EHR Queries
Just wondering how others handle physician communication or queries in
the electronic record. We have Meditech software with 95% of our record
electronic in the EMR. There is a hard chart on the floor but many
physicians do not look at them since only signed documents, outside
records and administrative info are hard copy.
I would be very interested in how others are handling this.
Sharon
the electronic record. We have Meditech software with 95% of our record
electronic in the EMR. There is a hard chart on the floor but many
physicians do not look at them since only signed documents, outside
records and administrative info are hard copy.
I would be very interested in how others are handling this.
Sharon
Comments
Almost any EMR has a function where physicians receive 'emails' that are completely internal to the system -- for Epic, an inbasket. This is the avenue they often receive notifications for documents, labs, orders, etc. that require co-signing, action, review, etc.
This is also an often utilized avenue (by design) for queries -- both the traditional coding function as well as concurrent. All of the same challenges for any query system (paper, email, electronic) exist -- prompt & accurate physician response, will the query be part of the legal medical record, where should the physician document, physician knowledge of how to handle or process the request, etc. The EMR is not a 'magic bullet' to solve query woes, but it certainly can be a powerful tool.
We use Epic -- so I can not speak to how Meditech software is built to handle the process. Hopefully someone will chime in with their direct experience.
Don
I have been in this role for over 3 years and have only queried electronically. Check to see if your EMR has a communication mode. Both systems we have used there has been a method of communicating clinical information via the record: one system had a tasklist in which I was able to send a query to a physicians tasklist and now we have EPIC and we send our queries via an In Basket to a folder labeled "Coding Follow-Up". We have only had EPIC for three weeks now so we are still working the bugs out of this system.
Cindy
and re-educate your providers on how you are going to be sending them
queries. If you send them via your EHR and they don't know to look for
them there or how to look for them there, you shouldn't expect a
response. Tools like this are great, but to work everyone involved has
to use them.
Robert
Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602
P: 989-497-2500 x13101
F: 989-321-4912
E: Robert.Hodges2@va.gov
"The difference between the right word and the almost right word is the
difference between lightning and the lightning bug." Samuel "Mark Twain"
Clemens
http://blogs.hcpro.com/acdis/2009/09/does-your-hospital-use-the-epic-software-system-lets-hear-about-it/
Gail -- would be happy to speak with you a bit more. I will email separately to arrange a time.
Don
Donald A. Butler, RN, BSN
Manager, Clinical Documentation
PCMH, Greenville NC
dbutler@pcmh.com
Never give in. Never, never, never, never--in nothing, great or small, large or petty--never give in, except to convictions of honor and good sense. Never yield to force. Never yield to the apparently overwhelming might of the enemy
Sir Winston Churchhill
Dawn M. Vitalone, RN
Clinical Documentation Improvement Specialist
Community Hospital
Greta Goodman
Clinical Documentation Improvement Specialist
Health Information Management
Virginia Hospital Center
1701 North George Mason Drive
Arlington, VA 22205
703-558-5336
ggoodman@virginiahospitalcenter.com