ambulatory electronic medical records management …

ENTITY NUMBER Hawaii Region 2006-136

DEPARTMENT ORIGINAL DATE Clinic Support Services 08/30/2006

POLICY TITLE REVISION DATE Ambulatory Electronic Medical Records Management 2/28/2014

LAST REVIEW DATE PAGE NUMBER: 2/28/2014 of 18

. K a i s e r P e r m a n e n t e H a w a i i R e g i o n

H o n o l u l u , H a w a i i

AMBULATORY ELECTRONIC MEDICAL RECORDS MANAGEMENT

1. Purpose The purpose of this policy is to standardize roles, responsibilities, and principles for the Ambulatory Electronic medical record. Effective January 1, 2006, the Ambulatory Electronic Medical Record is the primary Ambulatory Medical Record; the paper medical record is the historical record. Refer to Appendix A. In accordance with organizational, regulatory, accrediting, and billing

requirements, this policy shall serve the following purposes:

1.1 Require all Kaiser Permanente Hawaii Region practitioners to use the Ambulatory Electronic Medical Record as the primary source for all clinical documentation. Refer to Section 4.2.1.

1.2 Standardize the access to Ambulatory Electronic Medical Records. Refer to Section 4.2.2.

1.3 Standardize documentation of in the Ambulatory Electronic Medical Record. Refer to Section 4.2.3.

• Provide standards for documenting in the Ambulatory Electronic Medical Record.

• Making documentation corrections in the Ambulatory Electronic Medical Record.

• Provide guidelines to avoid indiscriminately copying and pasting another clinician’s progress note, discharge summary, electronic mail communication, and redundant information provided in other parts of the Ambulatory Electronic Medical record.

• Provide guidelines for eliminating the use of potentially confusing medically-related abbreviations in documentation.

• Provide guidelines for electronic signature and authentication.

• Provide guidelines for the timely completion of the Ambulatory Electronic Medical Record.

1.4 Provide guidelines for communicating with patients. Refer to Section 4.2.4.







• Provide guidelines for email communication via kp.org both inside and outside of the Ambulatory Electronic Medical Record.

• Provide guidelines for telephone messaging between practitioners and patients.

1.5 Provide guidelines to ensure that all open encounters are closed prior to a practitioner’s planned or unplanned departure as well as in the event an encounter is found to be left open after a nursing employee transfers to another department or is no longer employed at KP. Refer to Section 4.2.5.

1.6 Provide information on monitoring the Ambulatory Electronic Medical Record. Refer to Section 4.2.6.

1.7 Provide a form for Ambulatory Medical Record documentation when the Ambulatory Electronic Medical Record is unavailable (downtime). Refer to Section 4.2.7.

2. Scope This policy applies to all authorized employees, students, residents and fellows within the Hawaii Region, the Ambulatory Surgical Center (ASC), and its vendors and contractors, who are responsible for documentation and have been identified as users of the Ambulatory Electronic Medical Record.

3. Definitions • Ambulatory Electronic Medical Record. Electronically stored outpatient

medical records, including all surgeries and care that do not involve hospital or hospital-based services.

• APN. Ambulatory Progress Note (form) • Clinic Information Systems (CIS.) A formerly used electronic medical

record • Complete and accurate documentation. Documentation that supports the

diagnosis and the medical necessity for services provided. • Delinquent Medical Record. Any encounter not completed and closed by

end of day. • DPN. Downtime Progress Note (form) • Encounter. Mechanism by which direct or indirect patient care is

documented in the Ambulatory Electronic Medical Record. Encounter Types include, but are not limited to: o Direct Encounters (face-to-face):







o Allied Health/Nurse Visit o Group Visit o OB Office Visit o Office Visit o Procedure

o Indirect encounters (patient not physically present): o Letter o Message o Orders only o Patient email o Refill o Scheduled Telephone o Telephone o Scanned document

• Encounter Provider. The Ambulatory Electronic Medical Record term for

the scheduled practitioner or allied health professional who gives care and services to the patient.

• Full Functionality User. Ambulatory Electronic Medical Record user with security access to read, write, and order in the Ambulatory Electronic Medical Record.

• HIPAA. Health Insurance Portability and Accountability Act of 1996. • HPMG. Hawaii Permanente Medical Group. • Ambulatory Electronic Medical Record. Electronic documentation tool for

patient care in the outpatient clinics. This is a comprehensive system that will support the collection, retention, management and review of the data needed to effectively track and manage care.

