Best Practices EHRRisk Management & Customer ServiceA Wining Proposition

Nancy Babbitt, FACMPE

Objectives

Understand how EHR implementation and workflow impact risk management and customer service Learn how to use your EHR to improve risk management opportunities. Evaluate EHR workflow options to positively impact risk management and customer service.

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The Business Case• Strong Leadership • Physician Commitment• Vision• Objectives• Perseverance

• Appropriate Training• Buy-In• Workflow Redesign• Improved Quality• Return on Investment

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EHR Documentation Functionality• Leverage electronic documentation • Functionalities that reduce diagnostic error

rates and improve patient care:• Offers resources for clinical information and

guidelines• Aggregates and integrates data from clinical episodes

to permit a meaningful synthesis• Incorporates efficient workflow patterns

Shiff GD, Bates DW. Can electronic documentationhelp prevent medical error? N Engl J Med 2010 Mar25;362(12):1066-9 4

Workflow Redesign

• Simplify and eliminate wasteful activities• Patient Visit• Internal Operations• External Operations

• Target areas• Handoffs• Variability

• Exploit System Capabilities• Evaluate Current Workflow• Use Team approach for electronic solutions

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Top Workflows To Evaluate

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Referral Provider documentation – other sites

Messaging Results – in office

Lab order Results – external sources

Triage advice Charge capture

Procedure order Patient check in – notifying ready

Scheduling Rooming patient

Medication orders - new Provider notified patient ready

Medication order - refill Patient orders during visit

Provider documentation - office Patient discharge / instructions

Clinical Decision Support

• Meaningful Use• Disease Specific Management Tools• Template driven • National standards of care- HEDIS, NCQA

• Patient Centered Medical Home, PQRS, ERX• E & M Coding Calculator• Common Conditions/Areas Managed:• Diabetes Hypertension• Lipid Management Weight Management • Asthma Headaches

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Workflow Redesign Examples

• All clinical calls and recommendations are documented in the patients chart.

• Each medical assistant and Provider has a task list that organizes duties.

• Lab orders electronically generated, by common reasons; annual exam, diabetic check

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Workflow Redesign Examples

• Lab results electronically returned into Patients chart with abnormal alerts

• Medication reconciliation with step-by-step process embedded into workflow navigators

• Forms electronically generated• Web-based clearinghouse• Electronic messaging and scheduling

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EHR System Helps Improve the Quality of Care for Patients: An Interview with Dr. Karen Smith

• Review labs at home• Flag urgent cases• Ensure timely care

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http://www.healthit.gov/buzz-blog/ehr-case-studies/ehr-system-improves-quality-care-patients/

EHR Promotes Safe Care

• Instant access to current information• Medication reconciliation and tracking• Allergy and interaction checking• Legibility • Patient education and generated documents• Improved compliance• Clinical Trials/Research• Marketing “Practice Technology”

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EHR Risks • Massive amounts of data• Multiple screens• Excessive Scrolling• Data not in routinely viewed area• Functionality Abuse• Copy and Paste (“cloning”)• Charting by exception• Excessive Alerts• Typing in data, not using templates

• Risk management strategies during implementation

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Charting By Exception • Risks/Results• Checking wrong box• Inaccurate information• Patient harm• Malpractice Risk

California HealthCare Foundation. Clinical documentation: EHR deployment techniques [online]. 2010 Apr [cited 2010 May 18]. Available from Internet: http://www.chcf.org/~/media/Files/PDF/C/ClinicalDocumentationEHRDeploymentTechniques.pdf

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Free Typing / Texting• Documentation neither coded nor linked• Fail to trigger clinical or administrative prompts• Unavailable in searches of linked terms

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California HealthCare Foundation. Clinical documentation: EHR deployment techniques [online]. 2010 Apr [cited 2010 May 18]. Available from Internet: http://www.chcf.org/~/media/Files/PDF/C/ClinicalDocumentationEHRDeploymentTechniques.pdf

Other EHR Risks• Email • Unauthorized access• Communication failures• Drop down lists• Patient Name• Medications• Procedures

• Improper training• Documenting charting errors

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“e-iatrogenesis” patient harm in part from health information technology

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Mistyped e-script

Choosing wrong drug/dose/delivery from a lengthy drop-down list

Filling in prescription on wrong patient (when multiple patient windows can be displayed on a screen)

