they're having difficulties. And I didn't know this. If you look at, we'll get into this in a minute, when you look at EPIC, there's a little globe, and you click on that globe, that's their digital platform called EPIC Earth. And I've been using EPIC, and I honestly had no idea it existed. And so what we did is we basically got all the templates of ours, so you saw those people on the list. We basically pooled all of our templates together and made smart phrases to use those to access various clinical notes, consult notes, operative notes, so you don't need to reinvent the wheel. So if you're starting this, you can maybe take my carpal tunnel, mini open carpal tunnel template, take it to yours, copy it, tweak it to make it your own, rather than reinventing the wheel and doing it yourself. But obviously EPIC can be difficult to use, and so in EPIC, they have this It's Possible videos. And these are about 60 to 90 second videos that break it down, basically, of how to make your own smart list, how to personalize it. And these little quick bits of information that already existed, but we put it in a place where you can access. So again, this is free to any Hand Society member who uses EPIC. And so this is that globe that I was talking about. And essentially, when you click on this, when you've not used it first, you have to create an account. So you're basically asking what type of surgeon you are, orthopedics, plastics, general surgery, what your interest is. You do that once, you never need to do it again. And then you get this browser bar, and you just type in ASSH, and then this self-populates. And then it brings you to this. And this is EPIC's community library. And remember, I talked to you about that shoe. So you'll see on the left, basically, it's got a hashtag, ASSH, because when you go onto that, there's so many things. So you can scroll down, find ASSH, and then it breaks it down to anesthesia, arthritis, AVN, compartment syndrome, congenital. And what you'll see is that this is a living, breathing thing. So we may not have templates for every topic in there, but you can add your own. So the next member who's starting or wants to say, hey, I don't have a good one for, for example, congenital issues, they can go in there, click it, take it, and use it. So this is an example of a scaphoid excision four-corner template that you can get, and then take this, and I'll show you how to do this, and incorporate this into your own system. So this is the level that it was. So you're not just going to get this. You'll get all of this. So literally, plug and play of how I do this, and then you may say, well, I don't like that. I take the triquetrum routinely, so you can add that in, save it, saves in the system for others, and it also saves for you. So then with basically Mark Anderson, Angela Gaspi, and Pam Anderson behind the scenes using legal, we worked then with Epic to get a template to allow us to have this contract where we can actually do this for you. So how do you do it? And I'll show you this, and I'll show you a quick video. So if you go into the homepage, and we heard a lot about this from Han P. If you click on education, you get to this, okay, sorry, practice management, you get to this, and this is where Han P. is, and you can see in the bottom right, has this Epic tools, and then there's a little bit of introduction of what this is, just to remind you. The issue about these It's Possible videos is there, and then you click on that Epic Earth button that I talked to you about, and this is a video, hopefully the sound plays. Okay, the sound is not playing, but basically what you do is you go in, okay, there's that Epic Earth. This is narrated in real time. You type in your email. Remember the first time you've never done this before? And then it knows you're an Epic user, and then you have an account, okay? So you click that. Then it'll ask you your background. What type of physician are you? What type of interest are you? It's pretty generic. You just do this once, never again. So this is the sort of level that they're asking, so you can see it's not very detailed from that aspect. You just need to get into the system. The lady that's talking, actually, has a much more soothing voice than me, so when you watch it next time, you'll know what I'm talking about. Okay, so we'll just get through this little piece, and then it'll give you the nuts and bolts of how to use this. So then you come to this page, and this is that sort of living platform that you can interface with Epic people, and there's that It's Possible videos. So now you're going to go into the browser search bar, and you'll type in SSH, and there it comes up. And then there's all that content that we talked about in those slides, which is based on that shoe document that I mentioned, so you can see it's the gamut of different information. There's It's Possible videos down there for you, so you don't have to search for them. They're on that one page for you. So we're going to go into soft tissue defects, so you click on this, and it's just telling you that you're going somewhere to another platform. That's all that is. And now it takes you to Epica, and this is what you see. Okay, so you'll see in this, for soft tissue defects, there's only three sort of notes that are already populated for you. And so this is basically, you can get this, this is the website that you're going to. That's why I gave you that disclaimer that you're leaving that area. And then you have this sort of operative note there, sorry, progress note. And now you can scroll down even more, right? This is what I told you about. So this is just A, it goes down to Z. So you can see it's tagged by ASSH, because if you go up higher, there's different A's. And so you can see the number of notes, clinic notes, rounding notes, surgical notes that exist. And over time, this will populate more, so as more members use this, you can add yours there, so another member can use this. So this is an impatient note, for example, if you're rounding and you don't want