AppHealthCare Appalachian District Health Department Policy and Procedure
Policy Name: Section 1100 Approved Date: Laboratory Procedure 4‐25‐13 Policy Topic: Chapter 1108 Revision Date: EMR Lab Entry 4‐23‐15 PURPOSE: The Appalachian District Health Department electronic health record (EMR) was developed by Patagonia to allow for electronic reporting of all laboratory tests performed at Appalachian District Health Department (ADHD). This system also allows for the entry of tests performed at reference laboratories. POLICY: In accordance with HIPAA, access to ADHD EHR patient information is limited to those individuals having a need of this information for patient care. Users of this system include: medical providers, lab techs, management support, finance, WIC, and clinical staff. ENVIRONMENT REQUIREMENTS: The EHR is adequately protected against unexpected power interruptions and surges by using an uninterruptible power supply (UPS). Wires and cables are placed and maintained in a manner to ensure their protection and not to present electrical or trip hazards to ADHD personnel. Firefighting equipment is readily accessible. SYSTEM SECURITY: System Security of the ADHD EHR is based upon tiered authorization via unique user passwords to permit result viewing and/or access only to authorized users. Authorization of use of the system is determined by the user’s supervisor. Under no circumstances are users to share their passwords, or leave terminals unattended while logged on the system. When a user separates from service at ADHD, their password will be rendered inactive, and will not be reassigned to any other individual. Practice Administrators can update lab tests and lab staff can update lab tests and results. The following types of users can view lab results: medical providers, lab techs, WIC, and clinical staff. A. Order Entry in patient note: Authorized clinic staff and medical providers order lab tests from the computer ports in the clinic area. 1. Entering the patient’s name or date of birth will trigger the patient’s demographics to appear on the screen. 2. Select patient 1 EMR Lab Entry
3. Scroll down to Encounter Note
4. Select note format, program and Encounter Type.
5. Go to Assessment and Plan section
6. Enter patient’s diagnosis in the Create Assessment Group or select from Active Problems dropdown box.
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7. Click on Add Orders and Procedures
8. In the Order, Procedures section , type in name or CPT code of lab test to be ordered, either in the In‐house labs box or Outside lab box.
9. Once this area becomes “shaded” link the test to the correct diagnosis code. Enter the CPT code for the venipuncture in the Procedures box.
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B. Receiving an Order 1. Select patient from Pending Encounters on the dashboard and click on Summary.
2. Within the summary, scroll down to the Lab Results section. The lab test(s) that has been ordered will be displayed in this section. The user can also assign the encounter back to the provider from this page.
C. Entering Lab Results 1. Click on the Select Html Format in the In‐House Lab Results section.
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2. Click on the Template drop down box and choose Public Health In‐House Lab Results. 3. Enter patient’s lab test result(s) in the appropriate test area. All typed result MUST be entered using approved verbiage state in the individual laboratory test procedure. 4. Enter any additional information that may be required (i.e. Internal QC Acceptable/Unacceptable, “Fasting Time”, “Comments” etc.) 5. In the Read By: box, enter testing personal initials and date test completed.
6. Scrolls down, click Save then click “X” to close the window.
7. Within the summary, scroll down to the Lab Results section. Assign the encounter back to the provider and click Save.
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D. Documenting Critical Lab Value for In‐House Labs: 1. In the In‐house Lab Results section click on Select Html format.
2. From the dropdown box choose Public Health In‐House lab results 3. Document the critical results; Internal QC acceptable/unacceptable, time and date results were read and testing personal’s initials.
4. In the Comments box document the critical result, name of person critical result was reported to, the date, time and testing personal’s initials. Click Save.
E. Canceling a Test: 1. Within the encounter note, go to the Orders and Procedures section. Find the test to be cancelled and click on the X above the assessment code (in the top right hand corner of the shaded box).
F. Documenting an Error:
1. Results reported on the incorrect patient 6 EMR Lab Entry
1. Once the note has been signed, add an addendum to the encounter
note. Click on Add Addendum at the bottom of the encounter note.
Addendum will automatically populate in the note format field.
Scroll down to Addendum section and document the error.
It is inappropriate to list only the last correction made, as the clinician may have made a clinical decision based upon erroneous data rather than the “true” result. All corrections should be shown in the patient report. The previous result can be noted by using the “comment” or “free text” option. All corrections of this nature must be reported to the lab manager and documented as laboratory quality assurance issue. G. Additional Test Add‐On 1. Self‐Pay Patients 7 EMR Lab Entry
Contact patient by telephone to inform them their provider has requested additional test laboratory test which will result in an additional lab charge. Patient declines additional test due to financial reasons. 1. From the Pending Encounter screen click on New Telephone Encounter.
2. In the Message box document; name of the person who contacted the patient, what additional test provider added and reason patient declined to have the additional test.
