Common Pitfalls Associated with Increased Use of ... · nationwide coding and compliance seminars for ICD-9-CM, CPT-4, outpatient surgery and diagnostic imaging. She has consulted

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Common Pitfalls Associated with Increased Use of Electronic Health Records

December 4, 2015

2 Common Pitfalls Associated with Increased Use of Electronics Health Records Copyright © 2015 Deloitte Development LLC. All rights reserved.

Speakers

Marita Janiga, Executive Director - Investigations, Kaiser Permanente

Marita joined Kaiser Permanente in 2008 and oversees two groups, the National Special Investigations Unit

and the Hotline Operations Unit. Prior to joining Kaiser Permanente, Janiga had over 20 years of federal law

enforcement experience investigating criminal activity, the last ten years as the Special Agent in Charge of the Office of Labor Racketeering & Fraud Investigations, U.S. Department of Labor (DOL), Office of Inspector

General (OIG).

Karolyn Woo-Miles, Principal, Deloitte & Touche LLP

Karolyn brings more than 15 years of health care regulatory, compliance and operational knowledge, and provides leadership to organizations in their efforts to comply with Federal and State health care laws and

regulations while transforming their business. She has worked with some of the largest health systems in

California, Arizona, and New Mexico, on effectively bridging the gaps between regulatory requirements and operations by developing strategies to comply with regulations while balancing the needs of the business.

Kelly Wittmeyer, Regional Compliance Officer, Sutter Health

Kelly Wittmeyer, MA, CHC, CCS, CCS-P, is a Regional Compliance Officer at Sutter Health overseeing the

Compliance programs for twelve hospitals and two ambulatory care Medical Foundations. She has led

nationwide coding and compliance seminars for ICD-9-CM, CPT-4, outpatient surgery and diagnostic imaging. She has consulted in healthcare fields such as ambulatory surgery, physician practice, emergency

department, rural health, home health, and multiple other medical specialties. She has been a speaker for

the American Health Information Association (AHIMA), California Health Information Association (CHIA), the Health Care Compliance Association (HCCA) and the California Department of Public Health (CDPH).

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Contents

Introduction

Cloning / Copy & Paste

Meaningful Use

Clinical Quality Reporting

Data Analytics

Introduction

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BackgroundElectronic Health Record (EHR) adoption has been increasing rapidly in the United States over the past

several years. At large hospitals, EHR use has increased from 10% in 2008 to 72.9% in 2013¹

• Most of this growth has coincided with the EHR Incentive Program which provided healthcare

providers with billions of dollars in subsidies to adopt EHRs

• With the increased use of EHRs, increased attention from regulators has followed. The 2014 OIG

work plan stated that EHR fraud would remain a high priority through 2018.

While most think of the EHR as where the patient’s medical record is maintained, the term is also used to

refer to other types of Health Information Technology (Health IT), including patient portals, handheld

devices, health information exchanges, etc.

Adopting a new EHR has a significant impact on how patient care is delivered, especially in the short term.

In addition to impacts on your patients, EHR adoption can also impact:

• Employee Morale

• Quality scores

• Reimbursement

¹ Source: http://www.rwjf.org/content/dam/farm/reports/reports/2014/rwjf414891


EHRs and the OIG

The OIG has been reviewing the risks associated with the use of EHRs for several years and determined

that:

• Nearly all hospitals have recommended audit functions but are not fully utilizing them

• All hospitals have employed user authorization and access control

• Nearly all hospitals utilize data transfer safeguards

• One quarter of hospitals have Copy & Paste policies

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Common Pitfalls of EHR Use



Data Analytics

A function used select information from one record and copy it into another

record without need to verify and validate information. Inaccurate

information may result in increased charges or inflated and duplicated

claims.

Meaningful Use

Meaningful Use is using certified electronic health record (EHR) technology

to improve quality, safety, efficiency, and reduce health disparities, engage

patients and family, improve care coordination, and population and public

health, and maintain privacy and security of patient health information.

