Maximizing the EHR Review Kathy Downing MA RHIA

Maximizing the EHR Review Kathy Downing, MA, RHIA, CHPS, PMP Director Practice Excellence

Objectives • Brief Overview • Bridge Technology • Transition to EHR and meeting Meaningful Use • Document Capture • Best practices • Wrap and Questions 2

Transition to EHR • Past the Tipping Point for EHR Use – More than 50 percent of eligible professionals (mostly physicians) and – 80 percent of eligible hospitals having demonstrated meaningful use and received an incentive payment. 3

Polling Question • Are you satisfied with your use of the Electronic Health Record? – – 4 A. Yes B. No, find it frustrating to find what I need C. No, find it frustrating that every hospital is different D. No, find it frustrating that every system is different

EHR Implementation isn’t perfect (yet) • EHR Satisfaction Report – 39% said they would not recommend their EHR system to a colleague, up from 24% in 2010; – 37% said they were dissatisfied with their EHR system's usability, compared with 23% in 2010; – 34% of surveyed clinicians said they were "very dissatisfied" with their EHR system's ability to decrease workload, up from 19% in 2010 Source: http: //www. ihealthbeat. org/articles/2013/3/7/ehr-satisfaction-surveyreleased-clinton-speaks-at-himss-conference 5

Polling Question • Do you do most of your reviews in the EHR? – – 6 A. Yes B. No, we do not have access to the system C. No, they do not have an EHR D. No, they use a different type of system

EHR Bridge Technology • Workflow • Improved A/R Processing • There are many patient safety benefits of moving to the EHR 7

Polling Question • Which functionality do you access in the EHR? – A. Automated Forms or a worklist – B. Viewing of nursing notes – C. Physician Documentation / reports – D. Discharge information 8

• X-rays • Images • Fetal strips • Videos • Pathology slides • designated record set and legal health record External Records and Reports • History and physical • Orders • Progress notes • Lab reports (including contract lab) • Progress notes • Vital signs • Assessments • Consults • Clinical reports • Authorizations and consents • designated record set and legal health record Source Clinical Data Clinical Record What Record Types? • External records referenced for patient care: other providers’ records, records provided upon transfer • Patient generated records • Personal health records • designated record set and possibly legal health record*

• Super bills/encounter forms • Remittance advice • Case management records • designated record set only Secondary/Administrative and Statistical • Ethics committee or tumor board, if deciding on a course of treatment for an individual patient • Note: Documentation of findings could be reported in the patient’s medical record. Other legal privileges may apply to these records. • designated record set only Administrative and Financial Committee Reports (of patient-specific care decisions) Sorting Record Types • Tumor registries data • QI/QM reports and abstracts • Statistical data • Committee minutes (not patient-specific treatment related) • Neither

Document and Electronic Capture – where is the data coming from? • Basic design and purpose • COLD fed documents (print streams) • HL 7 to interface • Import/Use of electronic forms 11

You need to be reviewing the Legal Health Record • Support the decisions made in a patient’s care • Support the revenue sought from third-party payers • Document the services provided as legal testimony regarding the patient’s illness or injury, response to treatment, and caregiver decisions • Serve as the organization’s business and legal record

Legal Health Record vs. Designated Record Set • Healthcare organization must explicitly define both the LHR and DRS. • Multi-disciplinary effort. • Patient care needs must be met for the immediate, long-term, and research

Designated Record Set • Rights of individuals – Access – Amend – Restrict – Accounting of Disclosures

Designated Record Set • Defined by HIPAA and include: – patient medical records – billing records – Enrollment, payment, claims, adjudication, and cases – medical management record systems maintained by or for a health plan – information used in whole or in part to make carerelated decisions

Site Interviews – How do you provide access to auditors? • “They can view dictated discharge summaries, operative reports, medications, labs; pretty much everything, but the technicians pull charts from the list since we are hybrid. ” • How many of you have experienced this approach? 16

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Hybrid Records • • Many hospitals are still in the Hybrid Phase Paper , scanned documents and the EHR Management challenges Patient safety issues • Have you experienced auditing a hybrid record? 18

Why are we seeing the combination of EHR & Document Imaging? – Paper isn’t going away. Don’t want to pay offsite storage – Computerized, long-term archival of the legal medical record – Online access to the legal medical record – Multiple users can access the same time – Decreases the time required assemble the record – Eliminate viewing of administrative portions of the record 19

Site Interviews - site #2 • Our facility uses Cerner. – We can either sit with them or we can work with our IS department to get them access. – Our last several visits, we found it easier to have someone from the quality improvement team sit with them and go through the chart. 20

• Sometimes if it is a complaint where they want to look at several accounts, they may ask HIM to print the record. – We have found it easier to burn the documentation to CD and then they view the CD with the quality improvement representative. This way they can help easily navigate through the record. – The other nice thing about burning the documentation to CD is the sections of the record are bookmarked and easier to find various things they are looking for because they can do a search and easily find information 21

What Best Practices have you experienced with electronic reviews? • Site representative sits with you and walks you through? 22

Is one system better than another? • Do you have better luck with record reviews in certain systems? • Why are they better? 23

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What can be done before the visit? • Are there steps in the pre-review process that could help productivity and quality onsite? • Offsite review? 26

Other ideas to improve Reviews in the EHR • Getting what you need out of the EHR • Getting what you need for remote reviews • Making the most of your record review time 27

QUESTIONS/DISCUSSION 28

Resources • Fundamentals of the Legal Health Record and Designated Record Set: http: //library. ahima. org/xpedio/groups/public/documen ts/ahima/bok 1_048604. hcsp? d. Doc. Name=bok 1_048604 • LHR Policy Template • Retention and Destruction of Health Information: http: //library. ahima. org/xpedio/groups/public/documen ts/ahima/bok 1_049252. hcsp? d. Doc. Name=bok 1_049252 29

Resources Electronic Document Management as a Component of the Electronic Health Record http: //library. ahima. org/xpedio/groups/public/documents/ahima/bok 1_021594. hcsp? d. D oc. Name=bok 1_021594 Document Imaging as a Bridge to the EHR http: //library. ahima. org/xpedio/groups/public/documents/ahima/bok 1_018987. hcsp? d. D oc. Name=bok 1_018987 How to Use an EDMS in Your Journey to the EHR http: //library. ahima. org/xpedio/groups/secure/documents/ahima/bok 3_005664. hcsp? d. D oc. Name=bok 3_005664 AHIMA. "Managing the Transition from Paper to EHRs. " (Updated November 2010). 30