2/8/17
1
PRACTICAL PITFALLS OF THE
ELECTRONIC MEDICAL
RECORD
STEVE
WAXMAN
MD,
JD,
FCLM
ACLM
57TH
ANNUAL
MEETING
FEBRUARY
25,
2017
DISCLOSURES
Mid-‐America
Kidney
Stone
AssociaMon-‐Shareholder
TERMINOLOGY
Ø Electronic
Medical
Records
(EMRs)
Ø Electronic
Health
Records
(EHRs)
Ø Personal
Health
Records
(PHRs)
Ø Hospital
Based
Systems
Ø Office
Based
Systems
VENDORS
Ø Meditech
Ø Cerner
Ø McKesson
Ø Epic
Systems
Ø Siemens
Healthcare
Ø VistA-‐Veterans
Affairs
Ø AHLTA-‐U.S.
Military
Ø And
Hundreds
More
HEALTH INFORMATION TECHNOLOGY LEGISLATION
Ø American
Recovery
and
Reinvestment
Act-‐-‐-‐ARRA
Ø Health
Insurance
Portability
and
Accountability
Act-‐-‐-‐HIPAA
Ø Health
InformaMon
Technology
For
Economic
and
Clinical
Health-‐-‐-‐HITECH
Ø Affordable
Care
Act-‐-‐-‐ACA
Ø FDA
Safety
and
InnovaMon
Act-‐-‐-‐FDASIA
2/8/17
2
Stage
1:
Meaningful
use
criteria
focus
on:
Stage
2:
Meaningful
use
criteria
focus
on:
Stage
3:
Meaningful
use
criteria
focus
on:
Electronically
capturing
health
informaMon
in
a
standardized
format
More
rigorous
health
informaMon
exchange
(HIE)
Improving
quality,
safety,
and
efficiency,
leading
to
improved
health
outcomes
Using
that
informaMon
to
track
key
clinical
condiMons
Increased
requirements
for
e-‐prescribing
and
incorporaMng
lab
results
Decision
support
for
naMonal
high-‐priority
condiMons
CommunicaMng
that
informaMon
for
care
coordinaMon
processes
Electronic
transmission
of
paMent
care
summaries
across
mulMple
seangs
PaMent
access
to
self-‐management
tools
IniMaMng
the
reporMng
of
clinical
quality
measures
and
public
health
informaMon
More
paMent-‐controlled
data
Access
to
comprehensive
paMent
data
through
paMent-‐
centered
HIE
Using
informaMon
to
engage
paMents
and
their
families
in
their
care
Improving
populaMon
health
MEANINGFUL USE
EMR USAGE IN U.S. AS OF 2015
Ø Hospitals-‐90%
Stage
2
(Meaningful
Use)
Ø Offices-‐87%
Had
Any
EMR
Ø Offices-‐54%
Had
Basic
EMR
Ø Offices-‐41%
PaMents
Could
Download
Their
Own
Medical
Record
Ø Offices-‐19%
Could
E-‐Send
Their
Record
to
a
3rd
party
Ø Already
Way
Past
Being
the
First
One
to
Adopt-‐Don’t
Want
to
be
the
Last
to
Adopt-‐PenalMes
Ø Technology
Constantly
Advancing-‐Hard
Enough
Keeping
Up
With
Advances
In
Medicine
Ø It
Is
Very
Expensive
Ø Now
Add
the
Epidemic
of
Hacking
and
IdenMty
Theh
COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)
Ø Standardized
Order
Sets-‐Reviewed
and
Approved
by
Medical,
Nursing
and
Pharmacy
Staffs
Ø Orders,
Sets
and
Protocols
Consistent
with
NaMonally
Recognized
and
Evidence
Based
Guidelines
Ø Periodic
and
Regular
Review
by
Medical,
Nursing
and
Pharmacy
Staffs
Ø Hospital
Commiiees
Determine
the
ConMnuing
Usefulness
and
Safety
Ø Dated,
Timed
and
AuthenMcated
in
the
EMR
Ø Must
have
Robust
Training
and
Real
Time
Support
24/7
Ø Must
Ensure
“Workarounds”
by
Providers
Do
Not
Compromise
PaMent
Safety
or
Validity
of
EMR
CONTENT IMPORTING TECHNOLOGIES (CIT)
Ø PotenMal
Problems
During
an
Audit
Ø Progress
Notes
with
Physical
Exams
Nearly
IdenMcal
on
Subsequent
Visits-‐Over
Time
or
Changes
in
Dx
Ø MulMple
PaMents
with
Exactly
the
Same
Findings
Ø Extraordinarily
Long
and
Detailed
Progress
Notes
Not
Necessary
to
Address
the
Problem
COPY AND PASTE
Ø Good
For
Things
Like
a
Pathology
Report
Ø Standard
DescripMon
of
a
Procedure-‐-‐-‐i.e.