• Legal Name. A person’s current name that can be validated with official federal or state documentation and establishes the identity of the person. Examples of documents in order of priority: o Official document indicating legal name or a name change, i.e. birth

certificate, marriage certificate, adoption papers, certificate of legal name change, divorce decree, Military ID, State ID

o Social security documents/federal tax forms o Professional License (if this name is different than above legal name

indicate with note in files) • National Committee on Quality Assurance (NCQA). An accreditation

organization.







• Nursing Assistive Personnel. Authorized nursing personnel who assist licensed nursing staff in completing delegated nursing tasks or medical tasks as ordered by a practitioner and as permitted by law [e.g. Medical Assistants (MA), Ophthalmology Assistants (OA), Emergency Department Technician (ED TECH), Hospital Aides (HA), Nursing Assistants (NA), Health Aides, other technicians (TECH), and Ward Clerks (WC)].

• Ambulatory Medical Record. A legal record of ambulatory care and services for an individual—either paper or electronic—subject to a variety of statutes and regulatory rules that often define the use, disclosure, care, handling, and retention of Protected Health Information (PHI). Refer to Legal Medical Record Policy 2006-119. The complete and comprehensive Ambulatory Medical Record is comprised of the following: o Ambulatory Electronic Medical Record o Paper medical record

• Overdue Message. When MD is working, any kp.org e-mail message not responded to within two business days, excluding week-ends and holidays. When MD is on leave, any kp.org e-mail message not reviewed within two business days, excluding week-ends and holidays.

• Practitioner - The term “Practitioner” refers collectively to Licensed Independent Practitioners and Allied Health Practitioner.

• Licensed Independent Practitioner (LIP) - an individual permitted by law and by KPHI to provide patient care services to members without direction or supervision, within the scope of his or her license, and in accordance with individually granted Clinical Privileges. Licensed Independent Practitioner includes Medical Doctors, Doctors of Osteopathy, Doctors of Dental Surgery, Doctors of Dental Medicine, and Doctors of Podiatric Medicine licensed to practice in Hawaii.

• Allied Health Practitioner (AHP) a health care professional, other than a Licensed Independent Practitioner (LIP), who exercises independent judgment within the areas of his or her professional competence and the limits established by KPHI, the Professional Staff of a Kaiser Foundation Hospital, and applicable law. The following categories of Practitioners shall be considered Allied Health Practitioners when exercising the independent judgment in the care of patients described above: Physician Assistants, Certified Registered Nurse Anesthetists, Registered Nurses, Dietitians, Certified Nurse Midwives, Nurse Practitioners, Clinical Psychologists, Licensed Clinical Social Workers, Licensed Marriage and Family Therapists and Optometrists, and others, as required by state laws, regulatory and/or accreditation bodies.







• RNHO. Regional New Hire Orientation • TJC. The Joint Commission

4. Policy 4.1 Policy Statement

This policy shall provide direction to all users of the Ambulatory Electronic Medical Record to ensure current, detailed, accurate, complete and consistent documentation of patient care that:

o Permits effective and confidential patient care and quality review o Supports organizational, regulatory, accrediting, coding and

billing requirements. The ambulatory medical record is organized by encounter types which contain documentation fields for face-to-face and non face-to-face encounters.

4.2 Standards The Hawaii Region establishes ambulatory medical record standards to facilitate communication, coordination, and continuity of care and to promote efficient and effective treatment.

4.2.1 Ambulatory Electronic Medical Record Requirement Unless the Ambulatory Electronic Medical Record is down or unavailable, all full functionality practitioners who have been trained to use the Ambulatory Electronic Medical Record shall be required to use the Ambulatory Electronic Medical Record for all encounter documentation, orders, and prescriptions, in accordance with established workflows. Practitioners who have not been trained to use the Ambulatory Electronic Medical Record for documentation and order entry shall be required to use the Ambulatory Progress Note (APN) form for documentation of all encounters.

In instances where the Ambulatory Electronic Medical Record does not provide the appropriate documentation mechanism, exceptions to documentation on the appropriate and approved chart form shall apply.