Today, we are going to discuss the common pitfalls of EHR use as they relate to the following compliance topics. They are:

The process of reporting clinical quality data to regulators and other

agencies for the purpose of evaluating clinical performance, resource use

or reimbursement.

The use of data stored captured or stored with the EHR to produce

actionable information used in strategic decision making, monitoring or

reporting.


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What is Cloning?

"Cloning" medical record documentation means cutting-and-

pasting the information entered in the Electronic Medical

Record (EMR) from one date of service to another.

The indiscriminate use and abuse of the Copy and Paste

Functionality which may be considered a misrepresentation of

the medical necessity requirements for coverage of services.

Documentation is considered cloned when multiple entries in

the medical record for a patient are worded identically, and not

updated to reflect the specifics of the current encounter,

condition and treatment. Cloning may also occur when medical

record documentation is exactly the same for multiple patients.

• The Copy and Paste Functionality is the utilization of

EHR SmartTool technology, NoteWriter macros and the

Microsoft copy-paste option in order to insert information

into a patient encounter.

• EHR SmartTools are a group of shortcuts that let users

automate various documentation functions and facilitate

the documentation process.

Source(s): http://www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning#sthash.EIS2HMof.dpuf

https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-docintegrity-factsheet.pdf

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049377.hcsp?dDocName=bok1_049377


The Impact of Cloning

According to a survey …

• Facts (Journal of General Internal Medicine Survey):

Incorrect information in the EHR is the most common user related contributing factor in malpractice cases

Physician felt that copy/paste of notes led to outdated, inconsistent, and hard to find notes

60-70%

physician used the copy/paste function in their EHR 60-70%

30-78% of each note type is copied from previous notes 70-90%

Involved pre-populating and/or copy/paste as a contributing factor.

13% of malpractice cases

Source: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607489/

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Outdated Information

Conflicting Information

Reimbursement and Fraud

• A cloned note states that a patient will undergo

surgery at some future time, even though the

referenced surgery was performed days before.

• The inability to identify the author or thought process

of the EHR update

• Identical verbiage used repeatedly for all patients seen

by a provider for a specific timeframe with little or no

modification regardless of the nature of the presenting

problem or intensity of the service

CMS states, “When no documentation differences are noted

for several services for one beneficiary or services for

multiple beneficiaries, there may also be a question of potential fraud.”

Cloning can negatively impact patient care.

“EHR features such as macros and templates allow for auto-fill of information that can create

unintended documentation errors in the medical record” such as:

Source(s): https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-docintegrity-factsheet.pdf

https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf

https://www.aapc.com/blog/key-flaws-with-cchit-criteria/



These Copy and Paste Activities may also result in:

• Redundancy, which makes it difficult to identify the current information

• Inability to identify the author or intent of documentation

• Inability to identify when the documentation was first created

• Propagation of false information

• Internally inconsistent progress notes

• Unnecessarily lengthy progress notes

AHIMA’s positon on copy and paste:

The use of copy/paste functionality in EHRs should be permitted only in the presence of strong

technical and administrative controls which include organizational policies and procedures,

requirements for participation in user training and education, and ongoing monitoring. Users of

the copy/paste functionality should weigh the efficiency and time savings benefits it provides

against the potential for creating inaccurate, fraudulent, or unwieldy documentation.

Source(s): https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/ehr-docintegrity-factsheet.pdf

https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf

https://www.aapc.com/blog/key-flaws-with-cchit-criteria/, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf

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Examples of Cloning

• An Oncologist sees the same patient 1x month for 9 months. In the physicians note the blood pressure and weight is always the same; complaints are identical; medications never change; notes are about 4 pages long and all are coded as 99215.

• Medical assistant EHR entries indicate various weights and BP; patient notes changes in medications; different complaints throughout course of treatment.