Wrong patient information based on breakdown of patient identifier system

Formulary used by prescriber allows substitution (at point of prescribing)

Outdated medications on medication history

Alert blocks necessary treatment

User interface including pick list error or free-text input error

Treatment duplication attributed to "signing" versus "administering"

Distraction caused by alerts

Prescribing roles restrictions results in no treatment or unauthorized treatment

Journal of Healthcare Management 56:1 January/February 2011

Patient Safety – Malpractice Litigation • Failure to properly enter data in EHR

Equal To: not charting at all • When was important clinical data available

• Providers and users need to know system• Printed copy of the record provided upon

Medical Records request• Present the same information the Provider viewed

at the time of care and treatment• Knowing data was entered from clicking a choice

from a drop down screen or typed in own words

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EMR Liability and Risk, MAG Journal, Daniel J. Huff, Esp., Huff, Powell & Bailey, LLC

Electronic Discovery Laws

• 33% decrease in EHR adoption by hospitals in states that clarify use of “E” evidence

• Meaningful Use• Encourage adoption• Improve Quality• Litigation risk not addressed

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http://www.ftc.gov/be/seminardocs/090430amiller.pdf

“E” Discovery Laws – 2013 42 States

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Alabama Indiana Nebraska Tennessee

Alaska Iowa New Hampshire Texas

Arizona Kansas New Jersey Utah

Arkansas Louisiana New York Vermont

California Maine North Carolina Virginia

Colorado Maryland North Dakota Washington

Connecticut Michigan Ohio Wisconsin

Delaware Minnesota Oklahoma Wyoming

Florida Mississippi Oregon

Idaho Missouri Pennsylvania

Illinois Montana South Caroline

http://www.ediscoverylaw.com/promo/state-district-court-rules/

Mitigate Risks Page 1 • Thoughtful use of templates

• Standard of care• Record significant findings• Limit the number

• Ensure process activities timely/accurate• Revenue Cycle Controls• Capture, Entry, Utilization Critical Data• Requested changes to application/infrastructure• Security and data back up mechanisms• Training and support

• Consult end users to evaluate processes/changes

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Mitigate Risks Page 2 • Orders / Medications include

• Purpose (cough)• Age • Weight, when appropriate• Drug name, exact metric weight, concentration,

dosage• Precede decimal with a zero, 0.50ml• Avoid abbreviations• Drug name• Exact metric weight, concentration, dosage

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Mitigate Risks Page 3

• Procedure to regularly update/reconcile Medication list• Ask patients to bring all RX and OTC to

appointment• Print/give access electronic medication list to

patient• Make sure all Providers who practice at your facility

are informed and included in transition plans

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Mitigate Risks Page 4

• Adequate training• Conduct audits• Follow up on identified weaknesses• Provide refreshed courses

• Culture - feel empowered to request assistance• Assess and monitor errors, near misses• Evaluate cause• Make changes to software/process

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Mitigate Risks Email Policies Page 5

• Proper grammar, spelling• Establish turnaround time for messages• Auto reply confirm receipt, warn patients not to

use email for urgent matters• Inform patients privacy and security limits• Encourage concise messages• Inform patients who is responding, on behalf of..• Retain and incorporated into patient record• Policies for types acceptable for email • Ask patients to indicate reason in subject line

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Mitigate Risks Email Policies Page 6

• Instruct patients to include, name, insurance plan, patient ID number

• Inform patients when request is completed• Ask patients to acknowledge receipt of message• Policies for retention, archival, retrieval• Group mailings do not show others email addresses• End with Providers full name, contact information,

reminders about medical information, security, warnings using for emergencies

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Mitigate Risks Page 7

• Breach of Confidentiality• Access restrictions based on job duties• 2 point user authentication• No password sharing• Change passwords frequently• Review audits reports, regularly• HIT confidentiality policy• Enforce disciplinary policies• Enforce “logging out” policies

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VHA – A Case Study • VA outperformed all other sectors of U.S.

healthcare across 294 measures of quality in disease prevention and treatment

• (VHA) patients more likely to receive recommended ambulatory care because VA’s EHR system facilitates coordinated care and utilizes clinical reminders

• EHR available to VA healthcare workers 100% of the time, compared with paper records’ availability 60% of the time

Wilson JF. Making electronic health records meaningful. AnnIntern Med 2009 Aug 18;151(4):293-6

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VHA….The Good and The Bad • 2005 Hurricane Katrina - EHR minimize disruption in

care dislocated patients• Month after healthcare workers at 200 sites, 48 states,

accessed clinical data electronically for 38% of patients who had been cared for previously in VHA medical facilities in New Orleans, Louisiana.

