2015 User Conference
Avoiding Medical Malpractice Workshop
April 25, 2015 (GEN-A95)
Presented by:
Susan J. Kressly, MD, FAAP
Medical Director, Office Practicum
2015 Office Practicum User Conference
Learning Objectives
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Understand how use of your EHR can hurt or help you in a malpractice case▪
Realize the importance of understanding how OP works “under the hood”▪
Identify at least 2 pitfalls to avoid to protect yourself▪
Identify at least 2 goals for using OP according to best practices to be better2015 Office Practicum User Conference
Disclaimer*
*I am NOT a lawyer. Information in this presentation does not constitute legal advice.2015 Office Practicum User Conference
Common EHR Error
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Gender Mismatch2015 Office Practicum User Conference
Understanding Your EHR
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Log ins/security/passwords/administrative users…oh my▪
How does your office workflow integrate with OP?Let’s take a closer look……
Please explain to the jury how Nurse
Ratchet entered data into the EHR when she was on vacation in the Caribbean for a week?
2015 Office Practicum User Conference
Security/Passwords
2015 Office Practicum User Conference
Best Practices
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Do NOT share logins/passwords▪
Do NOT write down logins/passwords▪
Consider using strong password functionality▪
Do NOT allow users to be simultaneously logged in to more than one workstation2015 Office Practicum User Conference
Why Does it Matter?
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The audit trail logs EVERYTHING you do▪ Who signed in when, on which computer and for how long
▪ What they did when they were signed it
▪ Changed records and what the record said before and after changes
▪
Audit logs are DISCOVERABLE andmalpractice attorneys ask for them as well as your documentation
You can run, but you can’t hide….... from the audit trail.
Doctor, tell us how you though that it was
reasonable that your office received no
imported lab results for two weeks in the
middle of cold & flu season?
2015 Office Practicum User Conference
Workflow Matters: Labs….
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Do you get lab results via an interface, on papers, both?▪
Do you have a written workflow?▪
Does everyone follow it?▪
How do you know if your lab interface goes down?▪
What do you do when a provider is on vacation?▪
Who notifies the patient and how do you document it?He wants you to
believe that he spends tens of thousands of dollars on an EHR, went to countless hours of training and he “doesn’t know what is in the template” that he used and signed?
2015 Office Practicum User Conference
Documentation Pitfalls to Avoid
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Missing information▪
Conflicting information▪
Putting key information where it isn’t seen or can’t be used appropriately for decisionsupport
▪
Using shortcuts/templates without knowing what they say▪
Not reviewing information▪
Ignoring alerts or using meaningless override reasons2015 Office Practicum User Conference
2 month old Girl with Failure to Thrive
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You use the FTT template and include newborn history▪
What’s missing here?2015 Office Practicum User Conference
Best Practices
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Agree where in the chart all users will put newborn screen information (scan?, NB hx, lab test?)▪
Have a practice protocol for tracking down missing screens2015 Office Practicum User Conference
Standing Reminders
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Standing order for staff to obtain NB screen on tasks attached to 1 week well visittemplate
▪
Requires staff to track outstanding tasks2015 Office Practicum User Conference
What else is a risk for this patient?
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Where’s the reminder for a hip ultrasound or documentation of result?What’s wrong with this picture?
Conflicting Information
2015 Office Practicum User Conference
Using Templates
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Know what the template saysAlerts
1
Alerts continued
3
2015 Office Practicum User Conference
Audit Reasons
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Are recorded2015 Office Practicum User Conference
Report Criteria
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Must know what sections are included into notes2015 Office Practicum User Conference
Well Visit Physical Exam
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Detailed vs School Exam▪
School Exam is what gets put on default forms▪
Currently can only beedited within the context of the visit before note is finalized
2015 Office Practicum User Conference
Good Habits
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Sanity check chart at every touch▪
No longer can review/preview beforeinformation gets sent out (portal or HIE)
You absolutely should understand that my client is a doctor! Doctors are very smart. She absolutely can remember what
happened years ago to her patient that was one of 27 she saw that day. Of
course it is reasonable for her to change her note and add information 5 years after the visit.
2015 Office Practicum User Conference
Finalizing Notes
▪
Have good practice habits▪
Finalize prior to leaving for the day▪
Use addenda if needed2015 Office Practicum User Conference
Questions
?
2015 Office Practicum User Conference
