Orders vs. Encounters
In most healthcare institutions, medical procedures are associated with orders or encounters. An order (or standing order) can be defined as rules, regulations, protocols, or procedures prepared by the professional staff of a hospital or clinic and used as guidelines in the preparation and carrying out of medical and surgical procedures. An encounter can be defined as a health care contact between the patient and the provider who is responsible for diagnosing and treating the patient.
Generally, you need to have an encounter to have an order.
If I am going to have some lab results drawn, the healthcare personnel will create an encounter (my visit) and then create the order for which particular lab results need to be performed. This order is either fulfilled internally (or at a cooperating laboratory) at the existing institution, or given to the patient if they are going outside of the network. The latter often happens for patients that have traveled to another location for a medical procedure, then return home, but still need follow-up care.
Lab results are taken care of internally or at a cooperating lab
The results most often are interfaced directly to the EMR. However, when the patient goes to an outside agency to have those lab results drawn, the order is given to the agency, and when completed, those results will most likely be faxed to the originating treatment facility. It is then up to that department to enter those results into their EMR using the existing order number.
External lab results
Often with transplant centers, they get external results for which orders have not been placed in their current EMR. For these cases, the people performing the data-entry of results have to create an encounter, create an order, release the order, and finally enter the lab results specifically to that order. They then often have to scan or attach the document to the order so it is part of the patient’s record.
For most Extract users, having an order number is paramount for being able to have the lab results file correctly into the patient’s record. During lab result verification, one additional essential piece of information is required to file results, the MRN. Even though Extract is technically a stand-alone system, there is no need to tab between our system and your EMR to find this critical information. Because we already have it.
As patients are registered or checked-in and as orders are placed and released from the EMR, those orders, encounters, and patient demographics are transmitted to Extract via orders and ADT interfaces. Order numbers, along with patient MRNs and CSNs are captured and stored in our secure database. During the verification process, the MRN is “magically” populated by Extract when we cross-reference the data we extracted from the document with the EMR data we received across the interfaces. We then do the same thing with the orders based on procedure and collection date. If we can’t find the perfect match, we have a friendly selection list that displays all of the existing orders that have been received by Extract for the particular order type, and the user can easily select the order.
Both of these processes save the user time and effort, as well as preventing potential typing mistakes.
Lab workflows are where we got started in the healthcare industry…but the features above don’t stop there. We have applied these concepts to pathology, radiology, clinical research, consult letters, and even junk faxes! Our specialty is determining the type of document your users are looking at, finding the important information within the document, matching to your EMR database as needed, and filing the data in the right place so it can be easily found and trended.
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about the author: Mike Beles
Mike Beles, Customer Support Specialist & Project Manager at Extract, has been involved with implementing and leading software projects for over 18 years. He has a well-versed background in software training, support, quality assurance as well as both product and project management.