NHS Human Services and Magellan Behavioral Health of Pennsylvania present:

Anti-Cloning Campaign: One Individual at a Time

RCPA Conference October 6, 2015

Presented By:

Magellan Karli Schilling, MA, Compliance Auditor

Patty Marth, Compliance Auditor

NHS Human Services Debra Luther, Ph.D., CCE, Senior Director

John Ciavardone, CCE, Senior Vice President

Learning Objectives PART I (Magellan)

• Review the purposes of documentation

• Review Regulatory references

• Review the definition and history of Electronic Health Records

• Discuss the pros and cons of Electronic Health Records

PART II (NHS) • Implementation of an Electronic Health Record

• Identify and discuss barriers and solutions

• Identify and discuss staff training

• Identify and discuss auditing practices

• Identify and discuss policies & procedures agencies can implement to protect against cloning

• Discuss the use of algorithms

Learning Objectives PART III (Magellan) • Learn about the Managed Care Organization’s role

• Discuss the nuances of auditing Electronic Medical Records

• Review Audit Trends and Risk/ Consequences

• Recommendations for Program Compliance

PART IV (NHS & Magellan) • Open Discussion

o Barriers and Challenges

o Other Best Practices related to Compliance and EMR

o Lessons Learned

Part I: Auditing Electronic Medical Records

The Managed Care Organization’s Perspective

Purposes of Documentation

Legal record

Continuity of Care

Plan the course of treatment

Monitor healthcare over time

Quality Assurance

Research and education

Ensures compliance with regulatory requirements

Supports claims

6

Important Regulatory References

Chapter 55 PA Code § 1101.51

Medical Assistance Bulletins and Policy Clarifications

MCO specific guidelines and requirements

42 CFR Part 455: Program Integrity Requirements for Medicaid

7

Electronic Health Records (EHR)

An electronic health record (EHR), or electronic medical record (EMR), refers

to the systematized collection of electronically-stored health information,

in a digital format, about an individual patient or a population.

8

History Lesson

Electronic Health Records (EHR) first appeared in the 1960’s

Same goals as today

Emergence of Ambulatory Care

IOM Report “To Err is Human: Building a Safer Health System”

2009 passage of Health Information Technology for Economic and Clinical Health Act (HITECH)

Incentive Program

2013 Statistics:

o 941 manufacturers

o 1,700 unique products

9

Electronic Health Records (EHR)

EHRs replace traditional paper medical records with computerized recordkeeping to document and store patient health information.

EHRs may include patient demographics, progress notes, medication logs, medical history, and clinical test results from any health care encounter.

10

PROs and CONs of EHR

Advantages Quality of Care

Legibility

Efficiency

Accuracy

Standardization

More Timely Information

Reduced Loss of Paperwork

Research

Continuously Updated

Other Capabilities

Disadvantages Quality of Care

Cost

Privacy Issues

Workflow changes

Temporary loss of productivity

Other Technological Issues

Software quality and usability deficiencies

Cut-and-paste/ cloning techniques

11

Quality of Care Debate

12

Do EHR‘s augment or diminish Quality of Care?

Part II: NHS’s Anti-Cloning Campaign

EHR Implementation

Barriers: • Multiple States and Payers

• Large Volume of staff

• Connectivity

Solutions: • Document modification

• Tiered roll out

• IT Support – Site based assessments

14

Clinical Documentation and Technology – The Downside

The NHS Anti-Cloning Campaign

Multifaceted Approach

• Etiology - identification of risk

• Training

• Policy & Print Media

• EHR modifications

• Audits & Algorithms

16

Risk Identification

• QI Audit Process

• Investigation process to identify scope

17

The NHS Anti-Cloning Campaign

It’s all in how you look at things…

18

19

20

The NHS Anti-Cloning Campaign

Training

• Anti-Cloning 101

• Anti-Cloning 102

21

Anti-Cloning Policy and Print Media

• Defining the issue

• Concretizing consequences

• Print Media

22

23

Observations

• Mood

• Communication: Verbal/Non-Verbal

• Insight

• Interactions

• Affect

• Appearance: Physical, Hygiene, Dress

• Mental Status Exam

• Engagement

• Strengths

24

25

Exercise: Describe what

you see

EHR Modifications

• Anti-Cloning Acknowledgement

• Disabled ‘Cut and Paste’ Functionality (Jquery)

