To combat physician and resident delays in completing and signing discharge summaries and operative reports, UC-San Diego Medical Center in 1992 started using homegrown software to administer a program whereby tardy physicians were fined and suspended until they completed the paperwork.

Suspension meant they couldn't admit patients, order prescriptions or perform operations until their reports were up-to-date. The rule was that physicians had 14 days to create a discharge summary and another 14 days to sign it. They had one day to create and sign an operative report.

In 1998, the hospital replaced the homegrown system with electronic signature and chart management software from 3M Health Systems, Salt Lake City, and mandated reports be electronically signed.

Upgraded software in 2006 better supported the characteristics of academic medical centers, such as accommodating documentation from attending physicians.

With the upgrade came a tightening of rules, recalls Christopher Clarke, clinical systems and documentation manager. Noncompliant physicians and residents not only were fined and suspended, but also locked out of the Invision hospital information system from Siemens Healthcare and the core electronic health record system of Epic Systems Corp.

The window to complete and electronically sign reports also shrank, to a total of 14 days for discharge summaries. An operative report had to be completed immediately after a procedure or by 8 a.m. if the surgery was done during the evening. The updated system also flags physicians and residents who don't get their annual TB test.

The changes stoked howls of protests from physicians, says Clarke, who showed de-identified e-mails he received during an interview with Health Data Management at the HIMSS 2010 Conference. The messages calling Clarke and/or administrators "evil" or "stupid" weren't even the worst ones.

Before 2006, 85 percent of operative reports were done within 24 hours; today, 95 percent are completed on the day of the procedure. Completion of discharge summaries averaged about 30 days four years ago. Now, 85 percent are done and posted the day of discharge and 97 percent are done within 14 days, Clarke says.

In March 2010, UC-San Diego Medical Center started to expand the program further to police the reporting compliance of physicians providing ambulatory care. The physicians are not fined and suspended, but are locked out of the hospital's core systems until their paperwork is up-to-date.

Clarke believes the ambulatory program will be successful because ambulatory physicians locked out the UC-San Diego computers have to ask colleagues to pull patient data for them. That will put even more pressure on recalcitrant physicians to complete their documentation.

--Joseph Goedert

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