Examples of Cloning

Physical Exam

Abd: soft, nondistended, with normal active bowel sounds. No hepatosplenomegaly, no masses, nontender to deep palpation

Assessment

A mass was palpated in the abdomen

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Examples of Cloning

• Chief Complaint: sinus problems HPI: Patient presents with 1 wk “stuffy feeling” in nose, yellow mucus, cough, headache, itchy, watery eyes

• ROS Eyes: denies blurring, irritation, discharge, vision loss

• ENT: denies ear pain or discharge, tinnitus, decreased hearing See HPI

• Resp: denies cough, SOB, dyspnea, excessive sputum

• GI: denies rectal bleeding


• Patient presents for a routine follow up for diabetes.

• The RN reviews the patient's current diabetic medication dose and asks if there are any other issues to discuss with the provider. The patient indicates “no”.

• The RN selects the "marked as reviewed" or "no changes" button in the review of systems section of the template.

• This action blows in the previous ROS from the prior encounter

• The provider's diabetic template offers a detailed examination.

• The provider selects normal for all elements associated with the template.

• This detailed exam, combined with the carried-over ROS, that results in upcoding a routine follow up with standard lab orders to a 99214.

• The correct code for this visit is 99213 without the erroneous ROS and the mislabeled detailed exam.

Examples of Cloning

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• Monitoring of EHR-assisted coding is not consistently performed

• EHR coding does not always match the billing system

• Coding “assistance” via the EMR product itself (CPT & ICD)

• Use of Modifiers and abbreviations

• Coding in EMR is valid although based on pre-determined design

• Lack of policies and procedures related to:

− Coding and documentation related to EHR

− EHR retention policies

• Completeness and accuracy of the problem list

− Prevention of auto population without clinician confirmation

− Allow for correcting errors on the problem list

Things to Watch For


How to Audit Cloning?

Two main approaches:

• Horizontal: Same patient, visit after visit

• Vertical: Different patients, same or similar diagnoses/complaints.

o Con: Side by side comparisons are still needed.

Considerations:

• Abnormal patterns of activity

• Routine documentation monitoring

• Routine coding monitoring and auditing

• Monitoring the computerized assignment of codes

• System generated warning messages

• Audit EHR access

Example:

• Provider bills 99214’s a majority of the time, sees 50 patients per day.

o How long does the provider spend in each patients medical record?

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MAC Guidance on Templates

Noridian Administrative Services, LLC

Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such

as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do

not support medically necessary information

that correlates to the management of the particular patient.

Part B MR is seeing the same auto-populated paragraphs in the HPIs of different patients. Credit cannot be granted for information that is not patient specific and date of service specific.

Source: https://www.noridianmedicare.com/shared/partb/bulletins/2011/271_jul/Evaluation_and_Management_Services_-_Documentation_and_Level_of_Service_.htm


CMS Manual System - Medicare Program Integrity Manual

Chapter 3 - Verifying Potential Errors and Taking Corrective Action

“Some templates provide limited options and/or space for the collection of

information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review

experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.

Physicians should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that

the medical necessity criteria for the item/service are met.”

Source:: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R455PI.pdf

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From Testimony of Lewis Morris, OIG

“For example, electronic health records (EHR) may not only facilitate more

accurate billing and increased quality of care, but also fraudulent billing.

The very aspects of EHRs that make a physician’s job easier—cut-and-paste

features and templates—can also be used to fabricate information that

results in improper payments and leaves inaccurate, and therefore

potentially dangerous, information in the patient record. And because the

evidence of such improper behavior may be in entirely electronic form, law

enforcement will have to develop new investigation techniques to

supplement the traditional methods used to examine the authenticity and

accuracy of paper records. “


Mitigating Risks Associated with Improper Use

Many hospitals have audit and compliance functions related to cloning but are not fully utilizing them to

assess or mitigate risk related to the improper use of EHR technology

Risk mitigating considerations include but are not limited to:

• Policies and Procedures

• Education and Training

• Performing Independent and Departmental Auditing and Monitoring Activities

• Enabling the EHR Audit Log and Monitoring Capabilities

• Regulatory Environment Awareness

• Tone at the Top – Messaging and Consistency

• Key Stakeholder Collaboration (not just IT and Clinical Leadership)

• Peer Pressure to Collectively Own the Patient’s Care

• Consistent, Open, Inclusive Dialogue and Healthy Debate

Source: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf

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What Should Your Organization Do?

