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Steve Waxman - Presentation - EMR · PDF file Steve Waxman - Presentation - EMR.pptx Author: Sue Peterson Created Date: 2/8/2017 10:42:28 PM

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  • 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.  

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    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

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