• Limited use of ‘Pull Forward’ functionality

26

Audits & Algorithms

Audit Process Enhancements

• Side by Side comparison of notes across days and within days of service

• Review of several weeks/months of notes simultaneously

• Group Services Audits

Algorithm Development

• Working towards a program to review strings of texts for duplicate content

27

28

95.88%

91.13% 92.75%

83.00%

93.75%

100.00% 100.00% 97.00%

100.00% 100.00%

83.25%

100.00%

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Oct '12 Nov '12 Dec '12 Jan '13 Feb '13 March '13

April '13 May '13 June '13 July '13 Aug '13 Sept '13

Pe

rc

en

t C

ha

rts

Wit

ho

ut

Du

pli

ca

te C

on

ten

t

Impact of Anti-Cloning Campaign - EHR

Variance due to auditor

29

41%

47%

63%

52%

66%

84%

96% 95% 92%

96%

83%

92%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rc

en

t o

f C

ha

rts

Wit

ho

ut

Du

pli

ca

te C

on

ten

t Impact of Anti-Cloning Campaign- Paper Based

Documents

Variance due to auditor

30

Part III: Auditing Electronic Medical Records The Managed Care Organization’s Perspective

Managed Care Organization Oversight/ Auditing

• Why do we Audit?

i. To ensure a consistent approach to treatment between providers, Magellan and our County partners

ii. Proactive Patient Safety activity

iii. To measure adherence to standards set by CMS, Pennsylvania DHS and Magellan’s national and local teams

• How do we Audit?

i. On-site Review

ii. Treatment Record Reviews

iii. Integrated Audits

32

Auditing The Differences between Paper Files and EHR

Clues identified when reviewing paper files

Differences in Handwriting

Missing Signatures

Altered Documentation

Changes in Date of Service

Clues identified when reviewing EHRs

Copy and Paste

Electronic Signatures

Over-Documentation

No proof of authorship

33

Audit Trends- EHR Records

Cut-and-Paste/ Cloning

Signatures Stamps pre-date end time of the session

Signature Stamps conflict with another session or activity

Empty Data Fields

Missing Notes

Pre-populated Code Definitions that don’t correlate to provider’s contract or applicable regulations

34

Implications for Providers using EHR

User Guide Usage Policies

Training Audit Logs

EHR Vendor

35

Risk/ Consequences

Increased Exposure

Corrective Action

Identified Overpayment/ Retractions

Extrapolation

Referrals to Oversight Agencies- BPI, OMHSAS, etc.

Referrals to Law Enforcement

Exclusion from future participation in federal health care programs (Medicaid, Medicare)

36

Recommendations for Monitoring Program Compliance

1. Accessibility to the Requirements

2. Documentation of the Requirements

3. Policies and Procedures

4. Tools to monitor Compliance

5. Audit Plan

6. Measurements of Effectiveness

7. Mechanisms to Correct and Report Non-Compliance

37

Part IV: Open Discussion

Key Points/ Takeaways

Provider’s Presentation

• Don’t over-customize your EHR

• Ensure timely roll out

• ID risks prior to roll out and train staff to avoid them

• Give staff the tools to be successful

• Harness the capacity of your EHR to capture risks

MCO’s Presentation

• Know and understand the regulations and other requirements for documentation

• Recognize both the strengths and limitations of implementing an EHR

• Acknowledge and address how your EHR system may affect Quality of Care

• Impact of EHR on Compliance

• EHR Essential items

• Know the risks and operate an effective Compliance Program

39

THANK YOU!