Steve Lefar - President MediRegs. Dwight Claustre, CHC - System Director, Corporate Compliance Catholic Healthcare West -2-

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2 Steve Lefar - President MediRegs Dwight Claustre, CHC - System Director, Corporate Compliance Catholic Healthcare West -2-

3 Learning Objectives Why compliance and IT must live together? How compliance and IT can come together? What are the primary issues for specific high risk systems? -3-

4 Compliance is about Information Compliance Right Information-The Right People-The Right Way Right Information: Exactly what people need to know to make the right decisions. Right People: The specific people that need to know. Right Way: The approach that imparts knowledge. Effective compliance requires Efficient Information exchange. -4-

5 Business Information is Highly Automated Emerging Areas Chargemaster Learning Management Intranets Compliance Management -5-

6 Clinical IT Has Hit a Tipping Point President George Bush -Collinsville, Ill., Jan. 5, 2005 "We need to apply 21st-century information technology to the health care field. We need to have our medical records put on the I.T." 109th Congress (Republican). Priority # four, Healthy America Act of Promote the rapid adoption and widespread use of individually owned, privacy-protected electronic health records Voluntary reporting system for healthcare providers Congressman Patrick Kennedy, February 2004 Currently, we practice 21st century medicine on a 20th century platform. The information revolution has transformed financial services, manufacturing, retail.. We need I.T. to transform medicine as well. Researchers at RAND in the New England Journal of Medicine 45 percent of the time, providers fail to deliver scientifically accepted care. -6-

7 All Core Processes Will be Automated Clinical IT installations in the U.S., July 2004 *EMR installations range in scope from a CDR to an EMR with order entry and clinical documentation. **CPOE implementations range in scope from single department use to enterprise use. -7-

8 Documentation Systems Are Growing Rapidly. -8-

9 And new technologies are evolving. -9-

10 IMPLICATION: Compliance will be ABOUT IT Electronic Health Records FRAUD & ABUSE Chargemaster STARK CONTRACTUAL ETHICS Cost Reporting MALPRACTICE PRIVACY Billing SAFETY Communications (Phone, Pager, , IM) Marketing tools Compliance Mgmt. Background Checking Credentialing Contracting IT (conversions, migrations outsourcing) -10-

11 These Systems Geometrically Expand Risks The Compliance Multiplier Effect % of claims % of medical records % of patients vs. Sticky notes Paper Files versus Searchable Electronic Document Discovery The Reply All Button! -11-

12 The Multiplier Effect: Billing PRE Automation One wrong paper claim Root Cause Human error False Claim Potential Post Automation 2,000 claims at $11,000=$22 million Root Cause Human error CDM Billing systems -12-

13 The Multiplier Effect: Credentialing Inaccurate Verification PRE Automation One by one checking Mis-credentialing of a person Root Cause Faulty research Post Automation Mis-credentialing of all employees Missed excluded parties Root Cause Faulty databases Faulty logic -13-

14 The IT-Compliance Challenge Getting a seat at the table So many systems, so little time Assessing the REAL risk -14-

15 Getting a Seat- Speak Their Language Strange Bedfellows---Synonymous Processes Compliance Tools Risk Assessments Action Plans Education On-going Monitoring Disciplinary Action IT Tools Requirements Analyses RFPs Implementation Planning Implementation System Monitoring Fix a bug/user rights -15-

16 Getting A Seat: Fit In Right Information: Relevant regulations Risk Assessment Suggested safeguards/requirements/monitoring program Right People: CIO/System selection team Trainers and implementers End Users Right Way: Compliance questions added as part of specification and RFP Compliance issues part of system training curriculum Audit process as part of system monitoring -16-

17 So Many Systems- Where to Focus? IT Compliance Risk Matrix High Marketing Interfaces Claims CDM Multiplier Effect Credentialing Intranet EMR Cost Reporting Low One Risk Areas Impacted/OIG Interest All -17-

18 Assessing Risk: Emerging Systems Clinical Systems Electronic Medical Records Handheld prescribing and charging Financial ChargeMaster/CDM Interfaces Admission to Clinical Clinical to Charging Charging to Billing -18-

19 ChargeMaster Benefits Standardization Compliance with rules Rapid updating Appropriate billing Compliance Risks Garbage In/Out Systemic errors Systemic changes Accuracy Change control DISCOVERY -19-

20 Interfaces Risks Wrong data Wrong patient Wrong items Wrong provider Compliance Approach Statistically valid testing. Training processes Error checking Automated audit -20-

21 Electronic Medical Record: Overall Benefits Standards of Care Elimination of Errors Better Service Increased Accuracy Increased Effectiveness Improved Care Compliance Issues Standards of Care Business Associates External access Clinical Research/IRB Marketing MD-MD Record Access Staff Record Access -21-

22 Electronic Medical Record: Charge Capture Benefits Streamlined Process Faster Billing Fewer Denials Compliance Risks Incorrect billing Audit Trail Up-coding MD-MD Record Access Staff Record Access -22-

23 Electronic Medical Record: erx Benefits Reduced Errors Medical History No Paper Formulary Dosing Compliance Risks Patient Consent Rx History Sharing Package Privacy History integrity -23-

24 Summary Compliance must play in IT Pick your battles by stratifying system risk RI-RP-RW is a simple method to ensure: You impart relevant wisdom You embed compliance You reach people effectively IT and Compliance are Not Strange Bedfellows -24-