HCCA Clinical Practice Compliance October 23-25, 2016

HCCA Clinical Practice Compliance Conference

October 23-25, 2016

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Strategies for Navigating the Bumps and Bruises from Implementing an Electronic Health Record (EHR)

Jenifer Carey, BS, COC, CPCO, CPMA, CPC-I Manager of Physician Education and Compliance

Michele Rohan, CPC, CPMA Coding and Compliance AuditorOctober 23, 2016

The EHR is no longer just a chart for an individual department for clinical documentation.

It is a complete “system” that is used by the entire organization.

Implementing the EHR is not an IT-only initiative!

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Who is affected by the EHR?EVERYONE!

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October 23-25, 2016

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Operations, Compliance – Billing, Coding and Documentation, Privacy, IT Security, Research,

Patient Access - Scheduling, Registration, Authorization, Ancillary Staff- Nursing and Medical Assistants, Scribes, Providers- Attendings, APRN’s and PA’s, Fellows, Residents and Medical Students,

Pharmacy-Electronic Formulary, Radiology, Surgery/Procedures, Sedation, Utilization,

Management-Case Managers, Finance, Diagnostic Testing, Professional and Hospital Billing, HIM,

Revenue Cycle, Customer Service, Risk, Quality, Legal, Privacy-HIPAA considerations, Health

Information Exchange and Supply Chain

The Journey Starts Here… The Discussion 5

Organizational Decision Points on the Use of a Shared Record

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TemplatesMU

Build to the System’s Fullest

Capabilities

Shared Histories

ROI

Problem List

Consistency

Security Access


October 23-25, 2016

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Templates

• All templates need to be built with the same basic parameters.

• The structure follows the CMS, Joint Commission and all other regulatory guidance.

• Compliance needs to be heavily involved in templates creation.

• Minimal customization allowed for specialties.

• Specific detail for section headers.7

Meaningful Use

• The EHR Incentive Program provides incentive for certain healthcare providers to use the EHR technology in ways that can positively impact patient care.

• Organizational decisions need to be made to ensure the proper implementation for Meaningful Use (MU):

15 Core + 5 Menu + 6 CQM = MU

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Beginners_Guide.pdf

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Build to the System’s

Fullest Capabilities• Think outside the box!

• EHR’s are an expensive tool. Decisions for automation and streamlined work flows need to be investigated to the fullest extent.

• Work smarter, not harder.

• Consider the gain/loss of building just to replace the current processes.

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October 23-25, 2016

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Release of Information (ROI)• Organizational decision points for consideration with ROI

in a shared medical record:

o Abstracting

o Scanning and Indexing

o Release of Information

o Coding and Billing

o Patient Confidentiality

o Research10

Problem List• Problem lists help with continuity of care by providing comprehensive

list of patients problems in one place.

• The problem list is a vehicle that consists of illnesses, injuries and other factors that affect the health of an individual patient and identifies the current or resolved condition(s).

• The organization and the medical faculty need to decide the implementation and maintenance of the problem list.

• Policies need to be created to reflect the decisions for correct use of the problem list.

• This is one of the core measures for meaningful use.

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Shared Histories

• Organization needs to decide how to use the shared histories.

• EHR provides the ability for the histories to follow the patient or be updated in the shared medical record. This allows for the provider to review the history section of the shared medical record and “mark it as reviewed”(to receive credit for E&M services).

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October 23-25, 2016

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Consistency• The organization needs to uphold the decision to build the

EHR with a consistent mindset.

• Deviation and customization can bring serious ramifications in the future.

• Be mindful that this is the beginning of the journey-not the final destination.

• Reduces risk to external audit.

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Security Access

Organization decisions (included, but not limited to) necessary for security access and control:

o Password Securityo Laptop Encryptiono External Devices - portable x-ray, ultrasound and EKG’so Scope of practice by roleo Security access by roleo System interfaceso Snoopers - Haystack

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The Journey Continues…Building the EHR

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October 23-25, 2016

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• Nomenclature needs to be the same.

• Validate that all print groups (headers) have the same pertinent information.

• Don’t be fooled by “specialization”- all templates need to have the same structure while still leaving room for specialty needs.

• Deviation from consistency can cause major headaches in the future. 16

Be sure to build all aspects of the EHR according to the CMS regulations, along with all privacy and legal considerations.

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Ask any/all clarifying questions – This is NOT the time to be silent!

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October 23-25, 2016

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Validate multiple options for new work flows. Key stakeholders need to agree.

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Research and build the system to its fullest capability. Understand that this will change how operations are currently happening.

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Meeting should be no longer than 90 minutes!!!!

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October 23-25, 2016

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All Key Stakeholders

Everyone’s participation is crucial! 22

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VET

VET

VET

VET

AND

RE-VET

AGAIN!!

Don’t “parking lot” the key stakeholders!

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October 23-25, 2016

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Conversation is Key! Take time for the deeper dive.

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All Key Stakeholders need to be fully engaged and physically present for all meetings. GoTo Meetings

are not a good substitute at this point in the process.

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October 23-25, 2016

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Don’t work in silos –Communication is vital to the success of the implementation of the EHR.

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Before the build moves into the production phase, any new process needs to be demonstrated to the key stakeholders and

entire department for any questions pending approval.

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The Journey Continues…The Implementation 30


October 23-25, 2016

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Don’t let the testing phase stop with IT. Although the EHR is electronic, it must have the capability to print any/all documents created within the system at any time. Below are examples of documents that should be reviewed for accuracy of format and legibility:

• Notes - All E&M services• Procedure/ Op notes • School letters/consult letters• Orders• Diagnostic tests and interpretation and reports• Lab results• Claims 31

• “Metadata” is the electronic audit trail for all entries in the EHR. Access is required!

• Be sure to explore the links in the encounter in order to validate that the coding guidelines are being followed and the correct credit is given for billing.

• Don’t be afraid to click in the EHR. Look for hidden links containing documentation and hidden work flows.

• All views of release of information need to be printed and reviewed for accuracy for every department.

• System maintenance and updates (i.e., regular IT updates and annual HCPCS, CPT, and ICD-10 updates).

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Education for the use of the EHR is never a one time event!

Continuous education for system functionality and user satisfaction need to be provided on an ongoing basis.

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October 23-25, 2016

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Documents

HCCA Clinical Practice Compliance October 23-25, 2016