ADT and Resident Information
Admission, Discharge and Transfer functions include all relevant and important resident information and demographics. This module also interfaces with the SOS billing system and is the source of information used in transfer sheet for temporary hospital discharges, face sheets and the CCD (Continuing Care Document).

The Electronic Chart (eChart)
The Optimus EMR^TM System’s eChart represents the new method of accessing and viewing pertinent and up to date resident data and virtually eliminates the need for paper-based charts. The eChart provides all caregivers with real-time access to all of the critical information in the resident’s electronic chart. It also provides caregivers a comprehensive, real-time view of all resident care activities and other clinical information, which greatly improves communication between caregivers and tracking of resident care. The eChart is available remotely for any authorized users, including physicians, nurses, therapists, and pharmacists.

Point-of-Care (POC) Documentation and ADL data collection
The Optimus EMR^TM System utilizes a variety of computer technologies to document at the POC, including hand held PDAs, wireless touch-screen computers, wall-mounted kiosks, tablet PCs, and laptops. The POC charting opportunities support all disciplines; the variety of devices allows the organization to select the right tool for each caregiver’s workflow. With the mobile devices, Optimus EMR^TM users can also take advantage of the unique ID located on the resident’s wristband and caregiver’s ID badge. POC documentation and unique IDs enhance accountability and staff performance, while increasing the amount of accurate data collected about each resident’s care. With the Optimus EMR^TM System, the data collected at the POC and elsewhere automatically complete all relevant sections of the databases for future access through the eChart, use in reports, the eCC alerts and MDS calculations.

Automated MDS
This automated MDS is unique to Optimus EMR^TM and a cornerstone of the Optimus EMR^TM system. The automated MDS module operates on demand, combining and evaluating all of the observations, assessments, nurses’ notes, MD notes, and ADLs collected during care and documentation, as well as all other pertinent clinical data in the electronic medical record. Once an assessment reference date (ARD) is selected, the stored clinical data (look back period) are compiled into five automatically completed MDSs through a set of sophisticated algorithms and calculations by the Optimus EMR^TM System. The data are always ready for the MDS calculations and the calculation process may be repeated for any appropriate ARD until the optimal date is selected.

Once the optimal ARD is selected from those calculated, the Optimus MDS is completed and ready for review and analysis. Instead of manual data gathering and manual data entry as required by all other software systems, Optimus EMR^TM converts the collected data into MDS responses that flow to the specific MDS that is ready to be reviewed, edited as necessary, and transmitted. In addition, the MDS program has embedded checking for illogical responses and possible errors/omissions, which eliminates the need for other MDS analytics software.

Coordinated and Integrated Interdisciplinary Progress Notes, Observations and Assessments
The Optimus EMR^TM interdisciplinary notes and assessments are fully integrated into the full EMR and automatically available for the MDS and the other pertinent areas of the EMR. Therefore, your facility can now capture accurate care data that result in accurate and usually higher ADL scores, RUG rates, and Medicaid case mix indexes. The specific modules are: physician notes, advanced skin and wound assessment, general and admission assessment, risk assessment, accident and injury reports, pain assessment, continence assessment, and many more. All Optimus EMR^TM progress notes, observations, and assessments are created with fast check-box, point-and-click entries through logical clinical paths, which create searchable narrative notes for easy review and clarity.

Optimus EMR^TM knows that clean and intuitive interfaces are a critical component in providing CNAs, nurses, therapists, and MDs the efficiency tools to capture data during their normal work procedures. The Optimus EMR System uses preformatted phrases and check boxes (structured notes), guided clinical pathways, and recognizable screen graphics to provide ease-of-use and documentation assistance for the staff. Free text input can be added when desired by the caregiver within each section. The system organization is very intuitive and follows normal caregiver workflows.

Also, the Care Plans are integrated with nurse orders, task lists and reminders for all staff that create alerts for incomplete actions on the eCC.

Electronic Control Center (eCC)--Management Dashboard
The Optimus Electronic Control Center (eCC) is an exciting executive digital dashboard for senior executives, administrators, and clinical managers. It provides "fingertip" information and controls of the key areas to be monitored to effectively manage the facility. Management and staff alike now have a tool that provides a complete view of the facility’s performance in real-time from their desktop, including user-defined thresholds for medical or operational alerts.

The eCC is comprised of several user interfaces or "information panels" that provide information, alerts, and analytic reports (graphs and charts) regarding the following areas:

• Census information
• Incidents, accidents, and injuries
• Incomplete clinical data and documentation
• Reminders regarding medication passes (eMAR) and physician orders (CPOE)
• Quality indicators
• RUGS and Medicaid case mix scores
• MDS schedule warnings
• Clinical exceptions, conflicts, and warnings

Each user of the eCC sets up his or her personal eCC screen preferences. The setup allows each user to choose which information panels are most important in the daily management of the facility. Whether it’s an administrator managing census and case mix scores, a DON keeping tabs on QIs and incidents, or a charge nurse monitoring clinical documentation compliance, the Optimus eCC is the first tool to provide your management team the real time and accurate information it needs to effectively manage your facility’s performance.

The Physician Order Module, or CPOE
The Optimus EMR^TM System supports two methods for order entry. The traditional physician order entry (PO) provides for all types of orders (medication, treatments, lab tests, dietary, therapy, safety, activity and ancillary), which are most often transcribed from written or telephonic physician communications and then entered into the system and conformed by other non-physician clinicians. The traditional monthly physician order, MAR and TAR "change-over" process is eliminated. This very expensive manual process is full of opportunities for errors. These problems and costs are eliminated with the real-time Optimus EMR^TM physician order and the related eMAR and eTAR modules.

