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Entering Test Results into UW Health Link (EPIC) (3.2.4)

Entering Test Results into UW Health Link (EPIC) (3.2.4) - Policies, Clinical, UW Health Clinical, Medical Records and Communication, Medical Record

3.2.4


UW HEALTH CLINICAL POLICY 1
Policy Title: Entering Test Results Into UW Health Link (EPIC)
Policy Number: 3.2.4
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: May 26, 2017

I. PURPOSE

The purpose of this policy is to ensure consistency and quality practices in the use of Enter Edit for
laboratory test results in the UW Health Link (EPIC) electronic health record (EHR).

II. DEFINITIONS

A. External Result - clinical test results collected and performed at healthcare facilities outside of UW Health.
B. LLB – Health Link/Epic term for performing laboratory.
C. LRR - Health Link/Epic term for laboratory reportable result.
D. Point of Care (POC) – clinical test results of a specimen collected and performed at a non-Laboratory UW
Health location
E. Collection Date – date the specimen is collected
F. Result date – date the testing was completed
G. Report date – date the testing was reported to the ordering provider via a paper report, fax or electronic
transmission into the EHR.

III. POLICY ELEMENTS

A. The UW Health Link (Epic) software provides a function called "Enter Edit Results" for purposes of allowing
users with designated security to enter discrete result information. It is important for continuity of clinical care
to have test results available in the EHR as discrete data elements. Only diagnostic procedure/tests ordered
by a UW Health physician or authorized prescriber will be accepted and executed. Authorized staff can
perform and result diagnostic procedures/tests within a defined scope of practice recognized by UW Health.
The use of Enter Edit results should be within that scope of practice. All diagnostic test/procedure reports in
the EHR must meet the requirements of all regulatory agencies, (e.g., Clinical Laboratory Improvement
Amendments (CLIA)) and accreditation agencies (e.g. College of American Pathologists (CAP), AABB, The
Joint Commission). Each clinical site entering test results directly into UW Health Link (Epic) will identify,
train, and monitor staff performing this function. Each clinical site manager/supervisor must comply with
auditing requirements defined in this policy.
B. The “Enter Edit Results” software function is used to enter results of clinical tests performed by staff in the
clinical system and is used to enter test results for patient care orders from or requested by a UW Health
physician or authorized prescriber but performed at healthcare facilities outside of UW Health ("External
Results"). This function can be used for entering results of other diagnostic studies such as radiology or
pulmonary function; however this policy addresses only laboratory test results. All external laboratory results
entered via Enter Edit are to be transcribed verbatim. Interpretations of results are to be entered into the
EHR via other methods available in the EHR.
C. This policy does not apply to the use of Enter Edit Result functionality by the Laboratories or HIM
departments.
D. Laboratory Test Results
i. It is acceptable to use Enter Edit functionality in the following defined cases:
a. Point of Care (POC) test result entry for tests ordered by UW Health providers and
performed at a UW Health site/location .
b. Diagnostic test result entry for any laboratory test ordered by a UW Health provider and
performed at a laboratory external to UW Health, if the result meets the following criteria:
1. Reported result is numeric or quantitative:(e.g. Creatinine 1.2 mg/dL)
2. Reported result is qualitative with a short and easily transcribed answer:(e.g.
Culture is positive or negative, Crystals are seen or not identified)
c. It is acceptable for the provider to indicate which components of a multiple component
result are to be entered via Enter Edit ;( e.g. the white blood count of a Complete Blood
Count (CBC)).
d. Exceptions for the departments of Transplant, Gynecology and Obstetrics, Oncology,
Hematology and Gynecology/ Oncology are outlined in Section III.D.iii.
ii. It is not acceptable to use Enter Edit functionality for the following defined cases:



