Clinician Communication

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Download the PDF guide to access the checklist of recommended practices for self assessment and a supporting worksheet to identify action steps to achieve those recommended practices.

The Clinician Communication SAFER Guide identifies recommended safety practices associated with communication between clinicians and is intended to optimize the safety and safe use of EHRs. Processes relating to clinician communication are complex and vulnerable to breakdown. In the EHR-enabled healthcare environment, providers rely on technology to support and manage their complex inter-clinician communication processes. If implemented and used correctly, EHRs have potential to improve the safety and safe use of clinician communication.

Communication is a key aspect of nearly all patient care processes and has enormous potential to impact patient safety.1-6 Communication breakdowns between clinicians are one of the most common causes of medical errors and patient harm. Communication processes have become increasingly integrated into EHRs.7,8 These include sending and receiving referral and consult communication, communication about transitioning a patient from the inpatient to the outpatient setting, and communicating clinical messages with the EHR. Several attributes of EHR-based communication can result in a disconnect between the sender and the receiver of clinical information, including the sender’s uncertainty about whether or when a message has been received, and a mismatch between single patient vs. multiple patient interactions. Messages may be incomplete, misdirected, or directed to an unavailable clinician, and may overload the recipient.5,9

This self-assessment is intended to increase awareness of practices that can improve the safety of EHR-based communication, and support the proactive evaluation of particular risks. It can help identify and evaluate sources of potential communication breakdowns, with a focus on processes related to electronic communication between clinicians. The self-assessment specifically targets three high-risk processes: consultations and referrals, discharge-related communications, and patient-related messaging between clinicians.

Completing the self-assessment in the Clinician Communication SAFER Guide requires the engagement of people both within and outside the organization (such as EHR technology developers). Because this guide is designed to help organizations prioritize EHR-related safety concerns, clinician leadership in the organization should be engaged in assessing whether and how any particular recommended practice affects the organization’s ability to deliver safe, high quality care. Collaboration between clinicians and staff members while completing the self-assessment in this guide will enable an accurate snapshot of the organization’s EHR communication status (in terms of safety), and even more importantly, should lead to a consensus about the organization’s future path to optimize EHR-related safety and quality: setting priorities among the recommended practices not yet addressed, ensuring a plan is in place to maintain recommended practices already in place, dedicating the required resources to make necessary improvements, and working together to mitigate the highest priority communication-related safety risks introduced by the EHR.

1

Urgent clinical information is delivered to clinicians in a timely manner, and delivery is recorded in the EHR.

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Rationale:

If active measures are not taken to inform clinicians of the presence of critical information, this information may be missed by clinicians resulting in delays in care.10,11

If primary care physicians (PCPs) do not receive a timely discharge summary they may incorrectly restart or change medications for which contraindications have been identified during hospitalization.

Examples:

  • The organization has a policy for verbal delivery of critical information that supplements use of the EHR.
  • Hospitals have policies and procedures to address timely electronic delivery of important clinical information. For example, hospital discharge summaries are delivered to clinicians responsible for follow-up within two business days.
  • Messages are automatically forwarded to an alternate clinician if not responded to within a time period appropriate to the time-urgency of the message.
  • The EHR allows automatic forwarding of messages to a surrogate clinician during a specific time period or circumstance, such as when the clinician is absent.
  • Messages are delivered to a "pool" that several clinicians are held accountable for and the individual responsibilities for follow-up are clear.
  • When a patient transitions to another setting, a clinician provides a summary of care record to the receiving hospital or clinician in a timely manner. The summary record should include, at a minimum, the Common Meaningful Use Data Set.12

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

2

Policies and training facilitate appropriate use of messaging systems and limit unnecessary messaging.

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Rationale:

Information overload is a significant problem in EHR systems. When a large amount of information that is not clinically relevant is transmitted through the same channels as information with high urgency, the latter may be missed, leading to potential patient harm.5,9

Examples:

  • The organization has a policy on secure messaging that specifies what should and should not be transmitted, and users are trained on it.
  • Messages are sent only to persons who may need to act on them. "Reply all" is used only when necessary.
  • Mechanisms are in place to allow communication of nonclinical information (e.g., appointment requests) in a way that does not impact communication of clinical information (e.g., abnormal laboratory results).

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration

3

The EHR includes the capability for clinicians to look up the status of their electronic communications (e.g., sent, delivered, opened, acknowledged).1

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Rationale:

Delays in care may result from referrals, consults, and clinician-to-clinician messages that do not receive timely attention.1,13,14

Examples:

  • A real-time tracking system allows referring clinicians to determine the status of all their referrals and consults transmitted and allows specialists to identify all their referrals and consults that are pending.
  • Clinicians and specialists are able to print a report of all their referrals and consults including the status of each.
  • Clinicians are able to identify whether their sent messages have been opened (e.g., "read receipt").
  • The EHR automatically notifies the ordering clinician or team when referrals or consults are canceled or completed.
  • Clinicians are notified if a message they sent has not been opened within a pre-specified number of days.
  • The EHR can track whether a message was received or not.
  • Outpatient practices with messaging systems that are not fully integrated into the EHR use additional tracking strategies to enable follow-up.

Suggested Sources of Input:

EHR developer, Health IT support staff

4

Messages clearly display the individual who initiated the message and the time and date it was sent.