The second type is the MD CPOE module, which allows for direct entry by the physicians either remotely or on-site. This module has been designed to provide maximum efficiency for physicians to enter the critical portions of each order and then be followed in the clinical workflow by nurses to conform and activate the orders based on facility practices, policies, and procedures.

The orders module utilizes an integrated industry-standard drug database that is updated monthly to capture all new medications, drug and allergy alerts and medication warnings. Both versions incorporate and allow for the use of clinical safeguards and good clinical practices and protocols to be applied to the ordering process, with nrequired tests, and documentation embedded in the resulting orders. Once the orders are entered and activated, they are automatically available and operational in the Optimus eMAR and eTAR modules.

Physicians may review and electronically sign all new and changed orders, either on-site or remotely from their offices.

The monthly review and approval of all orders by physicians may be performed electronically in full compliance with electronic signature requirements. All of these features deliver significant time savings for the physicians and facility staff.

eMAR and eTAR (Electronic Medication Administration Records and Electronic Treatment Administration Records)
The eMAR and eTAR functions with built in operational redundancy for this mission critical information. No other system has this redundancy and therefore does not have the primary safety feature of the Optimus System.

For the nurses, the eMAR and eTAR module is one of the most popular functions of the Optimus EMR^TM System. The eMAR and eTAR is fully integrated with the full Optimus EMR^TM, and as a result, the medication nurses are able to complete a large part of their clinical charting activities while they are administering medications or treatments. This charting, along with the associated recording of vitals, notes, observations, and assessments, automatically flows to the pertinent parts of the EMR and database, and creates appropriate alerts. The facility staff saves time during the medication pass and later, since much of the documentation has been completed simultaneously.

Medication errors are one of the most serious problems in all healthcare settings. The use of real-time information on portable devices allows for electronic tracking of medications administered, minimizes mistakes involving drugs and treatments, and provides many built-in required tests, controls, warnings, and reminders for the caregivers. Along with the pharmacy interface described below, the eMAR helps ensure that, the right resident, receives the right medication, at the right time. The Optimus eMAR is the only full-featured and integrated electronic medication administration record available in the industry. The Optimus eMAR and the physician order entry module can also assist your facility with cost containment through the customizable formulary management feature.

Pharmacy Interface and Interoperability
The electronic pharmacy interface sends physician orders directly to the pharmacy and delivers much better control and efficiency in the medication ordering and delivery processes, which leads to better medication administration and resident care.

The Optimus EMR^TM pharmacy interface is designed to improve accuracy and efficiency in the current cumbersome medication ordering and receiving process that exists among the physician, SNF nurses, and the vendor pharmacy. The pharmacy interface integrates with the pharmacy via an HL7 messaging engine. Using the interface engine, Optimus EMR^TM has completed or is finishing pharmacy interfaces with the most predominant pharmacy software systems serving the post-acute industry including: Omnicare, QS1, Framework, HBS and Rescot.

Some of the many features and benefits of the Optimus EMR pharmacy interface include:

• Pharmacy order queue and complete two-way communication of new orders, modified orders, and discontinued orders
• Reduced staff time for order communication and modifications
• Drug formulary alerts and ordering controls at both the facility and pharmacy
• Medication warnings available with the order and on the eMAR
• Positive medication check-in and verification
• Refill ordering though the eMAR and refill screen
• Bar code scans for positive medication identification during administration
• Patient verification through RFID bracelet and/or digital pictures

The Full Therapy (Rehab) Module
The Optimus EMR^TM therapy module provides complete electronic charting for PT, OT, and ST, and is integrated with the Optimus EMR^TM System. Now for the first time, therapists using the Optimus therapy module have full and real-time access to the resident’s entire EMR and eChart, providing instant clinical information to support the appropriate resident therapy decisions. All therapy documentation automatically populates the pertinent parts of the MDS, resident chart, EMR system, and a series of valuable reports.

Nursing staff using the Optimus EMR^TM now will have real-time access to all of the therapy notes, evaluations, and treatments. This provides facility management with powerful information to improve resident care, resident outcomes, and also to optimize reimbursement for Medicare Part A and Part B, and Medicaid in case-mix states.

Optimus EMR^TM has engineered the therapy module to be as automated as possible, similar to the design throughout the Optimus EMR^TM System. The result is automatic data flow to the MDS, reports, and to the SOS billing system.

The Optimus EMR^TM therapy system consists of the following functions:

• ADT module access for resident demographics and home environment assessments
• Physician order entry for evaluation and therapy orders
• Interdisciplinary screening
• Specific evaluations for PT, OT, and ST
• Daily and weekly notes
• Monthly notes and recertification support
• Input and capture of therapy minutes
• Therapy unit calculations
• Therapy cap calculations and compliance warnings
• CPT/HCPC codes applied to all therapy modalities
• Therapy information electronically interfaced with billing

Physician Full Clinical Module
The Optimus EMR^TM physician module was specifically designed for physicians managing long-term care residents. Physicians can now access the MD module while in the facility or from a remote location to do the following:

• Order entry (write new order) with electronic signatures
• Full physician clinical structured notes and free text for:
  • History and physical exam
  • Medical interim note
  • Quick notes for all systems
  • Transfer notes and orders
  • Medical progress notes
  • Podiatry
• Discharge/case summary
• Periodic Order review with electronic signatures

Complete support for CCRC campuses
Since many LTC organizations operate multi level campuses the Optimus EMR^TM supports the resident movement between settings and allows for the clinical history and records to be accessed and shared between settings as permissible.