Document & Data Integrity in the Legal Health Record

Transcription

1 Document & Data Integrity in the Legal Health Record Wednesday, April 15 th, :00 2:00 PM Darice Grzybowski, MA, RHIA, FAHIMA President, H.I.Mentors, LLC DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Darice Grzybowski, MA, RHIA, FAHIMA, President, H.I.Mentors, LLC Has no real or apparent conflicts of interest to report. HIMSS 2015

3 Learning Objectives Attendee should be able to: 1) Define the role of document and data integrity and its impact on the legal health record. 2) Describe various clinical documentation and data improvement techniques and how innovation within the electronic health record environment along with utilizing best practice record management processes can assist in building a robust foundation for the legal health record. 3) Explain how the electronic documentation management system (EDMS) plays a vital role as a component of the EHR in supporting the legal health record and ensuring document and data integrity from point of creation through use, maintenance, workflow, and archive processes.

4 An Introduction to the Benefits Realized for the Value of Health IT Health IT creates five kinds of benefit to patients, healthcare providers, and communities These benefits can be classified into Five Steps which create value in the following areas: S-Satisfaction T-Treatment/Clinical E-Electronic Information P-Prevention & Patient Education and S-Savings (financial and efficiencies)

5 Step Summary of Value Proposition for Improving Document & Data Integrity S - There has been a great dissatisfaction published recently in the press about EHRs. This presentation provides alternative techniques to improving end user satisfaction with the EHR T - When documentation is improved and more efficient for providers, improved clinical outcomes are evident for ongoing care delivery E - Utilizing appropriate technologies for a single,unique, and compliant legal health record is a critical piece of the EHR picture P - Patients have a right to access their health record and receive a printed copy. Without a proper foundation for the LHR, this cannot be achieved effectively - this presentation demonstrates this through examples S - The cost of documentation and data errors as well as inefficient processing can be overwhelming to an organization - by learning techniques to improve this, a facility can save significant dollars

6 Therefore We believe that Document and Data Integrity are essential components of creating a reliable, accurate, secure, and functional Legal Health Record. Yet we continue to see Electronic Health Records being implemented which have introduced redundancy, inefficiency, risk, and added cost into the healthcare system. So we ask - Why has this occurred and what can be done to remediate the problems and mitigate the outcomes?

7 Before We Begin Acronym Level Setting EHR = Electronic Health Record EDMS = Electronic Document Management System LHR = Legal Health Record HIM = Health Information Management Department

8 Defining Document & Data Integrity Document Integrity: Data Integrity: The process of ensuring all paper and electronic documents are received and included into a single medical record for each episode of care and are equally accessible through a single request, and purged with a single function. 1. The extent to which healthcare data are complete, accurate, consistent and timely. 2. A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally; also called data quality. Source: Strategies for Electronic Document and Health Record Management, AHIMA, 2014, p Source: "Strategies for Electronic Document and Health Record Management", AHIMA 2014, p

9 Stories of increasing provider dissatisfaction with workflow continues Healthcare IT News (1/23/15) reports that a coalition of 35 physician organizations led by the American Medical Association says docs are fed up their electronic health records and the multitude of requirements that come from the federal meaningful use program. Politico (12/29/14, Allen) reports that widespread dissatisfaction with the Administration s $30 billion effort to digitize health records, combined with a hungry new Congress, could pose a threat to the program. While many believe digital health will eventually bring huge benefits, physicians have seen few of them to date Fierce EMR March 20, 2014 reported via a Rand study that doc dissatisfaction appears to be worsening quoting, "If practicing physicians are correct, the current state of EHR technology has introduced several impediments to providing patient care, undermining physician professional satisfaction.," The authors concluded, "Many of these problems-- such as the proliferation of clinical information that doctors don't trust--also should be of great concern to patients. Patients, providers, payers, and vendors all have an interest in improving the usability of EHRs and integrating them into clinical workflows that produce better, more efficient care."

10 What are YOUR patient and family experiences? And now..joint Commission Sentinel Event 54

11 What s Going Wrong? Increased provider dissatisfaction with workflow Data integrity issues Documentation inconsistencies HIPAA violations Labor inefficiencies in HIM Departments

12 So Why Is Quality Documentation and Data So Important?

13 Quality/Utilization Uses of Legal Health Record Data Patient Care Research Education Legal Defense Risk Mitigation Reimbursement Marketing Certificate of Need (Planning) Budgeting/Resources Historical Documentation Compliance Physician Credentialing Contract Negotiation

14 How Can You Tell the Symptoms of a Sick EHR Environment? Documentation Inconsistency: Problem List Carryover Copy and Paste Proliferation Consultant-itis Diagnosis of the Day Fragmented Information Flows (i.e. Orders) Reconciliation Roulette Data Integrity Issues: Duplicate Medical Record Numbers Uncontrolled Patient Status/Type Changes Forgotten Forms Control & Management Release of Information from a Dynamic Template Missing Master Patient Index Control Who s Watching the Master Data Dictionary?

