Many years ago, a Patient Administration System (PAS) replacement project was discussing the concept of an imaginary dotted red line through screens and functions that would separate any Clinical functionality from PAS, for the simple reason that the project was dealing with replacement of the legacy patient system and the scope was limited to administrative and non-clinical functions only. It was then imagined that this dotted red line was drawn down the centre of the Emergency Department feature set, as any notion of clinically related ED should be out of scope. Several years later, the same dotted red line concept was discussed in relation to implementing Outpatient functionality, specifically where patients present (or don’t) for their first or subsequent appointment to a service.
In the ED scenario, the red line became harder to establish because some parts of the administrative and clinical processes in ED are tightly linked. The red line kept shifting as discussion continued around who would do what when, and the idea that PAS would do a hard stop rather than venture into the clinical space meant that the final process would have been too disjointed and would have left gaps in the recording of the patient’s journey. For example, triage and allocating the triage score was seen as necessary for reporting of ED activity but recording of signs and symptoms and provisional diagnosis was seen as clinical and probably shouldn’t be recorded in the PAS side, thus leaving triage out altogether was momentarily floated as a “non-clinical compliant” option. Anyone who was worked with or in an ED would quickly see how this would devalue the overall process and the implementation of any such system. As as result the red line moved over into the semi-clinical space stopping short of observations and vital signs and clinical documentation.
The reverse happened in the Outpatient area in another project where a failed-to-attend (FTA) patient had a note written in the record to document the FTA and the follow-up plan, such as rebook the appointment or organise home visit. As the patient hadn’t attended any service prior to this FTA, this was seen as an administrative rather than clinical requirement to document the need to follow-up with the patient and book the next available, as well as sending further information and documentation, despite the project “wanting” to make this a clinical outcome. In this case, the red line moved away from the clinical parts of the application to purely an administrative documentation of the outcome of an FTA appointment. Project staff being only used to the existing paper-based process of documenting such changes in a paper record requested that this became a clinical medical record note, and therefore needed a re-think of the purpose of the note and where it should be entered.
Where the system is clearly only a PAS or only an Electronic Patient Record system, it’s a lot easier to determine the split between PAS and Clinical information. When the System is a full Electronic Medical Record (EMR), it is harder to maintain the red line, or more commonly, the red line keeps moving depending on the workflow or the specific use case. It’s not always clear where the information belongs, and this requires careful examination of where the red line sits in the affected workflow.
One of the many principles of documenting clinical information for a patient is ensuring there is a valid relationship between a care provider and the patient. This means that before any documentation entry is made, it should be established that the person making the entry has a legitimate right to do so.
In the paper world and reading through the progress notes in a medical record, the care provider’s name and designation as well as the date and time is written along with the note. Using this information, it would then be possible to determine that this person was on shift in the ward, part of the care team, a consulting clinician, or an allied health professional contributing to the patient’s care, and therefore had a right to do so. It would be extremely unusual for a random care provider to come up to a ward and make a note in the patient’s medical record without a relationship having been established. In some applications, this is known as the Carer Responsibility or establishment of Carer Relationship, and sometimes is also a useful way to grant access to the patient’s record.
In the same way, this can then be extended to the EMR equivalent and ensure that the relationship and responsibility is established beyond simply creating a record of something in the PAS. In the outpatient appointment example, the common action may have been to write up a note in the medical record where the patient did not attend, however as there may have been no establishment of clinician relationship for that visit, and the patient hasn’t had contact with the Care Provider, the administrative note regarding follow-up action may belong on the administrative side of the red line. Contrast that with the scenario of where the patient does attend and is seen by the care provider. The relationship between patient and care provider is established and clinical notes and other information is record as part of the clinical activity.
The important thing to remember here is that being one system, all the information ends up being accessible and relevant in the patient record unlike the separate PAS and Clinical system scenarios. Being one system means that while the data is available, the view of this information becomes more important and accessible to the clinicians. Instead of referring to a clinical note, the patient’s history of attendance (or event summary) would be viewed, and the file note created when the FTA was recorded can be read and further decisions made. In this example, the red line has created a conceptual divide between PAS and Clinicals that does not exist, along with he perceived requirement to make a clinical entry for that appointment. The view of the relevant data and how it is presented to the clinician instead becomes more important instead of creating a list of data. For example, if this appointment is Orthopaedic, show the status of the last orthopaedic appointment with the outcome, rather than all appointments. This is where some assistive intelligence could be introduced to assist the clinician to cut through the noise of other data in the EMR.
Separating out PAS from Clinicals in EMR application is not a simple answer as to where the red line can be drawn. Sometimes it’s PAS, other times it’s Clinical, sometimes it shifts and sometimes it’s nowhere. In the case of ED, the red line needed to exist but needed to incorporate necessary aspects of some clinical data capture to not break the workflow and usability of the ED function for both administrative and clinical staff. In the case of OP patients who fail to attend their appointment, the red line should have been removed as documentation of the FTA action was not specific to a PAS or Clinical action and needed to only exist somewhere available to the clinician and for reporting.
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