Thursday, June 16, 2011

Why You Need a Clinical End of Day Procedure?

At the end of the working day, every healthcare organization performs a reconciliation of fee tickets and receipts to assure that all charges and payments were properly posted and applied.  This effort assures the integrity and accuracy of the financial records.  A similar process is needed to maintain and assure the integrity of your EHR based patient information.

EHRs include a wide array of information that traverse through an EHR life cycle to completion.  Some clinical lifecycles last a few hours and others may last years.  For example, a refill request may be completed in a few hours or even in the current session while an order for annual checking of a patient with an implant may be completed within the year.  Colonoscopy orders may take ten years to complete.

Note that paper charts have similar issues.  However, we cannot practically monitor or identify open items in a paper chart or unaddressed patient messages.  EHRs can instantly analyze the status of a particular message or identify all open messages meeting a certain criteria.  For example, we can produce a list of outstanding surgery orders that have not been completed.  This management capability allows you to improve patient service and monitor workflow.

In the course of an average day, each physician may generate or respond to a hundred or more clinical events, each with its own lifecycle.  The exchange and movement of these clinical events may involve several administrative and clinical personnel.  However, the EHR’s ability to support care and patient service can be undermined by not maintaining the correct status of various EHR items.

These lapses may be the result of a lack of training, temporary issues in the practice or a good faith effort to completely document a patient situation before completing the patient record.  A myriad of problems arise when users fail to control and track lifecycle events:

Messages - Tasks or messages may result from a variety of patient interactions and practice activities.  Patients calling in for refills or advice may generate a message.  Physicians may send a message to staff to follow-up or refer a patient issue.  Failure to maintain appropriate status of messages could lead to cluttered inboxes which will confuse doctors and staff.  For example, a review lab results message may remain open for results that have been reviewed.  New documents may be displayed as already been reviewed.  Users will waste time looking for the open tasks or in the worst cases stop using messages and tasks to document activities.

Orders – Many EHR systems accept orders for future services such as tests, procedures, and therapy.  Orders may be fulfilled by a service provided by the practice, or a report from a third party provider.  If the order status is not properly maintained, then the display of patient orders on the patient summary screen will be incorrect, and management tools to survey open orders across all patients will be distorted.  Note that corruption of order status may inhibit your ability to meet the Patient Reminder Meaningful Use Menu Measure.

Exam Note Signoff – Patient EHR notes require a signoff to acknowledge completion of the patient encounter.  Signing the note is essential to document physician approval of the note and plan for patient treatment as well as document the level of service.  With the best of intentions, some physicians prefer to leave notes unsigned in case a subsequent event affects the analysis or plan.  However, without checking each and every note, notes could remain unsigned long after the patient is seen.  Some EHR systems will automatically lock the note without the doctor ever signing the note.

Document Review – Incoming documents may be received by fax or scanned into the EHR.  Unlike paper records, electronic images can be tracked through the status of the image or associated messages.  However, failing to maintain the appropriate status can lead to inaccurate documentation of patient services and even missed opportunities to review the document.

Incoming Patient Portal Information – Patient portals facilitate the exchange of information with patients through a secure internet connection.  Typically patients can request appointments, submit refill requests, send messages, and even submit clinical information.  Each portal interaction is presented through the EHR to support physician activities.  However, these patient portal items have to be tracked and managed with the same due diligence discussed for messages.

In the event that the EHR status is not properly maintained, some practices have resorted to a shadow paper based system that further degrades the utility of the EHR, and undermines the maintenance of the patient medical record.


Many EHRs include a variety of tools to monitor the status of the patient medical record contents, messages and other patient service items.  However, such management tools are subject to the proper disposition of messages, orders, patient notes and other EHR patient information.  In order to maintain the effectiveness of the EHR and properly manage the patient medical record, the practice needs a daily process to assure that the EHR is being properly used and maintained.

The end of day clinical process should be based on a set of standards established by the doctors covering that various activities and tolerances for response or completion.  For example, doctors may have to sign exam notes before the end of the day.  The actual end of day process will mostly consist of reviewing lists of messages, orders and other items that exceed these limits and following up with the appropriate physician, or staff member.  Summary statistics should be maintained on a daily basis and reported to the administration on a weekly or monthly basis.

Message and Task Reconciliation –
Message and task management is the most complicated part of the clinical end of day process.  Messages and tasks analysis should be based on practice level performance standards for each type of task.  Thereby, the daily close procedure will actually consist of several different processes.  For example, messages classified as refill requests should be completed within 24 hours of receipt.  Patient care questions should be answered within 4 hours.  A separate reporting and analysis process will be performed for each type of message or task.

The EHR should have a management screen or supporting reports that present tasks and messages based on a date and time tolerances.  Users should make liberal use of start dates for messages and tasks.  However, stop dates for clinical messages and tasks should be carefully controlled.  In many cases clinical tasks do not stop, but are superseded by a new treatment strategy, or a change in the patient status.

Document Review – Unreviewed documents should be identified within the review standard established by the practice.  Some EHRs have time limits on document review and will automatically accept or lock the document into the chart.  The end of day process will have to work ahead of such a locking mechanism.

Provider Note Signing – Some physicians leave notes unsigned for any number of reasons.  In many cases, providers do not fully understand the implications of open notes or are reluctant to sign a note that could change due to receipt of new information or change in patient status.  Most EHR systems require signed notes to complete the note and maintain the information affected by the note.  Many EHR systems allow the provider to sign the note and then amend the note to account for any changes due to subsequently received information.  A practice policy should be created to address this issue.

Periodic Order Management – On a weekly or monthly basis, all orders should be similarly reviewed based on established standards for each order type.  Orders should be entered with a trigger and a due date.  The key issue will be follow up on orders that are past their due date with the patient and/or physician.  For example, certain types of orders beyond the due date may trigger sending a letter to the patient while other order types may warrant a phone call.  Be especially careful to insure that you can change the order status to correctly classify the patient situation.  For example, the order may be superseded, or the patient refused the care recommendation.

Recovery from failure to maintain the various life cycles of your EHR could entail an expensive and time consuming effort.  More seriously, the collateral problems could be felt for many months or years thereafter.  For example, the automatic locking of unsigned patient notes would not allow you to update an unsigned note.  In some cases, you may have to create a new note that duplicates the information from the old note.  In other situations, failure to follow up on prescribed patient treatment orders could expose the practice to a variety of patient service problems and potential medical professional liability exposure.

A clinical end of day process will allow you to monitor the appropriate maintenance of your patient service records and documentation to avoid distorting your patient records and undermining your substantial investment in EHR based patient records.

© Sterling Solutions, Ltd., 2011

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