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AUDITING EMR AUDITING EMR DOCUMENTATIONTRINA BIRINGER, BSN, RN, CCRCSENIOR CLINICAL AND RESEARCH NURSE AUDITORTHE NEMOURS FOUNDATIONTHE NEMOURS FOUNDATION
AHIA 32nd Annual Conference – August 25-28, 2013 – Chicago, Illinois
www.ahia.org
Contact Information:2
Trina L. Biringer, BSN, RN, CCRC Senior Clinical and Research Nurse Auditor Occupational Safety and Health Specialist
10140 Centurion Parkway NorthJacksonville, FL 32256Office [email protected]
M L f d f A d
When I am not reading protocols and reviewing EMR’s, I enjoy spending time with 2 i b
My Life outside of Audit.3
my 2 energetic boys.
A di i h EMRAuditing the EMR4
What’s Your VIEW?
EMR- The Journey……y5
Tribute to EMR and Journey’s Don’t stop believin’believin
Epic user group meeting kitskit
Audit Typeyp
Clinical/Operational Research Specific
6
Clinical/Operational Research Specific
EMR: The Documentation per OIGp7
The Standard
OIG Importance of Documentation
Auditing the EMR Documentationg
Identifying the Key Stakeholders:8
Identifying the Key Stakeholders:
WhoWho
Wh t YOUR i ti l t ti ? What are YOUR organizational expectations?
Wh f EMR (E i M di h )What type of EMR system (Epic, Meditech etc)
Why we Audit-Implementation of EMRy p
Quality & Safety9
Quality & Safety
Efficiency
Clinical decision support/Improve care dcoordination
Engage patients and families in their care
Why we Audit-continuedy
Improve population and public health10
Improve population and public health
Electronic reporting
Privacy and security protections
ComplianceCompliance
It’s the Law11
Electronic medical records like other Electronic medical records, like other medical records, must be kept in unaltered form and authenticated by the creator.[1]the creator.
Auditing Challengesg g12
? Is it a roadblock?
EMR Auditing Challengesg g
Integrity of the record13
Integrity of the record
Controls around access
Who documented what?
Signatures/authentication Signatures/authentication
Challenges-continuedg14
C t/ / t f tCut/copy/paste features
Cloning (defaulted documentation)
Macro’s
Transparency of the providerp y p
How Documentation is inputted in the EMR EMR
Documentation may be:15
Documentation may be:
dictated typed handwritten & or computer dictated, typed, handwritten & or computer generated.
Supporting documentation may be:
scanned, faxed, a “snapshot”, electronically copied from original source or a combination of multiple styles.g p y
Smart Text Language and Templatesg g p
“Make Me the Author” feature16
“Make Me the Author feature
Template by provider, department, p y p , p ,specialty or regulatory guidelines and standard of care practicesand standard of care practices
EMR Automatic Pathwaysy
Check your software’s default settings
17
Check your software s default settings
Can the provider override default settings when they Can the provider override default settings when they don’t apply to a particular patient or service
Don’t be afraid to use templates but be sure to individualize for each patientindividualize for each patient
Can the Provider modify or delete template Can the Provider modify or delete template language when it does not apply
EMR Automatic Pathways-continuedy
Was the organization diligent in the training efforts
18
Was the organization diligent in the training efforts on how to document in the EMR
Does the EMR select codes based upon “key words” in the documentation fields
Is the EMR set up to default information from previous Is the EMR set up to default information from previous entries to the current provider note?
S f h EMR
HIPAA d HITECH
Scope of the EMR19
HIPAA and HITECH.
Access and transport medical information across organizations
Interfacing with other systems and entities that li k t th i t tlink to the internet.
Ranking of Hospital EMR Installations by V d M d H l hVendor per Modern Helathcare (2011-2012)
TOP 10 VENDORS OF ENTERPRISE EMR 20
TOP 10 VENDORS OF ENTERPRISE EMR SYSTEMS
Meditech Westwood, Mass. 1,155 meditech.com Epic Systems Corp. Verona, Wis. 678 epic.comp y p , p Cerner Corp. Kansas City, Mo. 634 cerner.com McKesson Provider Technologies Alpharetta, Ga. g p ,
471 mckesson.com CPSI Mobile, Ala. 393 cpsinet.com
Top 10 Vendors continuedp
Healthcare Management Systems Nashville 352
21
Healthcare Management Systems Nashville 352 hmstn.com
Siemens Healthcare Malvern, Pa. 310 Siemens Healthcare Malvern, Pa. 310 medical.siemens.com
Self-developed — 260 — Self developed 260 Healthland Minneapolis 230 healthland.com Allscripts Chicago 178 allscripts com Allscripts Chicago 178 allscripts.com
Meaningful Use impact, is there any?g p , y22
Tis the season of electronic health records(EHR), now that both hospitals and ( ), pphysicians can qualify to earn incentives from the federal government when they
l h l d implement these solutions and meet “meaningful use” criteria.