• Develop a formal policy addressing the proper use of the

copy/paste feature to assure compliance with

governmental, regulatory, and industry standards

• Address the use of features such as copy/paste in their

information governance processes

• Provide comprehensive training and education on proper

use of copy/paste to all EHR system users

• Monitor compliance and enforce policies/procedures

regarding use of copy/paste and institute corrective action

as necessary

• Create a partnership with an influential Medical Director

• Encourage employees to bring questions forward

Source: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050621.pdf


Use of Scribes

• As patient load increases demand for provider productivity increases

• Use of scribes is becoming more common

• In some instances scribing, or authenticating notes made by another person, can be a fraudulent

act if not acknowledged

Example

A medical assistant may complete a history and physical on a patient in totality. The supervising

physician may subsequently log in to the record, evaluate only proof of positives and negatives,

and electronically sign the documentation in such a way that it overwrites the presence of the

medical assistant.

That overwriting misrepresents who provided the service, which could alter the amount that is billed.

Source(s): http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_038463.hcsp?dDocName=bok1_038463

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Meaningful Use


What is Meaningful Use?

“Meaningful Use” is using certified electronic

health record (EHR) technology to:

• Improve quality, safety, efficiency, and reduce

health disparities

• Engage patients and family

• Improve care coordination, and population

and public health

• Maintain privacy and security of patient health

information

•Both Eligible Hospitals (EHs) and Eligible

Professionals (EPs) can submit an annual

attestation to the Centers for Medicare and

Medicaid Services (CMS).

•If they meet certain criteria, EHs and EPs are

eligible for an incentive payment. Failure to attest

on an annual basis may result in payment

adjustments

•Is your organization maximizing their incentive

payments and avoiding penalties?

Stage 1

Data capture and sharing

Stage 2

Advanced clinical processes

Stage 3 Improved outcomes

Incentives Payments – Program to Date

• Over 450,000 physicians and 4,800 hospitals participating

• $31 billion in incentives paid since 2011

A 3 Stage Approach to EHR Adoption:

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In October 2015, CMS released a Final Rule designed to streamline the EHR Incentive Program by reducing the reporting burden for providers in the short term and introduce Stage 3 requirements. The following represent the significant proposed changes included in these rules:

• All providers may utilize a continuous 90-day reporting period to meet Meaningful Use in 2015

• CMS has modified the Stage 2 requirements to remove measures which are “topped out” or no longer

align with the long-term goals of the program, and has simplified the objective “menu”

• Beginning in 2015, all providers will utilize a reporting year based on the calendar year; EHs will no

longer use the federal fiscal year

• An additional 60-day comment period has been established for CMS to receive additional feedback on

the Stage 3 criteria and to allow for feedback on MACRA/MIPS to be incorporated into the Stage 3 rule.

Meaningful Use Recent Changes


The following represent 10 principles that successful organizations follow to achieve Meaningful Use:

• Know the Rules

• Provide Effective Governance

• Select a Project Manager

• Anticipate Clinical Workflow Changes

• Monitor Compliance

• Manage your EHR Vendor

• Validate Meaningful Use Reports

• Don’t Rely on Exclusions

• Conduct a Thorough Security Analysis Each Year

• Don’t Forget the Big Picture

Meaningful Use – Lessons Learned

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Stage 2

MU Requirements for 2015

Objectives Measure(s)

Protect Electronic Health Information

• Conduct or review a security risk analysis in accordance with the requirements under 45 CFR 164.308(a)(1)

Clinical Decision Support • Implement 5 clinical decision support interventions related to 4 or more CQMs• Implement drug-drug and drug-allergy checks

Computerized PhysicianOrder Entry (CPOE)