4.2.2 Access to Ambulatory Electronic Medical Record Systems







All Hawaii Region employees shall have access to the appropriate and minimum information required to complete their job duties using the Ambulatory Electronic Medical Record processes by the start date of work.

4.2.2.1 Upon creation or modification of job descriptions, job accountabilities shall be aligned with the minimum necessary security access and functional access requirements.

4.2.2.2 To obtain Ambulatory Electronic Medical Record access, all newly hired employees shall:

o Have their legal name ascertained and recorded in the system along with the other required information, and

o Complete Regional New Hire Orientation (RNHO) in the required timeframe

4.2.2.3 Upon arrival at the job site for orientation, all employees shall have appropriately assigned Ambulatory Electronic Medical Record access to complete their job responsibilities.

o Employees who by exception use alternative learning methods to meet accreditation and HIPAA and other regulatory orientation requirements shall attend RNHO Technical training to obtain systems access.

o New hires awaiting credentialing shall be assigned a profile appropriate to their status with functionally limited access until credentialing is obtained. Access shall be adjusted upon notice of credentialing.

4.2.2.4 Upon change of employee status as in termination, resignation, transfer, or addition of other position, information systems shall be readjusted in a defined timeframe. Terminations and resignations must be completed within 48 hours of notification per SOX policy. Access modifications for transfers and multi-position staff will be completed within 72 hours post status change. SOX approvals from Business Application Owners may be required.







4.2.3 Documentation Requirements for Ambulatory Electronic Medical Record Patient Encounters

Any practitioner who documents health care information in an Ambulatory Electronic Medical Record encounter shall adhere to the guidelines defined by scope of practice, security classification and job description in providing care for patients.

The Encounter Provider shall be responsible for oversight of all documentation in the encounter, which includes clinical documentation by other users within that encounter. The Encounter Provider and the signing/closing provider shall be the same.

Exception: When orders are transmitted by Nursing Assistive Personnel (NAP) in an encounter under the NAP’s name, the Practitioner who authorized those orders must close the NAP’s encounter, authenticating any orders within that encounter.

4.2.3.1 Ambulatory Electronic Medical Record Documentation Standards Documentation in practitioner encounters shall adhere to the Ambulatory Electronic Medical Records Documentation Standards. Refer to Appendix B.

4.2.3.2 Ambulatory Electronic Medical Record Documentation Corrections The author shall be responsible for making timely corrections to documentation errors in the Ambulatory Electronic Medical Record. The content can be corrected by an authorized practitioner under certain circumstances. (Refer to Section 4.2.8).

4.2.3.3 Ambulatory Electronic Medical Record Copy and Pasting Clinicians documenting in the Ambulatory Electronic Medical Record must avoid indiscriminately copying and pasting another clinician’s progress note, discharge summary, electronic mail communication, and redundant information provided in other parts of the health record.







If all or part of an entry made by another clinician is used, the clinician making the entry takes responsibility for the accuracy of the entry and through their authentication of the information affirms that it is relevant and appropriate to the episode of care. (See Utilization of Copy/Paste Functionality for Documentation for Hospital and Hospital-based services, Policy #2009-016).

4.2.3.4 Ambulatory Electronic Medical Record “Do Not Use” Abbreviations All practitioners must follow “Do Not Use” Abbreviation policy (See “Do Not Use” Abbreviations for Medical Records Documentation Policy #2006-074, and link to list on Intranet Home Page / Business Links / Abbreviations List)

4.2.3.5 Ambulatory Electronic Medical Record Documentation Signature Requirements All Ambulatory Electronic Medical Record documentation must be electronically authenticated at the time of entry (See Electronic Signature and Authentication Policy #6440-02-05).

4.2.3.6 Ambulatory Electronic Medical Record Timely Completion Encounters, whether in person, by telephone, or by secured messaging, shall be documented and completed at the time of the encounter, or by end of day. Practitioners shall complete all delinquent records open beyond the following threshold by the required date as appropriate: • 10 or more encounters open for more than 7 days • Any encounters open for more than 14 days Delinquent records shall be monitored on an ongoing basis and addressed accordingly. At the appropriate professional or operational chief’s discretion and in accordance with HPMG Policy time for completions might include: • Own time • Other effective solution as approved by the professional or

operational chief.