UW HEALTH CLINICAL POLICY 2
Policy Title: Entering Test Results Into UW Health Link (EPIC)
Policy Number: 3.2.4

a. Historical reported results on new patients that predate the first appointment within UW
Health. These results can be scanned into the record on the Outside Documents tab.
b. Reported results that are non-discrete, text based and/or lengthy interpretations (more
than a few words of text) e.g. genetic testing interpretations or cytogenetic results.
c. Reported results, even if discrete, that require significant context to interpret e.g. drug
screening results.
d. Isolates and Susceptibilities.
e. If the test result is complex or too detailed to be easily entered using the Enter Edit
functionality, then Enter Edit should not be used and the original report should be scanned
into the record in its entirety.
f. Any reported result in which the user alters or paraphrases the actual reported result of
the performing laboratory. For example, a Pap smear reported as Atypical Squamous
Cells of Undetermined Significance, cannot be interpreted as “negative” by the
user. “Negative” is not acceptable for entry into Enter Edit results.
g. Patient self performed over the counter test such as pregnancy test or glucose monitoring
or patient performed prescribed device testing such as home INR testing.
h. Verbal results.
i. Exceptions for the departments of Transplant, Gynecology and Obstetrics, Oncology,
Hematology and Gynecology/ Oncology are outlined in Section III.D.iii.
iii. Exceptions for specific departments and situations
a. For the departments of Transplant, Gynecology and Obstetrics, Oncology, Hematology
and Gynecology/ Oncology Enter Edit is accessible:
1. To enter initial historical data or limited critical data received from an external
laboratory that was not ordered by a UW Health provider if the result is required
to trend or treat the patient.
2. If laboratory result is not required in discrete form it should be sent for scanning
only.
b. POC INR tests performed in healthcare settings such as nursing homes or by home health
agencies may be reported via phone. A lab approved form must be used for
documentation of the verbal result, is used for entry into Health Link and for the audit of
accuracy. See section V.C.iii.

IV. PROCEDURE

A. Requesting Enter Edit Functionality
i. Point of Care Testing
a. UW Health Laboratory Testing Oversight Committee will approve, coordinate, and monitor
the use of Enter Edit results functionality by UW Health Clinics performing POC testing.
b. Designated Laboratory staff will coordinate with Health Link implementation teams to
ensure that clinic staff who will enter results have completed the approved training and are
competent for this task.
c. Designated laboratory staff monitoring POC testing will file ServiceNow tickets as needed
if LRRs (components) must be created for the POC tests to be entered.
d. Audit of POC results entered is the responsibility of the operational manager or designee
and must be completed as outlined below.
ii. External Results
a. Clinics requesting use of Enter Edit results for external results will make this request to the
respective Ambulatory Operational or HOD Director and Health Link Implementation
Team.
b. Clinic or service manager will include director approval with the submission to Health Link
for appropriate security via a CSAR (Computer System Authorization Request).
c. The following job titles have security for Enter Edit results:
1. medical assistants
2. licensed practical nurses
3. nursing assistants
4. medical records staff
5. clerical staff
6. lab staff



UW HEALTH CLINICAL POLICY 3
Policy Title: Entering Test Results Into UW Health Link (EPIC)
Policy Number: 3.2.4

7. UW employed data coordinators
8. pharmacists
9. pharmacy technicians
10. physicians
d. Each staff member must complete training for Enter Edit results and be deemed
competent. Documentation of such training is maintained by the operational manager.
B. Entry of Results for both POC and external results
i. Select the correct Order in UW Health Link (Epic) for the result being entered.
ii. Enter the following elements as appropriate for all test results entered into UW Health Link (some
fields may pre-populate, depending on test order):
a. Two patient identifiers (patient name and date of birth or medical record number).
b. Lab test/Component name (possible default from EAP name). If test does not default, it
may not be appropriate to use Enter Edit.
c. Specimen type if appropriate.
d. Lab performing the test - select from Drop Down List (Required)
1. POC testing, use appropriate UW Health site.
2. Outside facility results, choose a lab prefixed with EXT.
3. If one is not listed, the EXT LAB (OTHER): See SCANNED REPORT should be
used. Put in request for new LLB record if appropriate.
e. Collection Date (Required)
f. Collection Time (Required if given).
g. Result/Value (Required).
h. Reference Range (enter low and high values) (Required if given).
i. Units of measure (Required if given).
j. Result Date (Required if given).
k. Result Time.
l. Status is Final (Required).
m. Abnormal flag is set correctly, if used.
n. Collector (who collected specimen)
o. Technician (who performed the test) (Required)
iii. Enter all available fields that are relevant to this test result such as comments.
iv. POC results must be entered within 3 business days of when the result was generated.
v. External results, the original laboratory report is always to be scanned into the record with the result
and should be viewable in a timely fashion (less than 14 days from result entry).
a. On the Paper/Fax report record;
1. Patient EHR Medical Record Number
2. Order number from Health Link
b. The exception is the form used for documentation of a verbal result. See section III.D.iii.b.
vi. If a result value is entered in error, the user must correct this report by:
a. Entering the result record and correcting the result value and the "c" icon (which indicates
a correction) in the abnormal flag field.
b. Entering a comment on the Narrative tab in the result using the smart phrase
EDITLABRESULT which states "The [name of the item] was corrected at date/time.
Disregard previous result of ***." (Staff will put the erroneous result in place of the ***s).
c. If other fields are corrected, add the "c" icon in the abnormal flag field and enter a
comment in the Narrative tab in the result using the smart phrase EDITLABRESULT which
states "The [name of the item(s)] was corrected at date/time. Disregard previous ***."
(Staff will enter the erroneous information [e.g. lab name, collection date, low/high
number, units, etc.] that was corrected in place of the ***s).
d. In accordance with laboratory policy, a Patient Safety Net (PSN) report should be
submitted for any test results that are changed in the EHR.

