Minimum Use Norms
Improper or inconsistent clinical information system (CIS) use can compromise clinical service and safety. Accordingly, all CIS users share interest in peer-endorsed minimum use for meaningful use. CIS minimum use norms apply to all clinicians who see patients where Connect Care is the record of care. Clinicians may comply directly or ensure compliance with the help of other members of the healthcare team. The norms, together with practical tips and metrics, appear in:
Connect Care will organize training, communication and feedback to promote adherence to the following CIS use norms where Connect Care is the record of care:
Adverse Reaction List - Allergies and adverse reactions should be reviewed at every first encounter and yearly to validate recorded reactions and screen for new ones.
Problem List - The problem list should be reviewed at every first encounter and yearly to add new problems, reconcile active problems and retire inactive problems.
Medication List - The current medication list should be reviewed at every first encounter and yearly to enter or confirm all current medications, mark medications not used, or expire medications no longer prescribed.
Diagnosis - At least one visit diagnosis must be selected for every outpatient encounter or one primary diagnosis for every inpatient encounter.
Ordering - All tests, interventions and medications that can be ordered in the CIS must be ordered in the CIS.
Documentation - Documentation of all encounters (ambulatory, inpatient, virtual, etc.) must be placed within the CIS, irrespective of how recorded (keyboard, speech recognition, dictation, transcription).
Professional Billing - All billable services, including telephone advice and prescription refills, should be recorded in the CIS for all prescribers who are required or elect to do this.
Encounters - All encounters should be closed in a timely fashion and, in any case, no longer than 3 weeks after provision of service.
Failure to adhere to minimum use norms can represent a lapse of professionalism, non-compliance with medical staff bylaws or non-alignment with organizational policies. More importantly, workloads can be unfairly increased for colleagues, the work of health care teams can be frustrated and patient safety can be compromised.
Significant and persistent non-compliance is evident to clinical leadership through minimum-use reports and is referred to Medical Affairs as appropriate.