15 But wait..there s more! HIPAA Violations: Enabling the Ability to Access, Without the Need to Know Identifying the Original and Only the Original Sir Accessing the Original, and Only the Original, Ma am Filling the Recycling Bins Source of Record Release Do you Know Where Your Records Are? Labor Inefficiencies in HIM: Are you adding vs. decreasing staff? Are clean up and audit activities taking center stage? How do you know you are reading a complete chart? (Coding/$ Impact) Record Retention & Purging Nightmares Release of Information Runaround Lack of focus on Concurrent Documentation Deficiency resolution

16 Please use this blank slide if more space is required for charts, graphs, etc. Please remember to delete this slide.

17 How Can We Use Technology and Process Innovation to Improve Documentation and Data Integrity? 17

18 Differentiating the Patient Care Focused EHR vs. the Discharged LHR The Patient Care Focused EHR: Input Focused Documentation Longitudinal Discrete Data Driven Utilizes Templates for Documentation Dynamic in Nature Single Source of Truth for Data Entry These are designed for different functional purposes, are symbiotic, yet require different technologies! The Discharged Legal Health Record: Output Focused for Long Term Document Management and Retention Episodic Forms and Document Driven Single Source for the Complete Record (integrated w Scanned & Workflow Documents Stable/Static Post Discharge Permanent Record Tells the Story of the patient in readable, Chronological Sequenced Order

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20 Tips for Improving Document Integrity Reduce Hybrid electronic fragmentation by ensuring your facility has a robust Level 3 electronic document management solution in place acting as your Legal Health Record (not just scanning tacked onto an EHR) Transform the role of the HIM Director from Legal Guardian of the Record to Chief Information Governance officer to provide enterprise-wide guidance on electronic document and health record management principles Complete a full Forms/Document Inventory from an Output Based perspective (printable) assuring input and output views are matched

21 Tips for Improving Document Integrity (continued) Complete a full Health Record Inventory if still in a paper/electronic hybrid environment Institute an (Electronic) Forms control policy and committee Perform daily reconciliation on complete discharge record (electronic) received and transferred into the EDMS from the EHR Implement a Clinical Documentation Improvement program that stops focusing on reimbursement and starts to link documentation with compliance, legal, and supports standardized language terminologies to support computer assisted coding

22 Tips for Improving Data Integrity Ensure the Level 3 EDMS is supported by full workflow functions including record completion/signature, coding & abstracting queues, release of information functionality, master patient index linkage, and retention/full purge from a single point functionality Create a master data dictionary for use in designing templates and output based permanent documentation forms Treat data (and documentation problems) as a key quality indicator Create Order Sets that are linked to reason for order (the why )

23 Tips for Improving Data Integrity (continued) Corrections and revisions to data are clearly visible to the end user and not hidden in versioning documents Utilize documentation based protocols for determining patient status from the Emergency Department Perform periodic five point compliance audits: Order, Documentation/Results, Coding, Billing, Reimbursement Promote centralized access and release post-discharge

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25 Summary: Five Steps and Benefits of Sound Document and Data Integrity for the Legal Health Record Your WIIFM Decreased complaints from clinicians and patients Mitigate risk and potential litigation problems Optimize coding accuracy and improve legitimate reimbursement with better capture and design of clinical documentation i.e. Present on Admission, Core Measures, Hospital Acquired Conditions, Observation Status, etc. Improve workflow for clinicians and HIM staff for improved productivity and satisfaction More meaningful information and better compliance with Meaningful Use standards (turnaround time for patient requests, ability to provide patient access to a clean record, etc.)

26 But Wait there s more.. Improved Interoperability of data Clean mergers of organizations Compliance with Record Retention programs Building a good foundation for advanced functionality i.e. Computer Assisted Coding, Biometric reporting/documentation Implementation of new EHRs (when we stop jumping off the cliff like the lemmings )

27 For more information on document and data integrity to support the legal health record you can download the following white paper: Forging a Path to the True Legal Health Record by Darice M. Grzybowski, MA, RHIA, FAHIMA, H.I.Mentors, LLC

28 Questions? Thank You! Darice Grzybowski, MA, RHIA, FAHIMA AHIMA Academy Approved ICD-10-CM/PCS Trainer/Ambassador Author Strategies for Electronic Document & Health Record Management (AHIMA 2014) President, H.I.Mentors, LLC One Westbrook Corporate Center, Ste. 300 Westchester, Illinois Twitter: dariceg1 Phone: