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EHR Systems: Risk Management StrategiesJuly 2013
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July 2013
Today’s host
• Ms. Essick has 35 years of experience inthe healthcare industry and has a broadunderstanding of the unique obstaclesthat providers must address on a dailybasis. During her years as a consultant,she became an expert in electronic healthrecord implementation and industrialhealth issues, including workers'compensation and wellness programdevelopment.
• Ms. Essick has held a registered nurselicense in North Carolina and Georgiaduring the course of her career. She is amember of the American Society forHealthcare Risk Management and theNorth Carolina Society for Healthcare RiskManagement, and she has earned herdesignation as a Certified Professional inHealthcare Risk Management.
Theresa N. Essick, RN, CPHRMVP, Clinical Risk Management
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July 2013
Do you know…
• How to access the PowerPointpresentation being used today?
• How you can use this program forfuture staff education?
• All of the risk resources availableto you as a MedPro insured?
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July 2013
Learning objectives
• Identify patient safety and compliance risks associatedwith electronic health record (EHR) implementation,use, and maintenance
• Discuss strategies and best practices to ensure safepatient care and an effective, efficient, and defensiblemedical record
• Explain how an EHR system can be used to supportpositive change in your practice through performanceimprovement activities
At the completion of the program, each participant shouldbe able to:
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July 2013
Pre-polling questions
• Is our EHR system customized to the practice patterns of ouroffice?
• Before implementation of new system features, do we assesscurrent clinical processes to ensure optimal workflow afterimplementation?
• Do we audit for consistent documentation practices inaccordance with our organization’s documentation policy?
• Do we have a performance improvement plan in place designedto assess high-risk issues specific to our patient population?
• Do we use system reports to check for receipt of test results?
• Is our EHR system’s alert function tailored to our patientpopulation?
• Have we developed evidence-based templates for use with ourmost frequently presenting health situations?
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July 2013
Survey results
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July 2013
Today’s speaker
Beth Michel, MLD, CPHRMClinical Risk ManagementConsultant
Beth has more than 15 years of experience inmedical malpractice litigation defense, dataanalysis, patient safety, quality improvementand risk management. She has served as aparalegal in the insurance industry and as aninternal leader in hospitals.
Beth is experienced in directing root causeinvestigations of serious safety events, and shehas led performance improvement efforts toimplement and measure the effect of changeon healthcare outcomes.
She is a graduate of Saint Mary-of-the-WoodsCollege with a bachelor of arts degree inparalegal studies and a master of leadershipdevelopment degree. She is a member of theAmerican Society for Healthcare RiskManagement and the Indiana Society forHealthcare Risk Management.
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July 2013
Today’s speaker
Linda provides comprehensive services to healthcaresystems, hospitals, clinics, and physicians throughout themiddle United States. She has more than 35 years ofclinical, administrative, and consulting experience in thehealthcare industry. She has held administrative andconsulting roles for providers, insurers, and managementorganizations.
Linda is an expert in managed care. She developed a riskmanagement program for a large national physicianstaffing and contract management company. Sheimplemented an award-winning risk management programat a community hospital, including physician monitoringand evaluation processes and introduction of new software.Linda also developed an innovative program for thealternate delivery of healthcare for a large nationalhealthcare insurer.
Linda obtained her RN degree at the Toledo Hospital Schoolof Nursing and her BE from the University of Toledo. She isa member of the American Society of Healthcare RiskManagement, as well as the North Carolina chapter of thatorganization. She is board-certified by the American Boardof Quality Assurance and Utilization Review Physicians, withsub-specialty certification in risk management.
Linda Kirchhof,RN, BE, CHCQM-RM,Senior Clinical RiskManagement Consultant
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July 2013
Mitigating overall risks
Factors Outside Your Control:
• Legal system
• Bad outcomes
• Plaintiff attorneys
• Litigious patients
• Healthcare reform/changes
Factors Within Your Control:
• Practice culture and processes
• Documentation
• Informed consent
• Communication and relationships
• Follow-up of diagnostic tests
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July 2013
Different worlds
=___________ ___________
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July 2013
Information management systems
EHRs are essential for:
• Patient safety
o Continuity of care
o Immediate access to patient information
o Decision guidance
o Templated information (evidence-based medicine)
• Quality initiatives
o Both internal and external
• Practice management and compliance
o Includes performance improvement, compliance and productivityreports, and data analysis
• Reimbursement
o Electronic submission of billing information and treatment data
• Legal defense
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July 2013
• Improved aggregation, analysis, and communication of patient-level information
• Evidence-based diagnostic decision support
• Therapeutic decision support via formularies and standardizedpractices/education methods
• Prevention of adverse events
• Clinical alerts and reminders
• Data reports to support performance improvement activities
o Any information in a discrete data field can be pulled intoa report
• Use of EHR for clinical quality improvement research
Certified EHRs support patient safety efforts
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July 2013
Workflow analysis
System implementation/management
Train staff forsystemknowledge
Integration with current systems
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July 2013
Implementation/maintenance strategies
• Establish a process for managing paper records oncethe EHR system is in place.
• Spend time up front developing templates that aremeaningful to your practice. Review templatesperiodically.
• Use information summaries/flow charts to enhancecritical thinking.
• Review alert settings and mandatory fills.
• Ensure privacy and security of protected health
information (PHI).
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July 2013
Implementation/maintenance strategies
• Lost data
o Transition
o Hybrid systems
o System failures
o System processes — e.g., test/consult results
• Process/workflow changes — new error pathways
• Stringent documentation guidelines — no workarounds
• Documentation
o Overreliance on templates and “check boxes” — thedisappearing narrative
o Array of patient data not conducive to critical thinking
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July 2013
Documentation risks and strategies
• Assessment and comparisonof findings from previousvisits
o Problem list
• Known or suspectedallergies: alerts
• Medication list/reconciliation: alerts
• Documentation shouldreflect critical thinking andtreatment plan
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July 2013
Documentation risks and strategies
• Patient education
o Patient and family involvement/special
circumstances
o Specific instructions/education given
o Preprinted/computerized
o Clear, specific, and explained
• Document receipt and
understanding with copy
in chart
o Language
o Literacy
o Culture
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July 2013
Documentation risks and strategies
• Patient compliance, including missed/cancelledappointments
• Treatment plan changes
o Receipt of diagnostic results
o Follow-up
o Patient response
o Telephone conversations
• After-hours contact
• Consults
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July 2013
Documentation risks and strategies: red flags
• Additions/deletions
• Late entries
• Omissions/incomplete records
• Failure to document follow-up
• Identifying generation of occurrence/incidentreport
• Inconsistent/contradictory entries
• Subjective remarks/finger-pointing
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July 2013
The medical record: robust EHRs as a defense partner
A well-documented patient chart within an EHR system:
• Demonstrates adherence to the best evidence-basedpractices
• Produces a complete, legible record readily availablefor the defense
• Verifies discussionof treatment withthe patient
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July 2013
Electronic discovery
• In 2006, e-discovery amendments were made to theFederal Rules of Civil Procedure.
o Require production of electronically stored data andmetadata if requested.
Metadata is the “hidden data” in other files, such asauthor of the entry, timestamp, changes to therecord, etc.).
Metadata may not be easily accessible.
o May include requests for email.
• Risk strategy discussion:
o Maintenance, retention, and destruction of records
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July 2013
Defining the legal EHR
• A legal EHR is an official record of patient care, withspecified content and required by regulation.
• Develop a policy statement that defines what yourpractice considers to be a legal patient record.
o When is the record considered complete foraccreditation/compliance purposes?
o What data are disclosed upon request for medicalrecords?
• Know what the printed copy of the legal EHR recordlooks like.
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July 2013
Emerging issues and data requirements
• Compliance plans
• Fraud and abuse surveillance
• ICD-10 conversions
• Value-based reimbursement
o Bundled payment and utilization decisions
o Incentives to avoid admissions/readmissions
• Medical home
• Population management (by zip code)
• ACOs — gaps in coverage
• Electronic patient communication
• New challenges: cloud computing, mobile devices,social media, data backups/archives
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July 2013
Federal audit programs — A-Z
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/recovery-audit-program/
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July 2013
Performance improvement: use of the EHR
• Performance improvement — equal parts philosophyand process.
o Focus is on continuously identifying opportunities toimprove outcomes and taking proactive steps to mitigaterisk.
• Underlying principles of performance improvement:
o Errors are more likely the result of process breakdownsthan human missteps.
o Evaluating data via critical thinking strategies is the bestway to identify and solve problems.
o Those who own the process should be involved withdeveloping solutions to problems.
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July 2013
Performance improvement: audits and high-risk metrics
• Consider quarterly report of amended records anddaily/weekly report of open records
• Billing/coding audits
• Practice management
o Patient population profiling
o Frequently used drugs/supplies
o Reconciliation of test results
o Status of incomplete charts
o Amendments (number and kind)
o Release of PHI and HIPAA compliance
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July 2013
Performance improvement: resources and recognition
• Summer 2013 Protector: Managing Risks AssociatedWith Electronic Health Records
• EHR Premium Credit Program
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July 2013
Risk-reduction strategies
• Adopt collaborative strategies to include all users ofthe system when evaluating the need to makechanges or updates.
• Set stringent documentation guidelines and eliminateworkaround processes.
• Tailor the system’s alert function to specific patientpopulations.
• Use system reporting functions to support an activeperformance improvement plan for risk reduction.
• Develop a comprehensive policy to define the legalpatient record.
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July 2013
Resources
• Websites
o www.ahima.org (see HIM Body of Knowledge® tab)
o http://www.healthit.gov/
o www.ihi.org (see Knowledge Center tab for performance improvement resources)
• Articles
o AHIMA e-HIM Work Group on Maintaining the Legal EHR. (2005, Nov/Dec) Update:Maintaining a legally sound record—paper and electronic. Journal of AHIMA, 76(10),64A-L.
o AHIMA Workgroup. (2011, Sept). Problem list guidance in the EHR. Journal of AHIMA,82(9), 52-58.
o Dimick, C. (2008, June). Documentation bad habits: Shortcuts in electronic records poserisk. Journal of AHIMA, 79(6), 40-43.
o Dougherty, M., & Washington, L. (2010, Feb). Still seeking the legal EHR: The push forelectronic records increases, the record management questions remain. Journal ofAHIMA, 81(2), 42-45.
• Handouts
o Self-Assessment Checklist: Efficient Use of Electronic Health Records
o Guideline: Using an Electronic Health Record System as a Risk-Reduction Tool
o Performance Improvement Template
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July 2013
What questions doyou have?
Thank You!
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July 2013
Disclaimer
The information contained herein and presented by thespeaker is based on sources believed to be accurate atthe time they were referenced. The speaker has made areasonable effort to ensure the accuracy of theinformation presented; however, no warranty orrepresentation is made as to such accuracy. The speakeris not engaged in rendering legal or other professionalservices. If legal advice or other expert legal assistanceis required, the services of an attorney or othercompetent legal professional should be sought.
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July 2013
Please take a few minutes to answerthe polling questions.
Watch for our next webinarin November 2013.
THANK YOU for your participation!