DOCUMENTATION TRINA BIRINGER, BSN, RN, CCRC SENIOR CLINICAL AND RESEARCH NURSE AUDITOR

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AUDITING EMR

AUDITING EMR

DOCUMENTATION

TRINA BIRINGER, BSN, RN,

CCRC

SENIOR CLINICAL AND RESEARCH NURSE AUDITOR

THE NEMOURS FOUNDATION THE NEMOURS FOUNDATION

AHIA 32ndAnnual Conference – August 25-28, 2013 – Chicago, Illinois

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Contact Information:

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Trina L. Biringer, BSN, RN, CCRC

 Senior Clinical and Research Nurse Auditor  Occupational Safety and Health Specialist

10140 Centurion Parkway North Jacksonville, FL 32256

Office 904-697-4289

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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.

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A di i h EMR

Auditing the EMR

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What’s

Your

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EMR- The Journey……

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5 Tribute to EMR and Journey’s Don’t stop believin’ believin Epic user group meeting kit skit

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Audit Type

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 Clinical/Operational  Research Specific

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EMR: The Documentation per OIG

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The

Standard

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Auditing the EMR Documentation

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Identifying the Key Stakeholders:

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Identifying the Key Stakeholders:

 Who

 Who

 Wh t YOUR i ti l t ti ?

 What are YOUR organizational expectations?

Wh f EMR (E i M di h )

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Why we Audit-Implementation of EMR

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Quality & Safety

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Quality & Safety

Efficiency

Clinical decision support/Improve care

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coordination

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Why we Audit-continued

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Improve population and public health

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Improve population and public health

Electronic reporting

Privacy and security protections

Compliance

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It’s the Law

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Electronic medical records like other

Electronic medical records, like other

medical records, must be kept in

unaltered form and authenticated by

the creator.

[1]

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Auditing Challenges

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?

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EMR Auditing Challenges

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Integrity of the record

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Integrity of the record

Controls around access

Who documented what?

Signatures/authentication

Signatures/authentication

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Challenges-continued

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C t/

/

t f t

Cut/copy/paste features

Cloning (defaulted documentation)

Macro’s

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How Documentation is inputted in the

EMR

EMR

Documentation may be:

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Documentation may be:

 dictated typed handwritten & or computer  dictated, typed, handwritten & or computer

generated.

Supporting documentation may be:

 scanned, faxed, a “snapshot”, electronically copied

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Smart Text Language and Templates

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Make Me the Author” feature

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 “

Make Me the Author feature

Template by provider, department,

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,

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specialty or regulatory guidelines

and standard of care practices

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EMR Automatic Pathways

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 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 patient individualize for each patient

 Can the Provider modify or delete template  Can the Provider modify or delete template

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EMR Automatic Pathways-continued

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 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

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S

f h EMR

HIPAA d HITECH

Scope of the EMR

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HIPAA and HITECH.

Access and transport medical information

across organizations

Interfacing with other systems and entities that

li k t th i t t link to the internet.

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Ranking of Hospital EMR Installations by

V d M d

H l h

Vendor per Modern Helathcare

(2011-2012)

TOP 10 VENDORS OF ENTERPRISE EMR

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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

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Top 10 Vendors continued

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 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

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Meaningful Use impact, is there any?

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,

y

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Tis the season of

electronic health records

(EHR), now that both hospitals and

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),

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physicians can qualify to earn incentives

from the federal government when they

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h

l

d

implement these solutions and meet

meaningful use

” criteria.

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US Government Incentive Categories

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Improve care coordination

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Reduce healthcare disparities

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Engage patients and their families

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Improve population and public health

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Ensure adequate privacy and security

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EMR and EHR Screenshots

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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 tab Review 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 Up

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Radiology

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Audit Trails: The Whyy

An audit trail is a safeguard built into an

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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.

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Audit Trail- continued

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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.

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Audit Trail- continued

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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 EMRs

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Potential Audit Trail Fields

 Timeframe 35  Timeframe  Patient  User  User  Action M d l  Module  Encounter type  Additional information

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Fueling the risk: Hot Topics in the EMR

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“ l d” t ( f d)

“cloned” notes (carry forward)Copy n paste (aka Plagerism)

Sh t t

Short cuts

Overuse/Misuse of generalized

templates templates

Automated charge capture functions

Scribing and Documenting by exceptionScribing and Documenting by exceptionAddendum use

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Cl i

M i

f “ l

d”

Cloning

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Monitor for “cloned” notes

Vendors 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.

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C

P

“M

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Copy n Paste

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“Most doctors copy and paste old,

potentially out-of-date information into

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patients‘ electronic records, according to a

new study looking at a shortcut that some

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experts fear could lead to

miscommunication and medical errors.”

R

H l h

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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 BILLING

DOCUMENT BILLING.

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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?

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Sh

T

l

Short cuts

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Templates:

 diagnosis driven  physician specific  procedures/tests

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Generalized templates

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Wh h ld

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h

Patients d

Why should templates have

text boxes?

and

families are not all alike, even with the same same

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A

d h

PROBLEMS

Automated charge capture

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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).

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Wh h

R k?

Scribing and Documenting by Exception

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What is the Risk?

Why do we test the documentation

for authentification?

for authentification?

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Add d

S b l l id if h

Addendum’s

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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 d physician when a “late entry” is added

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Look for Documentation that is:

Accurate

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Accurate

Timely

Complete and factual

By appropriate provider

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In Review:

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I i ll b

h VIEW

It is all about the VIEW.

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QUESTIONS OR CONCERNS ?

QU S ONS O CONC NS ?

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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.

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Save the Date

S

b 2 2 2

September 21-24, 2014

33

rd

Annual Conference

Austin, Texas

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Thank You!

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