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Rationale:

In order to make informed and appropriate decisions, clinicians need to know the source and timing of a message.

Examples:

  • The EHR message interface prominently shows the date, time, and sender.

Suggested Sources of Input:

EHR developer

5

The EHR facilitates provision of all necessary information for referral and consult request orders prior to transmission.1,15

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Rationale:

Referral and consult processing and routing may be delayed if information provided with the request is inadequate, resulting in care delays.

Referral and consultation requests without certain fields filled, such as “specialty” or “reason for referral” might be delayed.

Examples:

  • Templates are used to facilitate completion of electronic referrals and consults to meet the specialists' requirements.
  • Clinicians are prompted when certain key fields, such as the "reason for referral" or "specialty" field, are left blank.
  • Referral requests should include, at a minimum, the Common MU Data Set.12

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

6

The EHR facilitates accurate routing of clinician-to-clinician messages and enables forwarding of messages to other clinicians.

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Rationale:

Delays in patient care may result when important information is inadvertently transmitted to an incorrect recipient and cannot be redirected to the correct one.

Examples:

  • In the EHR, "To:" and "From:" fields are visible on the message inbox and at the top of message content.
  • The EHR supports forwarding of incorrectly routed messages to other clinicians.
  • Clinicians can forward messages they received incorrectly to the correct recipients.
  • Additional mechanisms exist for tracking acknowledgment and acceptance of forwarded notifications.

Suggested Sources of Input:

EHR developer, Health IT support staff

7

Clinicians are able to electronically access current patient and clinician contact information (e.g., email address, telephone and fax numbers, etc.) and identify clinicians currently involved in a patient’s care.16

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Rationale:

Patient care delays result from time spent searching for correct clinician contact information, a patient’s treating clinician, or provider’s care team members.

Care delays may also result from incorrect message routing based on inaccurate contact information.

Examples:

  • The EHR system is updated at least monthly with a contact list of all practicing clinicians, and, for hospitals, includes clinician coverage schedules.
  • The EHR automatically addresses internal messages between clinicians, so that email address or fax numbers need not be typed.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer

8

Electronic message systems include the capability to indicate the urgency of messages.

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Rationale:

Communicating the urgency of a message, such as a referral or consult, is necessary to facilitate triaging, and to ensure timely follow-up.

Examples:

  • The EHR has functionality to allow clinicians to flag referrals or consults as urgent when needed.
  • Specialists are given immediate access to all referral and consult requests, and can triage patients and schedule appointments based on urgency.
  • Messages that are administrative in nature are clearly differentiated from clinical alerts.

Suggested Sources of Input:

EHR developer

9

The EHR contains a copy of clinician-to-clinician communications.

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Rationale:

Clinicians may miss important information related to a particular patient because it is “hidden” in secondary data repositories or in paper-based record storage.

Delays in care may result when specialist recommendations (such as to order further testing) are not received by the ordering clinician.

Examples:

  • Written clinician-to-clinician communication is documented into or scanned into the EHR.
  • The EHR includes a secure messaging module with external access (i.e., to facilitate electronic communication with patients or providers who are not users of the EHR) that does not require separate, external software.
  • If clinical messaging systems external to the EHR are used, a copy of every message is stored in the EHR.

Suggested Sources of Input:

EHR developer

10

The EHR displays time-sensitive and time-critical information more prominently than less urgent information.

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Rationale:

Clinicians may miss urgent information when it’s commingled with other less urgent messages, resulting in delayed care.

A clinician may miss a small section of relevant and important information within several pages of a referral or consults note sent to him or her.

Examples:

  • Messages with critical or urgent information are made visually distinct (e.g., visually highlighted).
  • The EHR allows sorting of clinician-to-clinician messages by urgency.
  • When sending notes/documentation to other clinicians (such as for co-signing), the EHR allows the sender to add recipient-specific explanatory messages, highlighting, or markup.

Suggested Sources of Input:

EHR developer

11

Both EHR design and organizational policy facilitate clear identification of clinicians who are responsible for action or follow-up in response to a message.1

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Rationale:

On messages addressed to multiple recipients, each recipient may incorrectly assume that the other recipient(s) will take follow-up action, leading to no action being taken at all.

Examples:

  • Message screens display a "responsible clinician" indicator.
  • The system supports forwarding and accepting responsibility for follow-up.
  • The EHR is able to capture and display when responsibility for follow-up action is accepted by a clinician.
  • A comprehensive policy exists outlining responsibility for follow-up action for certain situations (e.g., no-shows).

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer

12

Mechanisms exist to monitor the timeliness of acknowledgment and response to messages.1,17

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Rationale:

System problems related to delayed acknowledgment of clinician-to-clinician messages may go unnoticed if monitoring systems are not in place and checked regularly.

Examples:

  • Referring clinicians, specialists, and/or leadership are electronically notified when no action is taken on a referral or consult request or a clinician-to-clinician message within 14 days.
  • Referrals and consult response times are tracked by organization leadership.
  • Messaging is periodically monitored to understand and improve quality of communication.
  • Policies and procedures are in place to prevent messages "lost" in the system, such as messages sent to clinicians no longer employed by the organization.

Suggested Sources of Input:

Clinicians, support staff, and/or clinical administration, EHR developer, Health IT support staff

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