• 2008, as a result of a software problem that affected how EHRs were displayed, patients in VHA facilities nationwide experienced treatment errors, including incorrect doses of drugs and delays in treatment, and may have been exposed to other medical errors.

Wilson JF. Making electronic health records meaningful. AnnIntern Med 2009 Aug 18;151(4):293-6

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Listening Less – EHR Syndrome • Clinicians engaging less with patients relative to

the use of paper records• More clinical information available• Physicians who spend more time looking at the

computer screen create sense of alienation

O’Malley AS, Cohen GR, Grossman JM. Electronic medicalrecords and communication with patients and other clinicians:are we talking less? Issue Brief Cent Stud Health SystChange 2010 Apr;(131):1-4

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Customer Service and Technology • Workstation placement• Facing patient• Eye contact• Conducive to conversation• Tablet - places to set down

• Optimize technology• Documentation orders complete by check out• Samples/education brought to room

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Customer Service and Technology • Patient Portal• Results • Medications, clinical summaries • Request medication refills• Request Advice • Download records

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Kaiser Permanente - Hawaii Integrated healthcare delivery system - 225,000 members

• Between 2004 and 2007, office visits decreased:• 25% in primary care• 21% in specialty care

• Increased use of nontraditional, patient-centered ways of providing care

• Scheduled telephone visits increased more than eight-fold, Secure e-mail messaging increased nearly six-fold

Wilson JF. Making electronic health records meaningful. AnnIntern Med 2009 Aug 18;151(4):293-6

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EHR System Helps Improve the Quality of Care for Patients: An Interview with Dr. Karen Smith• Improving the quality of care• Pay more attention - patient as a person• Patients love to email me• Efficiency -modify workflow able to see more in

same time• Achieve National Committee for Quality

Assurance recognition as a Patient Centered Medical Home

• Heart and stroke recognition

http://www.healthit.gov/buzz-blog/ehr-case-studies/ehr-system-improves-quality-care-patients/ 33

Functionality Pitfalls • EHRs may obscure data of uncertain accuracy• Poorly displayed data or data unnecessarily

spread across many screens• Hide important information in unexpected places• Generate errors

• Displays all of a patient’s laboratory results without searchable format - difficult to find clinically relevant results

• Searchable format supports analysis of clinical data for• Quality improvement• Research• Population studies

Hartzband P, Groopman J. Off the record—avoiding the pitfalls of going electronic. N Engl J Med 2008 Apr17;358(17):1656-8

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Managing Alerts and Communication • Define clear policies for using face-to-face or

“E” communication• Direct verbal communication for complex,

sensitive, or urgent situations• Electronic communication for administrative

tasks • Assess patient satisfaction with provider use of

EHRs• Layout of the patient examination room• Screen placement• Workflow patterns facilitate communication

between the physician and the patient

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“Alert” – Risk Management• Work with vendors to create a usable Alert

System• Allow clinicians determine urgency and

relevancy• Review Alerts that are overridden• Evaluate need for hard stop• Document decision making process

• Not using EHR Alert system, develop another• Document why using another system

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Future Functionality • Structured templates and vocabulary • Drive clinical support functions• Drug and allergy alerts or treatment suggestions • Based upon clinical guidelines

• Controlled vocabulary or coded terminology• Linked to clinical decision trees• Prompt additional actions, at the point of care

• Reimbursement codes• Referral to a specialist• Automatically link relevant laboratory results

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The Future – Information Exchange • Retrospective review duplicative medical tests• Pediatric patients• Receiving coordinated care across two healthcare

institutions• Each own EHR system

• 20% of cases had at least one duplicative test not clinically indicated

• Result of incomplete electronic record transfer among incompatible EHR systems

• Suggest EHR systems with integrated decision support could assist in minimizing duplicative testing at the time of patient transfers

