Electronic Medical Record Overview

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Saturday, January 31, 2015 POMA District VIII Winter Seminar

Farmington, PA Presented by: Paula Snyder, RN, CPHRM Regional Manager, Risk Management

Electronic Medical Record Overview

DISCLAIMER

The information contained herein and presented by the speakers is based upon sources believed to be accurate at the time they were referenced.

The speakers are not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought.

This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation and discussion.

Learning Objectives

This presentation will support your ability to:

►Identify potential risks with using an EMR.

►Apply risk management strategies to promote

patient safety and reduce medical liability risks associated with EMR use.

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EMR –The Changing Landscape

Care Workflow Communication Data Accountability Liability

Potential EMR Benefits

►Improved documentation

►Improved follow-up

►Improved communication and access to

information

►Decreased errors in prescribing and dispensing medications

►Records won’t be lost in event of disaster

Potential Risk Issues with EMRs

User Issues

►Incorrect use of system

►Communication issues

►Insufficient training

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Potential Risk Issues with EMRs

System Issues

►Faulty templates

►Ineffective workflow processes

►HIPAA/security issues

EMR Related Malpractice Claims

►22% due to system failure

►20% due to incorrect information in EMR

►16% due to hybrid systems or problems with

EMR conversion

►10% due to pre-populating or copy/paste

CRICO Study, 2013

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Documentation – Scanning

►Consistent workflow for lab reports, etc Abnormal results

►Train staff on scanning policies and procedures

►Periodic chart audits

AHIMA Position on Copying/Pasting

►“The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls… Users of copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent or unwieldy

documentation.”

American Health Information Management Association, March 28, 2014

Documentation – Copy & Paste/Templates

►Choose templates wisely

►Copy and paste policy

►Staff training

►Review entries before signing off/closing

►Periodic chart reviews

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Case Study – Medication Reconciliation

Discussion

►Where did this go wrong?

►What went right?

Risk Management Recommendations

Medication

Reconciliation Standardized Workflow Verification Correct discrepancies

Admission Inpatient transfer

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Prescribing from an EMR

April 2013 study on Rx errors via EMR

►Errors decreased from 24.6% to 3.8% in the

two years post-implementation

►Limited alerts to drug allergys

►Used capital letters to distinguish similar med abbreviations from each other

►Changed dispense field from text to

drop-down

“A Long-Term Follow-Up Evaluation of Electronic Health Record Prescribing Safety” by EL Abramson, et al. Journal of American Medical Informatics Association, April 11, 2013

Prescribing from an EMR

►Use caution with drop-down boxes or

pre-populated dosages

►Understand how your system handles

off-label uses of medications

►Adjust EMR alerts

►One chart open at a time

►Interface with outside systems appropriately

Alerts & Warnings

►Do not bypass alerts without a process

►Document rationale any an alert is

bypassed

►Consider limiting alerts to those of high severity

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Data Security & Integrity – Staff

►Unique username/password for each person

►NEVER share passwords with other staff

►Define standards/timeframe for when patient

encounters must be signed off and locked

►Close patient’s record when data entry or review in completed

►NEVER leave a computer unattended without

being locked

Data Security & Integrity – Administration

►Create appropriate levels of access restrictions

►Ensure that screens are not visible to public

►Encryption and HIPAA-required security

►Create a back-up and disaster recovery plan

►Ensure that your EMR can produce an audit

log

Security Policies

►Develop a confidentiality and security policy Educate staff

Notify patients

►Develop a policy to deal with employees who

access patient information without a legitimate business reason to do so

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Additional Resources

►MyNORCAL (policyholder-only website)

 March 2014 Claims Rx: “Why You Should Optimize Your EHR System”

 EHR articles (including sample worksheets, tools)

►American Health Information Management

Association (AHIMA) website has sample policies and procedures for members at http://library.ahima.org ►SAFER EHR Guides contain self assessments,

worksheets and tips to optimize use of EHRs

http:/www.healthit.gov/SAFERGuide

Q&A

Paula Snyder, RN, CPHRM Regional Manager, Risk Management NORCAL Mutual – Medicus, NORCAL, PMSLIC

855-882-3412

[email protected]