US Government Incentive Categoriesg
Improve care coordination23
p
Reduce healthcare disparitiesp
Engage patients and their familiesg g p
Improve population and public healthp p p p
Ensure adequate privacy and security
EMR and EHR Screenshots24
A Provider may take authorship of a note by opening the note by the Edit button. When exiting the note, it becomes the providers.Review of Scanned information on the Chart Review’s Media tabReview of Scanned information on the Chart Review s Media tab
25
26
27
Patient Header turns yellow when Type is changes to Research
Separation of notes by author
28
29
Warning-Pop Upg p p30
Radiologygy31
Audit Trails: The Whyy
An audit trail is a safeguard built into an 32
An audit trail is a safeguard built into an electronic medical record (EMR) that keeps an electronic record of who accesses an EMR the electronic record of who accesses an EMR, the time and date the record is accessed, and what record is accessed (and what specific what record is accessed (and what specific portion(s) of the record is accessed), and what notes are added if any Essentially audit trails notes are added, if any. Essentially, audit trails act as an electronic log-book.
Audit Trail- continued33
Often, hospitals use different audit trails for different aspects of medical care. There may be separate audit trails for patients' medical records and for specific departments such as radiology and departments such as radiology and pharmaceuticals.
Audit Trail- continued34
Under the Health Insurance Portability d A bili A (HIPPA) h i l and Accountability Act (HIPPA), hospitals
and other medical providers that use EMRs must take steps to ensure the privacy and security of the EMRsp y y
Potential Audit Trail Fields
Timeframe
35
Timeframe Patient User User Action
M d l Module Encounter type Additional information
36
Fueling the risk: Hot Topics in the EMR37
“ l d” t ( f d) “cloned” notes (carry forward)
Copy n paste (aka Plagerism)
Sh t t Short cuts
Overuse/Misuse of generalized templatestemplates
Automated charge capture functions
Scribing and Documenting by exception Scribing and Documenting by exception
Addendum use
Cl i
M i f “ l d”
Cloning38
Monitor for “cloned” notesVendors often boast about the automated f h “ h ll ” h Hi feature that “pushes or pulls” the History of Present Illness (HPI) forward from the
i i i I h hi ll previous visit. In theory, this allows physicians to simply review and update h i i i h f l h the visit—saving them from lengthy dictation or note taking.
C P
“M d d ld
Copy n Paste39
“Most doctors copy and paste old, potentially out-of-date information into
i ‘ l i d di patients‘ electronic records, according to a new study looking at a shortcut that some
f ld l d experts fear could lead to miscommunication and medical errors.” R H l hRueters Health
40
EXPERTS SUGGEST THAT COPYING SIGNIFIES A SHIFT IN HOW DOCTORS USE NOTES - AWAY FROM BEING A MEANS OF COMMUNICATION AMONG FELLOW HEALTHCARE PROVIDERS AND FELLOW HEALTHCARE PROVIDERS AND TOWARD BEING A BARRAGE OF DATA TO DOCUMENT BILLINGDOCUMENT BILLING.
Shift in Focus?
Stopping the Domino effectpp g
How to identify and stop the documentation domino
What 4 criteria for documentation would limit the
41 How to identify and stop the documentation domino effect?
domino effect from occurring?
Sh
T l
Short cuts42
Templates: diagnosis driven physician specific procedures/tests open ended versus pre-populated
Generalized templatesp43
Wh h ld l hPatients
d
Why should templates have text boxes?
and families are not all alike, even with the same same diagnosis.
A d h
PROBLEMS
Automated charge capture44
PROBLEMS:Checklists calculate based on how many “boxes”
h k d b th id t il were checked by the provider, not necessarily based on relevance to the presenting condition(s).condition(s).
Wh h R k?
Scribing and Documenting by Exception45
What is the Risk?
Why do we test the documentation for authentification?for authentification?
Add d ’
S b l l id if h
Addendum’s46
Separate box-clearly identify a change or addition
Generate a watermark in the background
Generate an email notice to the attending h i i h “l t t ” i dd dphysician when a “late entry” is added
Look for Documentation that is:
Accurate47
Accurate
Timely
Complete and factual
By appropriate provider By appropriate provider
In Review:48
What did we learn?
I i ll b h VIEWIt is all about the VIEW.49
Auditing the EMRg
50
QUESTIONS OR CONCERNS ?QU S ONS O CONC NS ?
Audience Participation
Additional Resources
[1]National Archives and Records Administration (NARA): Long-Term Usability of Optical Media
51
Media FDA Regulation Title 21 CFR Part 11-Electronic Records; Electronic Signatures “Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk”; Journal of AHIMA/June 2008 “Off the Record-Avoiding the Pitfalls of Going Electronic”: New England Journal of Medicine; Volume 358:1656-1658, April 17, 2008, Number 16 “Guidelines for EHR Documentation to Prevent Fraud”; Journal of AHIMA/January 2007 “Practical EHR Electronic Record Solutions for Compliance and Practical EHR, Electronic Record Solutions for Compliance and Quality Care”; Stephen Levinson, M.D.; AMA 2008 Biancheria & Maliver P.C (audit trails) November 19, 2012 • Modern Healthcare 33 (top vendors of Enterprise EMR systems) Article citation:
Dimick, Chris. "Documentation Bad Habits: Shortcuts in Electronic Records Pose Risk." Journal of AHIMA 79, no.6 (June 2008): 40-43.
Rueters Health Fri Jan 4, 2013 Copying Common in electronic medical records
Save the DateS b 2 2 2September 21-24, 2014
33rd Annual Conference Austin, Texas
52
Thank You!53