to do a note and you don't want to dictate a note, this is basically a templated note for you, or a discharge summary note, for example. Now if you like this, what you can do is that you can basically then email your IT person if you want to get it into your system. Okay? And you can see in the top right, she's clicked email, and you send it to whoever, and they can easily put it into your system if you want that as well, rather than having to go to Epic Earth every time to get a note that you like. So this is just scrolling down, and this is how you add those tags. So let's say you created a note and you don't like the tag. You can add your own tag and make it very personalized to you. So I think I'm happy to take questions about that, but that's just something that exists already on the system that will hopefully make it easier for you, rather than recreating the wheel, making your own templates, making your own notes, where you can use those, update your own, but also take those and make them your own in your practice. Thank you. Thanks, Sanj. That was excellent. Thanks for your work through the Hand Society on tackling that through Epic. Just by a show of hands, who in the room uses Athena? Okay, great. So, again, my name is Max Starr. I'm at Georgia Hand, Shoulder, and Elbow, and for the past eight years, we've been using Athena in our outpatient clinics, with our surgery center and our therapy department. So I'm going to, for those that may be shopping for a new electronic medical record, we'll kind of start off with just an overview and go through the patient chart basics, the provider home page. I'll touch just briefly on the revenue cycle management and quality management and reporting. Then we'll dive a little bit into optimizing and use of Athena with templates, including operative and procedure templates, clinic templates, both with our physicians and our therapists, surgical order sets, text macros, and additional features within Athena. So quickly to go through the patient chart, when you open the patient chart, it's going to look something like this. You'll see the patient banner at the top. It'll show you where the patient is. This patient currently is ready for their provider in the waiting room. The drop-down box shows you just pertinent demographic information about the patient. And then the sticky note that is circled with the exclamation mark is a place that we relay messages to our staff that I may put in that note. Next visit, please obtain grip views or follow-up cold results, just something we want to make sure we remember going forward. You can configure the patient briefing on the left side. We typically just leave it as the problems we're treating the patient for, medications and allergies, but you can click on the gear icon and configure that how you want to. On the right side, you'll see your last clinic notes, your assessment that you had along with follow-up visits. And then the recent activity will typically show you recent labs that have been ordered, imaging that you need to follow up on. The chart tabs allow you to quickly click through patient medications, allergies, lab results, and previous visits. So this is your provider homepage. This is what I'll see when I come to clinic and open up my day, so to speak. You'll see a list of the patients. We can import their photograph, and then we've created a tickler that shows what the patient is coming in for. On the left side, you'll see your inbox. The tabs I use the most here are the orders, prescriptions, and authorizations along with the lab and imaging section. And so opening up each of those, this is every day I'll check my inbox for labs and imaging, MRI results that have come through, CT scans, labs. My workflow, I typically like to leave these in my inbox until I've discussed them or reviewed them with the patient or seen the patient back or called the patient concerning the results. In the orders, prescriptions, and authorizations, this is something that we've changed over to recently, signing. This is an example of a therapy progress plan that's come from an outside therapy facility that goes into the inbox here. I sign it electronically, and we send it back to the outside therapy department. For the patients that are being treated within our therapy department, their notes are directly in the electronic medical record, but these have to be faxed and signed and sent back. I also sign, in this area, prescriptions my staff has sent to the pharmacy or MRI orders, et cetera. This is outside the scope of the talk, but just to mention revenue cycle management, Athena does allow you to customize reports well, so you know, you can do it for your therapy department, your surgery center, each provider, and look at the, you know, AR and collections over whatever time frame you want to, and this can be customized for each employee in the billing department and what they, what data they're looking to analyze. Similarly for quality management reporting, CMS requirements for MIPS, you can choose your initiative you want to track and track it through each provider and see where they stand on measuring that performance and compare it also to the Athena net average. All right, so diving a little bit now into the templating, which we've discussed with the other two systems, this is the page you're going to go to to create your template. This is an example of just creating a simple template for a trigger finger release. The code language I have listed in a handout that was provided to you is pretty simple, but here we basically just corrected different, or created different paragraphs with different drop-down boxes that you can then easily click through. When you're in the daily encounter, you'll find it under the procedure documentation. You just select trigger finger, it has my initials there, and then it pulls up this note that you can quickly click through the drop-down boxes to complete the note rather simply. Once it's completed, it looks like this within the note. So I would say the global templates available