• Required administrative leave, without pay

4.2.4 Communication Requirements for the Ambulatory Electronic Medical Record Address patients with the correct title (i.e. Miss, Mrs., Ms., Mr.) and use last names unless the patient indicates he/she wishes to be called by first name, nickname, or pseudonym. Do not refer to patients by only their last name or their medical conditions. Never use terms that belittle a patient’s dignity, such as sweetie or darling.

4.2.4.1 Email Communication Email should not be used for urgent communications (e.g., regarding sudden or substantive changes in the patient's health). Avoid anger, sarcasm, harsh criticism, and libelous references to third parties in messages. Never forward patient-identifiable information to a third party without the patient’s express permission.

4.2.4.1.1 Email Communication within the Ambulatory Electronic Medical Record

When feasible, email communication between providers and patients should be done using Ambulatory Electronic Medical Record functionality. This ensures that all clinically relevant messages and responses will be documented in the medical record, and that email responses to patients are not misdirected or otherwise become available to unintended parties.

Practitioners shall review and if appropriate respond to kp.org email message within two business days, excluding weekends and holidays.

Overdue messages shall be monitored on an ongoing basis and addressed accordingly.







At the appropriate professional or operational chiefs’ discretion, time for completing overdue messages will be:

• Own time • Other effective solution as approved by the

professional or operational chief. • Required administrative leave, without pay

4.2.4.1.2 Email Communication outside the Ambulatory Electronic Medical Record

If, in the provider’s professional judgment, a communication must be made with a patient outside the Ambulatory Electronic Medical Record, any such communications that contain clinically relevant information must be retained and stored within the patient’s health records.

If such communication is unencrypted, the provider must advise the patient about the risk and document the individual’s stated preference to the unencrypted communication. (See Electronic Communication Functions Policy # HI.IS.010, Section 10.2.5.)

4.2.4.2 Telephone messaging Between Practitioners and Patients

Practitioners will leave a minimum of information unless a written request from patient is obtained prior to leaving telephone messages containing PHI in a voice mail message, on an answering machine, or with anyone answering the telephone. (See Practitioner/Staff and Patient Detailed Telephone Messaging Policy # 2006-085)

4.2.5 Practitioners Leaving the Kaiser Permanente Hawaii Region and Nursing employees who transfer to another department or are no longer employed at KP

Upon notification of the practitioner’s departure:







o The Supervisor, Manager, or Chief shall be accountable to notify Human Resources and HPMG when a practitioner is leaving KP employment.

o The appropriate professional or operational chief shall assign responsibility for inbasket management of the terminating user.

Planned Departure. Upon notification of a planned practitioner departure, the immediate professional or operational chief shall communicate the expectation for all open encounters to be completed and closed, all dictations authenticated, and all medication verbal orders cosigned prior to departure. (See 4.2.2.4)

Unplanned Departure. Open encounters following a practitioner’s unplanned departure shall be completed by an assigned practitioner with same/higher credentials, as determined by the appropriate professional or operational chief.

When correction of documentation is required (i.e. per HIPAA) to be completed during a practitioner’s absence, the immediate professional or operational chief may perform the appropriate correction in collaboration with Medical Records Administration, the Electronic Medical Record Security team, and Release of Information Departments.

The Nursing Supervisor/Manager is authorized and shall be responsible for the closing of open encounters generated in their department(s) by nursing employees who have transferred to another department or are no longer employed at KP.

4.2.6 Monitoring

4.2.6.1 Monitoring Documentation—excluding Hospital Service Departments (HSD’s)

o Complete and appropriate clinical documentation o Standard: 95% or greater of all face-to-face

billable encounters shall have documentation that supports the services provided.

o Timely completion of ambulatory patient







o Standard: Timely Completion should be 90% or greater

o Delinquency Rate Threshold: No higher than10% An open encounter report shall be run

weekly to identify practitioners who have delinquent records that need to be completed and closed.

Routine audit reports as appropriate shall be made available to Clinic Managers and/or Physician Chiefs who are accountable to initiate corrective action.

4.2.9.2 Monitoring System Availability

Standard: System shall be available 99.7% 24 hours a day, 7 days a week, and 365 days a year.

4.2.7 Downtime

In the event that the Ambulatory Electronic Medical Record is down or unavailable:

• Local administration in collaboration with the Ambulatory Electronic Medical Record administration, shall invoke the downtime procedures. Refer to “KPHC Downtime (Suite)” posted on MyHelp.

