Sample Scenario for EHR Evaluation

This scenario was written by a family practitioner employed by HealthInsight and may be used by DOQ-IT practices. It is meant to help standardize vendor presentation so practices can more easily compare different EHR products. However, it is recommended that practices use this format to develop their own scenario based the typical conditions the practice sees that demonstrates routinely needed EHR features, leaving time for the vendor to demonstrate other features of interest to your clinic after the scenario—the scenario need not cover all of them.

Instructions: Send this scenario (or your own version) to the vendor. The vendor should enter the following data into their system before the demonstration. Once these data are entered, the vendor should be prepared to walk through the scenario listed below.

Vendors, please enter the following data before the demonstration:

Demographic information:

· Martha Edwards DOB 10/4/50

Problems:

· Hypertension

· Depression

· Asthma

Medications:

· HCTZ 12.5 mg qd

· Lopressor 100mg bid

· Wellbutrin XL 300mg qam

· Advair Diskus 1 inhalation bid

Allergies:

· Penicillin -> urticaria

PMH:

· Hospitalized once for pneumonia 1998

· Drinks occasional alcohol

· Influenza vaccine 10/05

· Pnemovax 1999

Mock visit information to be covered during the vendor demonstration:

Office staff interact with patient and enter the following

· Receptionist retrieves patient record and enters chief complaint of headache

· MA rooms patient and performs/enters:

o Weight 180

o BP 180/95

o Pulse 89

o Temp 37.5 C

o Resp 28 regular unlabored

o Checks needed preventive care

MD sees patient and enters the following:

HPI:

Patient reports new onset of headache 12 hours ago. Headache is characterized as located behind her right eye, sharp, or throbbing in nature. It was preceded by “flashing lights” in her right visual field. Associated with nausea, vomiting, and photophobia. She has no associated numbness or weakness. She had similar headaches twice as a teenager, but none since.

Her mother had “migraine” headaches. The patient had motion sickness as a child.

PMH:

· Menses irregular, last began 10 days ago and is still bleeding

· No alcohol during past 10 days

PE:

· Gen: Lying down with lights off

· HEENT: Photophobia limits examination. Discs not visualized. PERRL. TMs clear. Nose clear. Throat clear.

· Neck supple

· Lungs: RR 24. Clear to P. Mild diffues insp/exp wheezes on auscultation.

· Ht: Normal

· Abd: Normal

· Neuro: Alert, orientedx3. Light touch intact. Gross Motor symmetric. DTRs (deep tendon reflex) 4+=. Cereb: F->N, H->S normal CN 2-12 intact.

Tests:

· Peak Flow 210

· Pulse Ox 92%

Assessment:

· Migraine headache, possibly precipitated by perimenopausal status?

· Asthma exacerbation

· Hypertension, inadequate control

· Irregular menses, probably perimenopausal

Plan:

· Lab: Chem 6 (Hepatic Function A)

· Rx in office:

o Albuterol by nebulizer

o Maxalt-MLT 10 mg ODT (orally dissolvable tablet)

· F/U:

o Observe in office: 1 hr after treatment, pt reports headache resolved, BP 140/85, Peak Flow 320

§ MD Reviews these results in table or graph

o Return 2d for recheck and plan ongoing management of migraine, htn, perimenopausal status, asthma.

MD chooses charge level.

MD completes and signs note.

HealthInsight prepared this material under a contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (DHHS). The contents presented do not necessarily reflect CMS policy. PUB# 8SOW-OM-TN-04

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