medical records

Lab Result Orders and How to Get Them In The EMR With Automated Order Matching

Lab Result Orders and How to Get Them In The EMR With Automated Order Matching

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. 

Can Medical Record Abstraction Be Automated?

Can Medical Record Abstraction Be Automated?

Ahhh, the age old question.  Can (or should) tasks that humans can do very well, but perhaps not very efficiently, be automated with technology?  While the views on this topic would vary greatly from an abstraction service provider to a low-budget medical research project manager, there are perhaps a few things that could be defined to help one decide what is best for their particular medical record abstraction situation.  Consider these ideas:

Doing the Paper Shuffle

Doing the Paper Shuffle

The year is now 2017 and we have been a digital society for quite some time, but if you talk with people in the healthcare industry, you will find that paper is still floating around. In 2016, we worked with two major hospitals and you would be amazed by not only how prevalent paper documents are, but how these paper medical documents get copied and moved to different people through the hospital, this is what we call the “Paper Shuffle”. 

The 7 Million Dollar Clinical Data Problem

The 7 Million Dollar Clinical Data Problem

Your clinical staff must refer to paper, faxed, and/or scanned documents because clinical data found within these documents are not found in the EHR. Your interruptions to the workflow, that was carefully designed into the EHR, costs time, money, and frustration and it may even insert errors into the healthcare decision making process.

The Ugly Side of EMR Systems

The Ugly Side of EMR Systems

One of the major attractions of having an EMR system is the ability to track and trend patient data. Ideally, with a click of the mouse a clinician should be able to instantly see trending lab results to influence their diagnosis.  According to a studyby Mayo Clinic, 60-70 of clinical diagnoses and treatments are based off of lab results. In fact, the importance of having complete and accurate lab results in the EMR was included in step one of the Meaningful Use guidelines, as stated on HealthIT.gov.

5 Ways to Master Your Epic EMR

5 Ways to Master Your Epic EMR

I worked at Epic for 12 years and I'm a big fan of what they do to innovate their products to meet the needs of clinicians. However, no matter how good the Epic EMR software is, implementing an infinitely complex piece of software in an infinitely complex industry brings with it many short-comings.

A few that I saw the most during my tenure at Epic were:

Automated PHI redaction makes clinical data management easier

Automated PHI redaction makes clinical data management easier

Spend more time finding a cure and less time finding and redacting PHI.

No lab interfaces? No problem.

No lab interfaces?  No problem.

No interface?  No problem.  Automatically capture send-out test results into your LIS. 

Unfortunately, setting up lab interfaces to every reference lab isn’t an option. This is especially true for low volume, high value esoteric labs. 

What one medical director saw that shocked her

What one medical director saw that shocked her

Last week at a healthcare trade event, a director of a top program (I’ll call her Sandy – not her real name.) witnessed something so shocking that it nearly brought her to tears...of joy.

How to Navigate a Transplant System Improvement Agreement Process Blog #5: The IPRT Visit and Action Plan

How to Navigate a Transplant System Improvement Agreement Process Blog #5: The IPRT Visit and Action Plan

Today, we will discuss the Independent Peer Review Team (IPRT) and the action plan that will be developed and implemented following their visit. 

Three Things to Do Right Now to Tame Your Lab Results Data Entry Backlog

Three Things to Do Right Now to Tame Your Lab Results Data Entry Backlog

When you get to the office in the morning, is there a backlog of lab results waiting to be entered in patients’ electronic medical records for you and your team?  If so, then read on…

Were you thinking of the word dread?  Or how about, “I hate it when…

How to Navigate a Transplant System Improvement Agreement Process Blog #4

How to Navigate a Transplant System Improvement Agreement Process Blog #4

Previously we have discussed in general what happens when your center comes under regulatory scrutiny and what you can expect.  Today, we will begin to look in greater detail at what a System Improvement Agreement (SIA) entails, the items that the hospital commits to fulfill and some strategies for addressing them.

A fax machine walks into a doctor's office...the not-so-funny joke about health information exchange

A fax machine walks into a doctor's office...the not-so-funny joke about health information exchange

30 years ago, a fax machine, an eight-track tape player and a pager walk into a doctor’s office looking for a job. Which one of them is still working in that medical office today? Why, the fax machine of course!

What do a road trip and health information have in common?

What do a road trip and health information have in common?

I recently spent three days driving across the northern Midwestern States and through a good part of Canada with a longtime friend as we headed to a once-in-a-lifetime wilderness adventure.  As you might imagine our conversations spanning those 72 hours took as many twists and turns as did the roads we traveled.   However, one saying my friend repeated several times stood out among many insightful remarks he’d made, “Your judgement is only as good as your information.“

Is quality reporting in the EMR age not what you thought it would be?

Is quality reporting in the EMR age not what you thought it would be?

Despite massive adoption of electronic medical records over the past several years, the promise of easy and nearly effortless chart abstraction from electronic medical records enabled by an interconnected web of interoperable EMRs sharing standardized data has yet to be fully realized.  You need to look no further than the media tab to see the evidence that we have yet to arrive at this Utopian future.

How to Navigate a Transplant System Improvement Agreement Process #2: You Received a Letter in the Mail, Now What?

How to Navigate a Transplant System Improvement Agreement Process #2: You Received a Letter in the Mail, Now What?

Should you receive a letter from the Centers for Medicare and Medicaid Services (CMS), the focus will likely be on a failure to meet one of the Conditions of Participation, most likely related to either graft or patient survival relative to expected results.  Under the authority of 42 CFR §488.61, a transplant program may request that CMS consider mitigating factors in the re-approval process.  There are three general areas that will be reviewed to determine whether a program can be approved based upon mitigating factors.  These areas include, but are not limited to, the extent to which the outcome measures are met or exceeded, the availability of Medicare-approved transplant centers in the geographic area or extenuating circumstances that may have a temporary effect on the program's ability to meet the Conditions of Participation. 

Can clinical data abstraction improve care quality?

Can clinical data abstraction improve care quality?

Clinical data abstraction is often one of the last steps in the patient care information workflow. Typically it's performed for the sole purpose of submitting data to compliance or quality improvement measurement programs.

Is Your EMR Inbox Managing You?

Is Your EMR Inbox Managing You?

There’s no question that users rely on the EMR In Basket for day-to-day workflow management. The “In Basket” or “Inbox,” depending on what EMR you’re using, provides a centralized location to receive notifications and important patient information, such as admission and discharge notifications, new lab results, refill requests, patient calls, appointment reminders, patient portal communication and much more.

An ounce of prevention: Getting data into the EMR

An ounce of prevention: Getting data into the EMR

An ounce of prevention is worth a pound of cure. Or, reduce medical errors through better documentation. Which one of these expressions do we tend to remember? In healthcare we hear quite a bit of talk these days on reducing medical errors. Of course this is with good reason. When getting data into the EMR, errors such as inaccurate or delayed results, can negatively impact patient health and lead to extended hospital stays, unnecessary treatment or worse. As a matter of fact, many healthcare organizations are now striving to eliminate mistakes and streamline efficiency by adopting principles such as Six Sigma and other business practices which are designed to continuously evaluate and improve best practices.