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 expectations of one another. "Minimum Use Norms" are about safe and equitable use of the CIS. They apply to all clinicians who see patients where Connect Care is the record of care. Clinicians may comply personally and directly. Alternately, they may participate in groups that ensure compliance as a team responsibility.
The minimum use norms, together with practical tips and metrics, appear in:
Bottom Line
Connect Care users require (of one another) adherence to the following CIS minimum use norms wherever Connect Care is the record of care:
Adverse Reaction Reconciliation - Allergies and adverse reactions should be reviewed at every first encounter and yearly to validate recorded reactions and screen for new ones.
Problem Reconciliation - The problem list should be reviewed at every first encounter and yearly to add new problems, reconcile active problems and retire inactive problems.
Medication Reconciliation - 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. Medications should also be reviewed and updated at every discharge or inter-facility transfer.
Diagnosis Reconciliation - At least one visit diagnosis must be selected for every outpatient encounter or one primary diagnosis for every inpatient encounter.
Order Entry - 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.
Encounter Management - All encounters should be closed in a timely fashion and, in any case, no longer than 3 weeks after provision of service.
Importance
Adherence to minimum use norms by all Connect Care clinicians helps;
Improve ability to find clinically important information in consistent locations, minimizing safety risks arising from missing, misplaced or miscommunicated information.
Improve performance of search functions.
Capture, review and use essential structured data needed for basic decision, documentation and inquiry supports.
Share information burdens among all users to decrease burnout and inattention.
Comply with Alberta Health Services, College of Physicians and Surgeons of Alberta (CPSA), accreditation, medical staff bylaws and health record regulations.
Promoting Compliance
Feedback about trends in norms compliance can help clinicians identify potential workflow challenges and consider options for optimizing both the user's experience and the quality of the health record. Connect Care dashboards are provided for both individuals and groups wishing to explore compliance with minimum use norms.
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.