• 60% of medication orders• 30% of laboratory orders• 30% of radiology orders

ePrescribing • 50% of prescriptions (EP) and 10% of discharge medications (EH) are queried for a drug formulary and electronically prescribed

Summary of Care • A Summary of Care record is provided electronically for 10% of transitions of care

Patient Education • 10% of unique patients are given education suggested by the EHR

Medication Reconciliation • Medication reconciliation is performed for 50% of transitions of care received

Patient Electronic Access • 50% of unique patients are provided only access within 4 business days (EP) or 36 hours (EH) of their encounter

• At least 1 patient views, downloads or transmits their health information

Secure Messaging • The capability for patients to send and receive a secure electronic message with the provider was fully enabled

Public Health Active engagement must be achieved for the following public health options:1. Immunizations2. Syndromic Surveillance3. Specialized Registry4. Electronic Lab Reporting

EPs must select 2 from #1-3, EHs must select 3 from #1-4. #3 may be counted multiple times


The Summary of Care Measure (also known as “Transitions of Care” or

“Health Information Exchange”) requires Eligible Hospitals and

Professionals to send a summary of care record electronically for greater

than 10% of transitions of care

MU Requirements: Summary of Care

A transition of care occurs when follow up care is ordered and a patient is discharged into the care of another provider or facility

The Process

• Patient name• Sex• Date of birth• Race and ethnicity• Preferred language• Smoking status• Current problem list• Current medication list• Current medication allergy

list• Lab test results• Vital signs

• Referring or transitioning provider’s name and office

contact information• Care plan fields(s) to include

goals and instructions• Procedures

• Care team members• Discharge instructions

• Reason for referral• Immunizations

• Encounter diagnosis• Functional status

A summary of care record is created by the EHR, which contains the following fields:

The summary care record is sent electronically to the receiving to provider or facility for greater than 10% of transitions of care

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Incentive Payments and Penalties — Some Key Takeaways

• EHs are eligible to receive significantly more incentive payment dollars than EPs

• EPs who are eligible for both Medicare and Medicaid incentive dollars, should register and attest for

the Medicaid EHR Incentive Program due to the higher incentive dollar amount available

• EH Incentive payments are determined based on data entered at registration related to total

discharges, growth rate and other factors. The payments are then made over a 3-5 year period

depending on the state and whether it is a Medicare or Medicaid hospital

• The opportunity to receive Medicare incentive payments ends in 2014, whereas Medicaid payments

are available until at least 2016, depending on the state

• Penalties begin start in 2015 for providers who have never met Meaningful Use


Meaningful Use Audits

CMS is targeting approximately 10% of all providers for audit in a given year. All aspects of the

attestation are subject to audit, as Meaningful Use is an “all-or-nothing” program.

CMS began pre-payment audits in January 2013 and the OIG has added elements of Meaningful Use to

their work plan for fiscal year 2014.

CMS audits require supporting documentation to be provided to the auditor to validate the submitted

attestation data.

Audits to date have typically requested the following information:

• Proof of ownership of certified EHR (i.e. vendor letter, license agreement, etc.)

• Explanation of what locations the EP practices at and whether they utilize CEHRT

• Meaningful Use reports for Core and Menu measures

• Evidence of the completion of the Security Risk Analysis

• Evidence of compliance with Public Health Measures

“Non-compliance with the Security Risk Analysis measure is the top reason providers fail Meaningful Use audits” - Elizabeth Holland, CMS

Source: EHR Incentive Programs Supporting Documentation for Audits and EHR Incentive Programs Audit Overview

http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_SupportingDocumentation_Audits.pdf

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Meaningful Use – Additional RisksAside from receiving incentives and avoiding penalties, participating in MU can create additional risks:

Patient Portals – Ability to provide health information and other functionality online can be a huge driver of

patient satisfaction or competitive advantage

Are you effectively engaging your patients?

Interoperability – MU requires the exchange of health information across the care continuum

Is your organization ready to start sharing this information?

Security – MU requires a security risk assessment to be conducted annually which covers ePHI created or

stored by the EHR

Security risks are constantly changing, are you taking steps to mitigate these risks?