Stewart BA, Fernandex S, Rodrigues-Huertas E, et al. A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. J Am Med Inform Assoc 2010 May 1;17(3):341-4 38

Resources• ECRI Institute Healthcare Risk Control EHR https://www.ecri.org

/Products/patientsafety_quality_risk/Documents/MedRec1_1.pdf• NORCAL Claims RX, EHR Recognizing and Managing the Risks http

://www.ischool.drexel.edu/faculty/ssilverstein/norcal.pdf• Electronic Discovery and EMR http://www.ftc.gov/be/seminardocs

/090430amiller.pdf• Legal Health Record, AHIMA Leadership Model• http://www.ahima.org/downloads/pdfs/about/LegalHR.pdf• HIM EHR Data Integrity Analyst Sample Position Description http

://www.ahima.org/downloads/pdfs/resources/EHRDataIntegrityAnalystJD.pdf

• HealthIT.GOV http://www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes

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Changes to consider: • Train users to question data that doesn’t make

sense• System to verify mistakes are fixed• Quality Control

• Round on users• Peer to peer chart reviews• Standards/Favorites• Share best practices

• Incremental Implementation• Change Management Program not an IT Project

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“Price is what you pay.Value is what you get.”

- Warren Buffet

Nancy Babbitt, FACMPEBabbitt & Associateswww.BabbittandAssociates.comNancy@BabbittandAssociates.com

Thanks for attending!

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AttachmentsEHR – Risk Management

Action Recommendations

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Action Recommendations – Page 1• Become actively involved in the organization’s EHR planning and

implementation.

• Ensure that current information concerning Medicare and Medicaid incentive payments for EHR adoption is made available to the EHR implementation team.

• Refer to “Resource List” to remain alert to the availability of federal and state resources for EHR adoption, and provide information about these resources to the EHR implementation team.

• Seek out best practice resources from hospitals and health systems that have implemented EHRs, and provide this information to the EHR implementation team.

• Ensure that education, training, and support are provided on an ongoing basis to employees and medical staff to ensure that patient safety components of EHRs and computerized provider order-entry systems are used appropriately.

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Action Recommendations – Page 2• Implement policies and procedures for reporting adverse events and near

misses related to EHRs and new EHR components.

• Analyze adverse event and near-miss reports related to EHRs, and provide feedback to health IT and other involved personnel, including patient safety, clinical engineering, quality improvement, nursing, and medical staff, as may be appropriate.

• Develop and implement policies and procedures for use of an EHR’s “copy and paste” functionality.

• Conduct periodic or random documentation audits to monitor for inappropriate use of the “copy and paste” functionality, and alert the facility’s regulatory compliance officer to potential problems related to this functionality.

• Develop and implement policies and procedures for physician office practices regarding effective and ineffective use of EHRs as a means of communication among providers, staff, and patients.

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Action Recommendations – Page 3• Involve clinicians from various specialties in reviewing proposed clinical

templates to ensure that they meet clinical needs and do not create a perceived need for “workarounds.”

• Modify administrative processes and clinical workflows to maximize interpersonal communication while using an EHR

• Monitor for use of “sticky notes” and other forms of paper communication among providers in an EHR environment, and identify reasons for such “workarounds.”

• Analyze malpractice claims that involve medical record documentation error, whether in paper or electronic form, and report findings to relevant departments, teams, and committees for consideration.

• Obtain legal review of complex contracts with EHR vendors.

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EHR Documentation FunctionalityAmong EHR documentation capabilities that may reduce errorand support quality care are the following:• Provides access to historical patient information• Offers resources for clinical information and guidelines• Facilitates immediate access to consultants for referral, testing, or further

assessment• Records and shares assessments among clinicians• Documents the patient’s evolving history and ongoing assessment• Maintains patient problem lists• Tracks medications• Tracks tests and test results• Aggregates and integrates data from clinical episodes to permit a

meaningful synthesis• Enables and tracks follow-up care• Provides checklists and prompts to support diagnostic thoroughness• Provides an embedded calculator for identifying diagnostic probabilities• Incorporates efficient workflow patternsShiff GD, Bates DW. Can electronic documentationhelp prevent medical error? N Engl J Med 2010 Mar25;362(12):1066-9

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