• All practitioners, whether or not they currently document in the Ambulatory Electronic Medical Record, shall be required to use the appropriate “Downtime Progress Note” (DPN) form. The appropriate form shall be completed as soon as possible after the visit occurs, and no later than 24 hours after the visit.

5. Responsibilities The Ambulatory Medical Record Business Owner and the Medical Record Physician Owner shall be responsible to ensure physician and non-physician compliance with current, detailed, accurate, complete and consistent documentation of the Ambulatory Medical Record.

The Ambulatory Medical Record Business Owner shall be the designated custodian of the Ambulatory Electronic health record.







KP Information Technology and the Ambulatory Electronic Medical Record Clinical Applications Manager shall be responsible to ensure adherence to appropriate Ambulatory Electronic Medical Record systems access guidelines.

Clinic Managers and Physician Chiefs shall be responsible for adherence to the provisions of this policy.

6. Maintenance This policy shall be reviewed at least every three (3) years or more often as required and revised as necessary.

7. References • Center for Medicare and Medicaid Services (CMS) • Code of Federal Regulations 42 CFR 422.112(b)(4)(ii) • Copy/Paste Functionality for Documentation for Hospital and Hospital-Based

Services Policy 2009-016 • Documentation When the Ambulatory Electronic Health Record is

Unavailable Procedure • “Do Not Use” Abbreviations for Medical Records Documentation Policy 2006-

074 • Replaced by User Access Management Policy # HI.IS.012 • Electronic Signature and Authentication Policy 6440-02-05 • Replaced by Electronic Communication Functions Policy # HI.IS.010 • Hawaii Downtime Procedures – Outpatient version 1 4.0 • Hawaii Revised Statutes and Federal Regulations • KP HI Documentation Standards • KP HealthConnect Online Guiding Principles (6820-01) • Legal Medical Record Policy (2006-119) • MedQuest Section 12 • Medical Record Retention Policy (6440-04-07) • National Committee on Quality Assurance (NCQA) • Practitioner/Staff and Patient Detailed Telephone Messaging Policy 2006-085

8. Implementation A. Effective Date







This policy becomes in effect upon approval of approving authorities and shall be published and disseminated within 30 days.

B. Distribution

• Upon approval, this policy shall be distributed to all process stakeholders and the affected entities and departments.

• As applicable, affected entities, departments, and individuals may prepare and implement procedures consistent with this policy and as necessary conduct appropriate education to assure consistent and uniform implementation.

• This policy is accessible on the KP Hawaii Region intranet.







9. Endorsement and Approval Contact Person: Jeniffer Zimmerman

Manager, Medical Records - Clinic

Reviewed By: Wil Kouke Director Clinical Services Maile Howick, RN KPHC Clinical Applications Manager Winnie Sze, MSN, APRN-Rx, CDE, CHC Supervisor for Ambulatory Nursing Practice & Clinic Compliance leader Roxanne Morey Manager, KPHC Build, Security and Support Paulette Nakamura, APRN Ambulatory Nursing Practice Laura Sherrill Privacy & Security Officer

Date: 10/31/2013 Date: 3/7/2014 Date: 3/7/2014 Date: 3/7/2014 Date: 3/7/2014 Date: 2/28/2014

Endorsed By: Benjamin Tamura, MD Associate Medical Director, Primary Care/Internal Medicine and PIC, Primary Care Clinics Ambulatory Medical Record Physician Owner

Date: 3/9/2014

Approved By: Quality Committee Date: 4/10/2014

Next Review Date: 2/2017 Replaces: 00000-AMR-P1: Automated Medical Records

Management

10. Appendices Appendix A: Composition of the Ambulatory Electronic Medical Record Appendix B: Ambulatory Electronic Medical Records Documentation Standards







APPENDIX A

COMPOSITION OF THE AMBULATORY ELECTRONIC MEDICAL RECORD

The Ambulatory Electronic Medical Record is comprised of the following:

TYPE DATE RANGE

1. Paper Medical Record November 1958 to November 2012

2. Clinical Information System (CIS) October 2001 through December 19, 2004

3. KP HealthConnect Ambulatory April 18, 2004 to Present







APPENDIX B: AMBULATORY MEDICAL RECORDS DOCUMENTATION STANDARDS

ambulatory electronic medical records management …

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