in Athena are pretty weak for hand and upper extremity surgery. I would assess a negative for Athena, something that could be improved upon, similar to what's been done in Epic, but this is what is available globally to kind of pull from from Athena. This is an example of constructing a template for a general hand exam. You can see that you, talking about the incision in this aspect of the exam, the skin exam, you select your normal, the incision being well-heeled, and then you select your contradicting statements you want to have available. And then on the right here, it shows a preview of what your template is going to look like that you would then click through when you're filling the note out. There are some exam findings specific for hand surgery available within the Athena global network, such as special tests for the hands, such as the phalanx test, compression test. The sensory exam, I think, is kind of weak in general, could be improved upon. And then musculoskeletal examination also, things such as tenderness of the bone or the metacarpal or tenderness at the A1 pulley, you know, and exam findings such as is the FTP intact, is the FDS intact. Those things are all globally available to construct a template if you take the time to do it this way. This is what it looks like when you're doing it within the note after it's been constructed. It'll default to the normal hand exam findings, and then you can click on the arrow over here to the side to open up that area of the exam if you have any abnormal findings or positive exam findings, and then it opens up to these boxes you can click on. So compression tests for the carpal tunnel is positive. You can change that and leave everything else to be normal as an example. I think it's more helpful to create your own templates if you take the time to do it. They're just more detailed, you know, more customized, obviously, and so similar to what we talked about for the operative note, you can do that for your exam findings. This is just an example of creating a custom template for a post-op carpal tunnel. Again, you have your normals, and then you have your contradicting statements that you can create and quickly click through to complete the post-op exam for carpal tunnel. So our hand therapists also use templates. This is an example of their daily therapy note. They have a lot of text boxes they've created where they can put the diagnosis in or the surgery performed, the date of the surgery, the daily pain rating scale, and they do have a lot of boxes they click through for the physical examination, and then, you know, things that are important for the payers to see, too. Why is skilled therapy needed? We have... They have a section, actually, they have the modality codes and CPT codes that they can click and select that they've performed to help with the billing process also. Once the note is created, it's going to look more like this within the patient chart. The other thing Athena allows you to do is just to copy and paste your previous HPIs, previous assessment plans and physical exam. You can see that here for, you know, a patient that's coming back with wrist arthritis or thumb CMC arthritis where maybe the HPI is basically the same every time you see them every three months. You can kind of... You can pull that forward along with the exam and the plan, and that makes it pretty quick to complete that clinic note for the day. Custom surgical order sets. This is something that we began doing a few years ago as well. You can create custom order sets within Athena for your outpatient surgeries for, you know, common procedures. You select that in the assessment and plan section of the note. And then it'll pull up the CPT codes, which is really helpful for our staff, you know, as opposed to me having to tell them every time with the CPT codes. It's already stored there. It ties it to the ICD-10 code, which helps with pre-authorization. It also has my preferences, so this is for a shoulder scope. It lists the CPT codes. You know, if I'm not doing the distal clavicle, I'll tell them to take off the 29824 and leave the other numbers. But it just... It speeds up the process a little bit. It also has my preference for arthrax anchors, you know, and positioning. And so I just basically say, you know, just use my order set for shoulder scope, and they pull this up and can take it from there. Once the order is complete, it goes into your note in the assessment and plan section, and then can be sent for pre-authorization. So text macros in ATHENA, I think this is actually utilized more than templating in our clinic. It's pretty straightforward, pretty easy to create these, and can be very helpful for common visits. In the HPI section, physical exam or assessment and plan, if you spend the time to, say, type in your plan for lateral epicondylitis, and you realize that you can use this every time you see somebody with lateral epicondylitis, you can save it as a text macro just by clicking on this star over here to the right, and then creating a shortcut. You can also create these macros outside of a patient chart by going to the gear function. This is the code language that, again, is used across the board in ATHENA, and is in your handout if you want to take this back and work on templating or macros. It shows you how to make tables, bulleted lists, drop-down lists, et cetera. Once you've created your macro, the next time that you need to use it, you can just go to that section and type your dot and your shortcut, and it'll pull in your macro. So just an example of a post-op carpal tunnel release, you can say your standard HPI, patient's pain is controlled, he's been in his dressing, working on motion, and his numbness and nocturnal pain have improved. Go quickly to your physical exam, put .CTPE, incisions clean, dry, and intact, five out of five strength, two-point testing is normal, full range of motion, and then same thing for your assessment and plan, .CTAP, and it pulls up doing well, sutures removed, wound care discussed, home exercises