Speaker 1: Allscripts Enterprise EHR Building a Patient's History through the ACI Demonstration Brought to you by Galen Healthcare Solutions Welcome to Building a Patient's History through the ACI. ACI stands for Add Clinical Items. The ACI page allows the user to add a patient's history, allergies, medications, orders, prescriptions, and more. During this demonstration, we will focus on building the patient's history. The ACI can be accessed by using one of the three icons on the clinical toolbar, Problems, Rx, or Orders. Each page of the ACI works similar to the next. The main tabs include History Builder for entering the patient's history, which most sites obtain the data through an intake or health history form from the patient or chart, Rx Orders for entering medication and orders, and Problem-Based Orders for entering medication orders based on a patient's active problem. The sub-tabs for the History Builder screen are Active Problems, Past Medical History, Past Surgical History, Family History, Social History, Allergies, Medication History, Immunization History, and Chief Complaint. Components found on the left-hand side of the screen are configurable workspaces that provide easy access to frequently used items. Once a sub-tab is selected, My Favorites will be displayed in the view. I can change that view to a Specialties Favorites list as well. As I type the problem I am searching, my Quick Lists items appear. If I hit Enter, it will search the entire database. This search feature works the same throughout the ACI. My Favorites is a customized list of frequently used dictionary items and is user-specific, although an administrator can copy one user's favorites to another. Specialty Favorites are pre-defined favorites by the site that list all items relevant to the selected specialty. Quick Lists items are a subset of My Favorites, which contains your most frequently used items. Once I find my item, I simply put a checkmark in the box selecting it. The Past Medical History and Past Surgical History tabs work the same as Active Problems. Since this is not a training video, but merely a demonstration, I will highlight some of the different features of the other tabs. In the Family History sub-tab, you have the ability to indicate the relationship of the family member for the history you wish to add. Therefore, if the patient's maternal grandfather has hypertension, I can make that specification here. If unsure of the relationship, you can click on Family History and then click on the problem. Under the Social History tab, you can indicate a patient's response was negative. As an example, if a patient denies alcohol use, I simply right-click on the item, select Deny, and it will be added under the sub-category of Denied. When adding allergies, click on the Medication or Non-Medication radio buttons to specify the allergy type you are searching for. To indicate that the patient has no known allergies, simply put a checkmark in the box. The system will display this information in the patient banner. When adding a medication to a patient's history, the system will display a formulary status icon next to the drug name, indicating whether the patient's pharmacy benefit plan covers the drug. A green smiley face indicates the preferred formulary, while the yellow face would indicate an approved formulary. If you saw a red frowny face, this indicates that the medication is a non-approved formulary. When a PA appears next to the drug, this indicates that prior authorization is required. OTC, such as this one, indicates an over-the-counter drug medication. If no icon appears next to the medication, this simply indicates that no formulary information is available for the selected medication. Now to add an immunization history, such as a varicella injection, I would simply click on the varicella, bringing up a dialog box. Now one thing about the Oscripps Enterprise EHR is that any yellow field that you see indicates that it is a required field. If I do not know the date and simply know the year, I can type in that information and then click save and return to ACI. Once I am done building my patient's history, I click OK, which returns me to the clinical desktop. Once on the clinical desktop, I can see that I have changes that I need to commit to the patient's record. I simply click on the commit button in the clinical toolbar, which brings up the encounter summary. I can verify the information added and click save and continue. This completes our building a patient's history through the ACI. Galen Healthcare Solutions hopes you enjoyed the Oscripps Enterprise EHR, building a patient's history through the ACI demonstration. For more information, contact info at galenhealthcare.com.