Vasectomy
or
Informed
Consent
for
Radical
Prostatectomy
Ø Bad
When
ImporMng
Material
That
is
Inaccurate
or
Not
PerMnent
to
the
New
Encounter
Ø Also
Bad
When
Copied
Material
is
Not
Properly
Edited
to
Accurately
Reflect
the
Current
Encounter
Ø “Note
Bloat”
Makes
it
Tougher
to
Find
Clinically
Relevant
InformaMon
Related
to
Current
Visit
Ø Unnecessary
Loading
of
Detailed
InformaMon
From
the
Past
Lessens
Credibility
of
the
Note/Provider
Ø Ugly
When
>
50%
of
Providers
note
is
Copy/Paste.
Metadata
&
Plagiarism
Sohware
Picks
This
Up
Easily
Ø Different
From
Specialty
Offices
Which
May
See
a
Large
Number
of
Similar
CondiMons
PRE-‐POPULATION AND INFORMATION PULLED
FORWARD
Ø Demographics
Ø Past
Surgical
History
Ø Past
Medical
History
Ø Meds
Ø Allergies
Ø Review
of
Systems
Update
Ø Pressures
to
Aggressively
Code
Ø Limit
the
Types
of
Data
to
Pull
Forward-‐Demographics
and
Relevant
Info/Procedures/Reports,
etc.
2/8/17
3
TEMPLATES AND AUTOMATED TEMPLATES
Ø Good
in
That
They
Facilitate
Uniformity
and
Ease
of
Retrieval
Ø Need
Room
to
Free
Text
and
Personalize
the
Encounter
Ø Problems
Arise
When:
Ø The
Note
Appears
to
be
“Canned”
Ø Default
Seangs
are
Normal
or
“Auto
negaMve”
Ø Was
Every
Item
Examined?
Ø Were
they
All
Really
Normal?
Ø Looks
Bad
When
Caught
Red
Handed-‐Normal
Neuro
Exam
on
Paraplegic
PaMent
Ø Upcoding
or
Overcoding?
FREE TEXT AND DRAGON
Ø Allows
the
Provider
to
“Personalize”
the
Note
Ø Templates
Should
Be
Adjustable
Ø Some
Templates
are
Designed
to
Capture
a
Level
of
Code
Rather
Than
Address
the
Problem
Ø Need
Complete
CollecMon
of
InformaMon
to
Achieve
Each
Level
of
Code
Ø However,
Is
the
Problem
Appropriate
to
JusMfy
the
Level
of
Care?
Ø i.e.-‐-‐-‐DocumenMng
More
Intensive
Services
Than
Were
Reasonable
and
Necessary
Under
the
Circumstances.
Level
5
for
Minor
LaceraMon
or
Ankle
Sprain
Ø AuthenMcaMon-‐Diagnosis
Codes,
Level
of
Complexity
and
Care,
Is
It
Correct?-‐
Is
It
Warranted?
Ø Machine
Generated
Level
of
Care
Code?,
Frequent
Use
of
Time
Spent
With
PaMent
Override
to
Increase
Code
CLONING
Ø Suspicious
When
Every
Entry
in
EMR
is
the
Same
or
Similar
to
the
Previous
Entries
Ø Between
Entries
of
the
Same
PaMent
or
Between
Entries
of
Different
PaMents
Ø Similar
is
OK
if
Record
Accurately
Reflects
Clinical
SituaMon—i.e.-‐Cold,
Flu,
GastroenteriMs
Ø Medicare
Audit-‐True
Cloning-‐MisrepresentaMon
of
Medical
Necessity
Requirement
of
Services
Ø Office
of
Inspector
General
(OIG)-‐-‐Over
docum
