Abstract
Background
Electronic health records (EHRs) have revolutionized clinical practice, but clinicians
and institutions have not yet fully optimized their use. Inconsistent documentation
of ophthalmic test results can increase potential medicolegal risks if providers bill
for tests without properly documenting clinical interpretations.
Objectives
To address this, we developed and implemented a logic tool in Epic (Epic Systems,
Verona, Wisconsin, United States) that prompts clinicians to document diagnostic test
interpretations as discrete data before closing the patient chart.
Methods
We implemented a “Close Encounter Warning” using logic rules to redirect clinicians
to the Imaging and Procedures section of the Epic chart for documenting test interpretations.
The implementation only allows clinicians to finalize each outpatient encounter's
charting as closed if the logic rules confirm that no unsigned test results remain.
The logic rules were revised many times to accommodate the unique workflow of the
Ophthalmology department and to consider the roles of fellows, residents, and staff
who also work with encounter charting. We implemented the initial logic rule on October
23, 21 and the final iteration on February8, 22. To evaluate the impact, we compared
the number of closed charts containing unresulted diagnostic tests from October 2017
to December 2024.
Results
Before we implemented the logic rules, clinicians closed an average of 897.1 charts
per month with unresulted diagnostic images (median: 916, interquartile range [IQR]:
170, 5.78% of all outpatient encounters). After implementation, this number dropped
to 8.3 per month (median: 8, IQR: 5.75, 0.05% of all outpatient encounters), a 108%
reduction (p < 0.001).
Conclusion
The Close Encounter Warning logic rules significantly reduced the number of Imaging
and Procedure-type diagnostic tests lacking final attending signatures in the Ophthalmology
department. By implementing this EHR change, we successfully minimized potential medicolegal
liability for our clinicians and institution.
Keywords
electronic health record - health information management - discrete data - ophthalmology
- clinical informatics - clinical operations
