F4 Auditing EMR Documentation - · PDF fileAUDITING EMR DOCUMENTATION TRINA BIRINGER, BSN,...

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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 904-697-4289Trina.Biringer@Nemours.org

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

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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

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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

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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

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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

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Patient Header turns yellow when Type is changes to Research

Separation of notes by author

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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

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Timeframe Patient User User Action

M d l Module Encounter type Additional information

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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

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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

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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

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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

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Thank You!53