Journal of AHIMA - July 2011

Questions to Ask Regarding Electronic
Query Systems

x Will the query software interface with the current EHR?
x Are log-in credentials based on role-based access?
x How will physician communication occur (e.g., e-mail,
system prompt)?
x Can the physician “override” the communication?
x Does the software allow the physician to sign one que-
ry at a time or all queries with one click?
x Where will the queries attach to the EHR (e.g., progress
notes, dictation, physician orders)?
x Does the query software allow for electronic signa-
tures? Does the electronic signature contain a date and
time stamp?
x What standard reports can be obtained from the sys-
tem?
x If multiple query forms are needed, does the system
have the capability to handle multiple forms?
x How are query forms updated or revised?
x Can the system handle both concurrent and retrospec-
tive queries?

on a routine basis. In addition, log-in credentials for the query system should meet the organization’s policies and procedures for system access security.

Other issues to consider for implementation include how testing will occur, who is responsible for testing, and who will be responsible for training on new functionalities.

Query Status and Location

Finally, organizations should clearly define how the query affects the legal health record and the location of the query within the EHR. Each individual organization must determine if the query is a part of the legal health record.

Some organizations do not feel that the query directly affects the care of the patient and the addition of a query does not change the course of treatment and is therefore not a part of the legal health record. Other organizations utilize the query to demonstrate transparency in documentation and clarification, specifically to third-party auditors, and consider it a part of the legal health record.

If the query is considered part of the legal health record, then organizations should determine its place within the record. As part of the legal health record, the query then becomes a component of the record that is analyzed for completion.

Analysis of the record would include a review of the query for a physician signature. Organizations must then determine if an unsigned query is a deficiency for the physician. These deficiencies may or may not be part of the suspension process; however, the time frame for completing the deficiency should be the same as other deficiencies. For example, if the organization requires all deficiencies to be completed within 30 days of discharge, the