V. QUALITY ASSESSMENT

A. The desired quality standard for Enter Edit is 100% accuracy of all components outlined below.
i. Verify with two patient identifiers. (Required)
ii. Specimen Type (Required).
iii. Resulting Lab Info (i.e., Lab performing the test, with city and state) (Required).



UW HEALTH CLINICAL POLICY 4
Policy Title: Entering Test Results Into UW Health Link (EPIC)
Policy Number: 3.2.4

iv. Collection Date (Required).
v. Collection Time (Required if given).
vi. Test (Required).
vii. Result (Required)
viii. Reference Range (Required if given).
ix. Units of measure (Required).
x. Result Date (Required if given).
xi. Result Time.
xii. Status is Final (Required).
xiii. Abnormal flag is set correctly, if used.
xiv. Collector (who collected specimen)
xv. Technician (who performed the test) (Required)
B. The process of entering paper or faxed results on a single patient with a scan viewable in the EHR within 14
days is considered a correct entry.
C. Auditing
i. Initial training period or if retaining is required.
a. Step One: The first ten entries will be reviewed by manager/supervisor or designee for
accuracy in real time and if 100% accuracy achieved move to step 2.
b. Step two: In the first month, the manager/supervisor or designee will audit a minimum of
20 entries with a required accuracy of 100%.
c. If 100% accuracy is not achieved then retraining and repeat of step one and two until
100% accuracy is achieved.
ii. Ongoing random audits should be performed to verify 100% accuracy.
a. Quarterly, the manager/supervisor is to submit 10 entries or all entries if less than ten per
employee with external Enter Edit activity.
iii. Documentation of audits performed
a. Use of external entry reports or screen prints of above data is to be used for auditing.
b. Summarized data of quarterly POC testing entry audits are to be sent to laboratory POC
coordinators. Use Health Link Enter/Edit Audit Summary Sheet (located on U-Connect:
Documents/UWHC Documents & Forms/Clinical Laboratories/Forms).
c. Summarized data of quarterly audits of outside lab results are to be sent to the UW Health
Laboratory Testing Oversight Committee for review (These also may be sent to the POC
coordinators to be forwarded to the committee). Use Health Link Enter/Edit Audit
Summary Sheet.
d. Failure to complete required audit or poor performance on entry of POC or external results
via Enter Edit as determined by the UW Health Laboratory Testing Oversight Committee
may result in loss of this functionality.

VI. FORMS

Health Link Enter/Edit Audit Summary Sheet

VII. COORDINATION

Author: Director, UW Health Clinical Laboratories
Senior Management Sponsor: SVP, COO
Approval committees: UW Health Laboratory Testing Oversight Committee; UW Health Clinical Policy
Committee
UW Health Clinical Policy Committee Approval: May 15, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VIII. APPROVAL




UW HEALTH CLINICAL POLICY 5
Policy Title: Entering Test Results Into UW Health Link (EPIC)
Policy Number: 3.2.4

Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

IX. REVIEW DETAILS
Version: Revision
Last Full Review: May 26, 2017
Next Revision Due: May 2020
Formerly Known as: Hospital Administrative policy #7.98