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Clinical quality reporting has been historically accomplished via manual chart abstraction. Automated, electronic clinical quality reporting directly from the EHR is still an immature process

However, starting in 2016, certain CMS programs, including Inpatient Quality Reporting, will require clinical quality measure (CQM) data to be submitted electronically using an EHR.

• These deadlines are advancing timelines for the electronic reporting of CQMs (eCQMs), forcing organizations to evaluate when and how they will begin the complex transition from manual chart abstraction to automated reporting from their Electronic Health Record.

The implications of electronic reporting are as follows:

• Technology upgrades and workflow changes need to be implemented to support accurate clinical quality reporting

• eCQMs must accurately represent the quality of the institution as they will be shared broadly with patients and used to drive reimbursement

• A mechanism for electronic submission must be selected and implemented

36

Center for Medicare and Medicaid Services (CMS) Quality Measure Goals

Efficiency

Smooth Transitions

of Care

Eliminating Disparities

Effectiveness

Transparency

Where care does not harm patients

Where quality care is reliably received

regardless of geography, race, income, language,

or diagnosis

Where care is evidence-based

and outcomes-driven to better manage diseases and prevent

complications from them

Where care is well-

coordinated across different

providers and settings

Where information is used by

patients and providers to guide

decision-making and quality improvement efforts, respectively

Where resources are used to maximize quality

and minimize waste.

Copyright © 2015 Deloitte Development LLC. All rights reserved.

Safety

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As the healthcare industry moves to a value based care model, clinical

quality reporting will take on a larger role in determining reimbursement. Is

your EHR ready to meet the reporting demands?


The number of programs which have some sort of clinical quality reporting is growing rapidly:


• Auditing of accuracy of reporting measures

• Investigations related to poor quality care

• CIAs related to quality

• OIG reports (examples: copy/paste in EMR, adverse events, home health/hospice quality of care issues not identified in state surveys and

many more)

• OIG work plan topics

• CMS data mining of quality reports, PEPPER, CERT, PERM, RAC

OIG / CMS Activities


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• Tied to payment — false claims

• Tied to performance incentives — accurate reporting

• Settlements and Corporate Integrity Agreements (CIAs) related to quality

• Potential for sanctions, monetary penalties or exclusion from state and federal health care programs

• More quality topics are being included in the OIG annual work plans

• Expectation that Medicare will be auditing the accuracy of quality measures reported

• Reliance on electronic record or abstracted data

• Quality data is publically presented — transparency

What does all of this have to do with the Compliance Department?



Center for Medicare and Medicaid Services (CMS) Quality Measures – Examples of ImpactSource: Kaiser Health News (http://khn.org/news/value-based-purchasing-medicare/)

Safety


721 Hospitals Penalized For Patient SafetyHospitals with high rates of potentially avoidable mistakes that can harm patients, known as “hospital-

acquired conditions.” Penalized hospitals will have their Medicare payments reduced by 1 percent over

the fiscal year that runs from October 2014 through September 2015. To determine penalties, Medicare

evaluated three types of HACs. One is central-line associated bloodstream infections, or CLABSIs. The

second is catheter-associated urinary tract infections, or CAUTIs. The final one, Serious Complications,

is based on eight types of injuries, including blood clots, bed sores and falls.

Nearly 1,500 Hospitals Penalized Under Medicare Program Rating Quality

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Electronic Reporting Challenges

Vendor prescribed eCQM solutions assume the data lives in specific places.

If forms, templates and order sets do not promote consistent data capture

the reporting process breaks down

In many instances, required CQM data elements is being documented in a note

or disparate system that does not allow the EHR to use it for reporting purposes.