discussed, follow-up five weeks for repeat exam. So you can quickly click through that note, you know, within 30 seconds in your clinic. Some additional features in Athena that we utilize, inserting a photo into the clinic note or examination, this is something that I just learned how to do recently, but our therapists have been doing for a while, and this works well for us, because a lot of times our post-op patients will go to our therapy department before they see us, they're flexor tendon repair, they've been taken out of their splint, they've been put in their orthoplast splint, dressing's changed, and our therapists will just take a picture of the wound, and when they come up to our clinic, we just quickly, you know, can look at the picture within the chart. Obviously, it works well for things like open wounds, cat bites, you know, dog bites, trauma that is being treated in the therapy department as well, and you can look at the photos and follow that without having to take the dressing down yourself in your clinic and spend the time doing that. So underneath physical exam, you'll find ad photos with Athena Capture, and you have to have Athena Capture downloaded as a app on your phone, but you go and you're in the patient chart here in the physical exam, you click on the ad photos with Athena Capture, it gives you this barcode to scan with your phone once you're in your Athena app, you scan that and take a picture of the wound you want to put into the chart, this is just from a humoral non-union, and then you can import it directly into that daily progress note. You can also do it if you've taken the, already taken the picture and you're not in the patient's clinical note for the day by just adding a document in the patient's chart and then again selecting Athena Capture and importing the picture that's already on your phone. You can do this with other documents as well. If you had an EMG and nerve study and for some reason you weren't going to scan it in your chart, you could even just take a picture of that. You select where you want it to go into the patient's chart, scan the QR code, and then just import it. The Athena app I do utilize and I think is user friendly, I typically use it to pull up my clinic day, I can also just, if I'm out of town, check labs and test results easily through the app. And then one other thing to mention that some of our providers use is iScribe, again no disclosures for me with any of these products, but iScribe allows you to use voice to text dictation and it links directly into the EHR. This is helpful I think for new patients, it's hard to template a new patient and be efficient with it, but if you have a new patient, again with lateral pecundilitis, you can dictate your HPI and then just insert your macros that you've already created in Athena for the physical exam, the assessment and plan by asking the iScribe to insert the macro. So it's kind of a hybrid system that allows you to quickly go through the day. Future directions of Athena, things that I think could be improved upon, I've kind of touched on some of that with improving the global templates, I also think improving integration of radiology imaging such as in Epic, it's nice where you can pull up the report and then click to go straight into the image to see it. You know, with Athena you have to have two different systems, you're opening up your PAC system and Athena, there's no way to go directly from Athena to that PAC system to view the image. Our group is currently in beta testing with Athena working on more specific surgery order sets that could be utilized for Athena for things like hand surgery and just there's a lot of things in the surgery order set now that are not needed for our practice and we're working on customizing those for things like hand and orthopedic surgery. So that's pretty much it. Thanks. Guys, you want to come up here and maybe we'll just, if there's any questions, I'd be happy to field those now. Any questions? Any questions? Sir, with regards to Epic, what I understood is there's not a way to directly go to Epic or grab those notes and bring them into your Epic system. What you do is, so when you click on the chart, on the note that you like, in the top right there's an email function and you email it to, because sometimes it's hard directly to do it yourself, but in every practice there's always, I think, an IT person or whatever can help. So you email that person and that person can then install it into your Epic system so you don't have to always then go back to Epic Earth to find that note that you liked. And so that's the best way to do that. It's the most efficient way. You can sometimes highlight it all, copy, and then make a new one in your own and insert it, but sometimes it doesn't translate all across the little sort of tags behind the scene so that's why we put that email function in, because some systems have these firewalls that it may work once but not again. The beauty is that you can then add your notes onto that sort of Epic Earth platform as well so another member in the Hand Society can use it or whatever and that's the beauty of it. For Cerner specifically, that's something that I don't know if there's a good upfront interface with the producer itself. Having done it throughout residency, IT can gather, but it is a bit onerous. So the metadata for sure exists within Cerner, but it's not a convenient way that I've found, and I think that led to a lot of chart reviews in that regard. Yeah, there definitely is within your group, but I don't think there's a good global way to do that at this point. I think that's something that could be improved with Athena, but there are global templates that are within Athena, but if you create one, I don't think you can import it to the Athena global network, but we do share between providers in our group. Anything else? Thanks for getting up early to discuss the electrodynamic work.

electronic health records

EHRs

integration

researchable data

claims processing

clinical efficiency

templates

radiology imaging