Keeping track

Technically Speaking

Gilly Munavalli

Dr. Munavalli is the medical director of the Goslen Aesthetic Skin Center in Charlotte, N.C. He represented the AADA on the Physicians EHR Coalition.

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How electronic logs of biopsy and lab test results can make your practice more efficient

I have found that how physicians store and retrieve information in the office is very individualistic. On our desks, we can potentially have a mish-mash of paper in progress, journals, articles from throw-away publications, patient charts, letters/correspondence, and other items. All of these can be in varying states of readiness. Several basic organizing strategies are employed. Some of us are spreaders, some are stackers, and some are filers. I tend to spread things out so I can see them, but I know deep down that is probably the worst strategy of the three. The same analogy holds true on our computer’s electronic desktop. It’s pretty sad when I can’t see my latest cool desktop background pic because of all the darned icons. When will I ever learn?

In the EHR world, things are supposed to be easier. Inbound reports are automatically directed into the patient’s virtual chart and we can retrieve at a moment’s notice. That’s the idea anyway, but often in “EHR-land,” things are not as they seem. In this month’s column, we will discuss ways to use EHR to tame the beast that is laboratory paperwork, arguably some of the most important papers on our messy desk.

One of the first tasks we desired to automate when we instituted our EHR was to look into methods for electronically importing lab work/reports — including items like pathology and blood work reports. I figured this wouldn’t be too difficult. It’s all electronic, right? [pagebreak]

In retrospect, I couldn’t have been more wrong. We use an independent dermatopathologist for all of our biopsies, as opposed to a national pathology lab chain or university department. We are quite happy with our decision, but during the initial integration process, we realized this would be an obstacle. For starters, several of the national pathology chains offered to integrate their path reports into our new EHR system at their cost, if we used their services. It was nice of them to show up right after we bought our system. I wonder how they knew? They even offered fancy graphical interfaces for inputting biopsy details and free label makers. We decided against this and tried to work with our independent dermatopathologist to incorporate his reports into our system. After months and months of working with his smaller pathology software-reporting company and more time/money/patience spent on HL7 data bridge interfaces and hassles with embedded PDF formatting, we were able to import most details. However, the format of the EHR-generated report was not very professional in its appearance. We had no control over the page layout and the report looked like a typewritten high school book report (remember those?). Ultimately, we reverted back to electronic faxing and scanning and operating within the confines of the EHR to develop a system that worked for us. I have described our system below, developed ingeniously by our office physicians and staff, knowing that it may not be applicable to other EHR users due to inherent differences in the software. Scanning and file importation are additional steps we would rather not have to do, but with practice it has become very efficient and works well for us.

Once we received the pathology report, it was immediately scanned or imported (in the case of eFaxes) into our EHR under the specified patient’s file. This pathology report was assigned to the provider that performed the biopsy. The pathology report was then immediately available for review. The provider then documented their recommendations for treatment in a document labeled “pathology review” under the patient’s file. This document is assigned to the assistant or surgical scheduler that is designated to notify the patient of their pathology results. This document also allows the assistant/scheduler to document each call attempt made to the patient giving the exact date and times of the call attempt. Once the patient has been notified, this is noted on the same document. This document can then be assigned to a surgical scheduler to coordinate surgery with the patient and one of our providers. All of the notifications are very easy to follow because they are on the same document. An electronic log is still kept for each biopsy taken, but it is again easily accessible. [pagebreak]

If several call attempts are necessary, electronic documentation allows the pathology to be viewed by any of the employees at any time. This allows several assistants to make call attempts without having the physical copy of the pathology report as it is already in the EHR. Storing the pathology notification attempts in our automated task list allows us to receive daily reminders about notifying the patients. This means that patients do not slip through the cracks. We can see exactly which stage in the notification protocol that the patient is in.

With paper documentation and notification, the paper pathology report would transfer from the front office to the lab for logging, then to the provider for sign off, and finally to the person who would make the patient notification. The margin for error was a lot greater, and in a busy office, could cause the pathology report to become “lost.” This also would increase the amount of time from receiving the pathology report to patient notification. When paper documentation was used, it could take up to three to four days for the patient to receive their results from the time that the office received the pathology results. Whereas with electronic documentation, the patient can potentially receive their results the same day that the pathology report is received. Previously, in order to properly follow if all patients had been notified of their pathology results, a paper log book had to be used to closely watch for any “missing” reports. If a patient called back for their results before we called them, the actual paper pathology copy had to be located in real-time, in order to notify the patient. [pagebreak]

We had to fight a similar battle with our clinical pathology lab. Since we are located in a large medical office building that has a pathology lab at the ground floor, our patients often find it convenient to go downstairs to get labs drawn after their office visit with us. We faced another obstacle because the lab, which is a mid-sized expanding national chain, was not able to send us results electronically. They refused, at the time, to implement any type of interface to help with our EHR integration. We considered just recommending to patients to use another lab that would send us results electronically, but ultimately relented because of the patient convenience. We found that the same aforementioned system also works for laboratory blood work , cultures, etc. Using the EHR system of “to-do” tracking and alerts, we can manage all inbound clinical pathology labs after they have been scanned or imported.

Ironically, I was the last to be converted away from the paper log. I liked having all the reports in hand and reviewing them on paper, all at the same time, to make sure I didn’t miss anything. When I realized that things still occasionally slipped through the cracks because of lost reports going from one person in the office to the next, etc., I saw it was a good time for change.