Workflow changes must be prioritized based on what will have the most impact

on eCQM reporting while minimizing disruption in the clinical setting

Manual abstraction has been used for years, and represents a significant cost

to health systems. It is reliable, trusted and is viewed as “low risk”, which

creates unease amongst quality departments as they move to eCQMs

Quality departments will be forced to focus their reviews on the data available

in a structured format instead of the entire medical record. Developing

standards for what should be included in the electronic record, where it should

be documented, how quality is monitored, etc. is vital

Inconsistent or redundant EHR build

Clinical workflows do not facilitate consistent capture of structure data

Ownership of the quality of the electronic record is not established

Reluctance to embrace true automation of measure abstraction

The ChallengeCurrent Gaps

As organizations begin to plan strategies around developing eCQM solutions, they should consider the following:

Data Analytics

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What is Healthcare Compliance Data Analytics?

• Health systems are generating a tremendous amount of data, but the industry still struggles with how to harness that data into actionable information

• Data analytics refers to using information to impacts revenue growth, operating margin, asset efficiency, and risk management. Compliance departments can use data to evaluate enforcement, reputation, quality and efficiency

• Effective data analytics and information management can provide hospitals with an advantage that safeguards them from reputational/regulatory risks while improving their quality and patient experience

• Analyzing compliance data is now more important than ever, but compiling and understanding that data can be complex


Outcomes of Compliance Data Analytics

• Asses the dynamic nature of controls

and whether controls are still effective

• Mining for data will assist in identifying

risk areas

Risk Mitigation

• Discover best practices and

provide lessons learned

• Provide new metrics for Quality

Improvement and Process

Improvement and establish data

standards

Quality/Process Improvement

Educational/Training Needs

• Identify Education/Training gaps

• Determine average compliance

knowledge level of work force

Collaborative Opportunities

• Establish collaborative initiatives

between compliance, finance, IT, and

operations departments to improve

risk mitigation efforts

• Create data warehouses that enable

audit intelligence

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Challenges with Compliance Data Analytics

1

2

3

4

5

Mining and Structuring Data

Not all data will be alike. Compliance analytics teams must identify data and categorize data.

Protecting & Storing Data

Healthcare entities work with sensitive data that must be kept save from fraud and abuse.

Analyzing Data TrendsData in compliance has traditionally been used as a method to monitor, Now it must

predict.

Executive Dashboarding

No matter how useful data is, data is useless without executive understanding.

Investigations Derived From Data

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Example of Compliance Metrics

Prescribing Pattern Studies

• Analysis of prescribing patterns to uncover anomalies.

Drug Utilization/Drug Seeking Behavior (DSB) Studies

• Analysis of prescription data to identify early refills and duplicate prescriptions.

Prescriptions After Death Studies

• Analysis to compares known date of death from Social Security death records with patient’s Social Security number.

Part D Studies

• Analysis designed to address and comply with the Part D requirements and requests for information.

Pyxis Studies

• Override trending report, drugs removed/administered, waste, removed after discharge, death, or transfer, no associated pain scale, unassigned nurse drug removal.

Drug Utilization & DSB Studies Can Uncover Medical Identity Fraud

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Medical identity fraud occurs when someone

uses a fictitious identity to fraudulently receive:

• Medical services

• Prescription drugs and/or goods

Medical Identity Fraud


Medical Identity Fraud results in:

• Unnecessary

o Tests

o Medical procedures

o Prescriptions (primarily pain killers)

• Potential patient safety issues

• Inaccurate billing

• Patient service delay

Impact:

• Increased cost of care

• False or comingled medical records

Medical Identity Fraud

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Medical Identity Link Analysis

Names

Demographics

• Addresses

• Phone Numbers

• Gender

• Relationships


Storyboard

Kaiser Permanente Source Data

Identity Algorithm

Who is She?