Patient approves additional test 1. Follow the steps listed under Order Entry in Patient Note using the encounter note format “general clinic”. NOTE: Do not charge the patient the venipuncture fee. 2. Patient’s with insurance 1. Follow the steps listed under Order Entry in Patient Note using the encounter note format “general clinic” . NOTE: Do not charge the patient the venipuncture H. REFERENCE TESTS Tracking of reference tests is done using the lab log, printing a manifest log from Lab Beacon, and verification through the Electronic Lab Results Widget. I. VERIFYING RESULTS Data entered into the computer system either manually or by automated methods must be reviewed by authorized testing personnel to ensure the accuracy of the input data before final acceptance and reporting by the computer. 1. Audit trail 8 EMR Lab Entry
Testing personnel responsible for the performance and/or verification of all individual tests are uniquely identified in the system’s audit trail. Specimens are also uniquely identified throughout the testing process. The date and time results are reported are reflected in the patient report. 2. Printing reports a. Example reports The content and format of all computer‐printed reports will be in accordance with CLIA ’88. Appropriate reference ranges will be reviewed and approved by the Clinical Consultant on an annual basis. J. VIEWING RESULTS Only designated persons who need access to perform their jobs will have access to lab results. K. DATA RETRIEVAL AND STORAGE The entire platform has to be available for users 24/7. All functions of the Patagonia EHR and billing system must be operational all the time. To achieve 99.95% or better availability, 1. Replication: At any point, 2 servers are running in parallel with mirror configurations. Database, configuration and application are replicated for a hot backup. 2. Failover: If any server goes down, the other mirror can take over. 3. Disaster recovery and remote backup: Database, configuration and application are backed up to a. Local storage b. Cloud storage c. Remote servers. These servers can be activated within a short period if the primary data center faces a catastrophic disaster. 4. Monitoring: Hardware and all software is continuously monitored for potential errors and critical faults 5. Hardware redundancy: Data center can replace hard disks or entire servers, in case of failure, within minutes a. Redundant network routers and firewalls b. Redundant network carriers to the datacenter c. Redundant power supply to datacenter. All hardware powered by separate power lines 6. Upgrades: Before upgrading the production server, a mirror image is upgraded on a test server. This undergoes 3-7 days of regression testing before production server is upgraded. In case of failure, backups are restored within minutes. 7. Testing: Failover server is regularly tested to verify data validity.
L. QUALITY CONTROL Quality control results are not presently stored in Patagonia at this time. 9 EMR Lab Entry
M. SYSTEM MAINTENANCE Downtime for maintenance is scheduled to minimize interruption of patient care services. In the event that unscheduled downtime occurs during clinic hours, as a contingency plan, the laboratory will institute a requisition system of reporting results, to ensure continued accessibility to laboratory services. Lab requisitions will be given to the clinic staff to fill out patient demographics, date, time, tests ordered, ordering physician, and bring to lab for processing and completing. Appropriate results will be recorded on the lab requisition, copy given to ordering clinic. Once the EHR is operational, all off‐line, written lab reports generated in the interim will be entered into the LIS. All scheduled and unscheduled maintenance will be documented. 1. Hardware maintenance Information Technology maintains warrantee support for all C server infrastructures ensuring that replacement parts will be available within one business day. All hardware malfunctions are fixed promptly. 2. Software maintenance Backup procedures The system must be checked after each backup and/or restoration of data files to ensure that no inadvertent alterations have occurred. Errors detected during system backup must be documented, along with corrective action taken and reported to the Safety and HIPAA Officer. Software changes All changes, additions, and deletions of lab tests are the responsibility of the practice administrator. Additions and deletions in program test menus, and major computer functions must be approved by the Patagonia Clinical User Group. All modifications will be documented with notification provided to affected system users. N. SYSTEM SUPPORT Tommy Havelos is the primary contact when software or hardware technical assistance is needed. Each problem should be documented in detail, including any error codes, etc. O. VALIDATION AND QUALITY ASSURANCE Computer programs must be checked for proper performance when first installed, and after changes or modifications have been made. After initial installation, dual methods of reporting (both electronic and hand‐written requisitions) were employed for comparison purposes for a minimum of 60 days. In addition, patient data on reports and video displays must be periodically compared with original input data to detect errors in data transmission, storage, or processing. This is performed by comparing data from instrument printouts and the Daily Lab Log. As a part of on‐going quality assurance, each electronic report printed by the laboratory is compared with the original results recorded on the lab log. The date of review and ID of 10 EMR Lab Entry
the individual conducting the review are documented on each electronic report under the “printed by” section at the bottom of the form. P. TRAINING Training will be provided to new system users, whenever the EHR is modified, or if a new system is installed. Training will be provided by their supervisor. Documentation of training will include the names of the trainee(s), the trainer, the date, and the type and reason for training. A current list of users and their level of authorized use will be maintained by their supervisor.
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