Common Identifiers

Multiple

Patients IdentifiedMedical

Services

Medical Chart Review

Additional Commonalities (e.g., oophorectomy,

LLQ, N/V)

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Name and Demographics (Data is Created)

Member ID DOB Name Address City StateCreateDate

1 4/15/1981 MCKINNON DEBBIE123X SINGINGWOOD

CIRLAUREL CANYON CA 7/17/2014

2 8/14/1981 BRENNAN TERRY123X SINGINGWOOD


3 9/12/1980 MCKINNON ANN123X SINGINGWOOD


4 9/21/1980 JORDAN LYNN123X SINGINGWOOD

CIRLAUREL CA 9/12/2014

5 10/24/1980 MCCLELLAN ANN123X SINGINGWOOD


6 10/13/1980 MACLENDON KAREN123X SINGINGWOOD


• Similar DOBs

• Similar Names

• Exact Address Matches

• All Different Create Dates


Identity Web Summary

41 Identities/MRNs

All Females With DOBs between 1980 – 1981

19 Address Variations Across 10 Cities and 2 States

Stated Allergies • 40 of 41 – Allergic to Morphine

• 37 of 41 – Allergic to Doxycycline

Stated Medications• 37 of 41 – Keppra

• 36 of 41 – Trileptal

• 31 of 41 – Yaz

Stated Conditions• 40 of 41 – Oophorectomy

• 35 of 41 – Epilepsy/Seizures

• 39 of 41 – Appendectomy

Patient Presents • 39 of 41 – Abdominal Pain

• 35 of 41 – Diarrhea, Nausea, and Vomiiting

• 32 of 41 – LLQ Pain

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Pyxis Studies Can Uncover Drug Diversion by Healthcare Workers


Estimates of health care providers with alcohol and/or drug dependency challenges.*

• 15 percent of pharmacists.

• 10 percent of nurses.

• 8 percent of physicians.

Easy access is highly correlated with drug misuse.

Of top 17 abused prescriptions in 2013, 16 (94%) are classified as Schedule II, III, or IV medications.**

Bureau of Labor Statistics May 2013 Report.

• 287,420 pharmacists in U.S. – 43,113 is 15 percent.

• 2,661,890 nurses in U.S. – 266,189 is 10 percent.

_________________________________________Source(s): * Ron Buzzeo and Machelle Neal: “Hospital Drug Diversion and Abuse –Creating an Effective Surveillance and Prevention Program.” Cedegim Company, January 2013.

**Alex Philippidis: “Top 17 Abused Prescription Drugs in 2013. GENnsight & Intelligence.

Hospital Drug Diversion

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Commonly Diverted Medication in Hospitals

Dilaudid (Hydromorphone)Dilaudid (Hydromorphone)

Demerol (Meperidine)Demerol (Meperidine)

MorphineMorphine

FentanylFentanyl

LorazepamLorazepam

HydrocodoneHydrocodone

AlprazolamAlprazolam

Valium (Diazepam)Valium (Diazepam)


Red Flags for Hospital Drug Diversion

• Inconsistent or incorrect charting.

• Offers to medicate other nurses’ patients on a regular basis.

• Displays inconsistent work quality; high and low efficiency.

• Obtains larger dose of narcotics, documents remaining as waste.

• Requests to care for specific patients.

• Patient reveals that medications are not having the desired effect.

• No pain scale in chart.

• Medications dispensed to patients right before discharge.

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Proper Documentation Helps Everyone

• Medication order

• Pre and post pain scale

• Medication dose matches medication order for pain scale

• Medication Administration Record “MAR” is properly documented

• Waste is accounted for

• Witness is responsible, too –DON’T SIGN UNLESS YOU WITNESS

• Log out - You are responsible

• Read chart notes

Make sure the documentation

is there.

Glucose Test Strip (GTS)

Analytics Can Uncover Fraud

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GTS Analytics

Utilization by total quantity

Utilization by average GTS per day

GTS utilization with no lancets

GTS utilization with no diabetes diagnosis

Number of days since last HGA1C

Number of days since last doctor’s office visit


Data mining study indicated excessive use of GTS

Patient obtained 18,800 test strips between 8/5/2013 and 5/7/2014

Daily use comes to 67 strips

GTS Analytics

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Patient Interview

Patient checked when GTS refills were available

Admitted to filling prescriptions every

couple of days

Admitted to selling 14,000 GTS on eBay with

proceeds of about $10,000

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