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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
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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 documentaMon-‐InserMng False or Irrelevant DocumentaMon
Ø Concern Over EMR-‐Facilitated Entries That Generate Extensive DocumentaMon With a Single Click of a Checkbox
USER INTERFACE ISSUES
Ø Menus and Checkboxes
Ø Risk-‐”Adjacency Error” Checking the Item Next to the Intended Item
Ø Concern-‐Structuring the Menu Lists by Forcing Choices of More RemuneraMve Services or CreaMng False DocumentaMon
Ø More Time Spent Face to Face with Laptop Means Less Time Face to Face With PaMent
Ø When to Document/Dictate into the Note?
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ALERTS, PROMPTS, AND WARNINGS
Ø Alert FaMgue-‐DesensiMzed to Alerts-‐Either Ignored or Silenced Ø Clinical Decision Support (CDS)-‐Review CDS Prompts Annually-‐Update and Edit Prompts-‐Weed Out
Irrelevant Ones and Reinforce the CriMcal Ones
Ø Access and NavigaMon Controls-‐Don’t Want Too Many PaMent Charts Open at Same Time-‐ Prevent Puang Notes or Orders Into the Wrong Chart
Ø Search and Retrieval Capability-‐Design and Modify Systems to Facilitate Ease of Access to Providers
Ø User “Unfriendly” Systems Lead to Increased Risk of FrustraMon and Errors and PotenMal PaMent Harm
PROVIDER AWARENESS OF OTHER DATA IN EMR
Ø Screen Shots of What the Provider Viewed
Ø Results Visible in One Program But Not in Another
Ø Provider Not Aware of Data-‐Labs/Radiology Results/Other Providers Notes in the EMR
Ø Changes, Corrected Results and CriMcal Results-‐Knowing The Results Were Seen and Acted Upon By The Provider
Ø Are All The FuncMonaliMes Being UMlized In the EMR-‐Lab Tab/Radiology Tab
Ø EMRs-‐You Get What You Pay For-‐And None are Cheap
AUTHENTICATION ISSUES
Ø Log-‐in Controls Ø User IdenMty Ø Medical Record AuthenMcaMon
Ø Providers With Same Last Names Geang Each Others Results
Ø Privacy, Security, Unauthorized Release of Medical InformaMon
Ø Increased Liability for Providers and Hospital for Improper Use of EMR
Ø If Provider Relies on EMR RecommendaMons and There is Injury-‐Are Hospital and Vendor also Liable?
CLINICAL DECISION SUPPORT (CDS) FUNCTIONALITY
Ø Recommend Course of AcMon Ø Warn Ø Assist Ø Advise Ø Applying Treatment Guidelines Using Evidence Based Sources Ø Algorithms—”Cook Book Medicine”? Ø AutomaMc-‐Rules Based Prompts or Surveillance Alerts
Ø On-‐Demand-‐Allows Physician to Ask For Assistance Ø Hard Stops-‐Prevent an Error Which Could be Injurious Ø But SMll Must Allow a ConMngency For Non-‐Standard Orders
CODING AND BILLING SUPPORT FUNCTIONALITY
Ø Concern-‐Geared to Maximize Reimbursement
Ø Encourage Providers to Pad the EMR DocumentaMon to JusMfy Greater Reimbursement
Ø Sohware-‐Accuracy and Reliability of the Recommended Coding is ProblemaMc
Ø ImplementaMon Policies and Procedures Adopted by the Providers
Ø Programs Cannot Evaluate the Medical Necessity of the Elements Listed in the EMR
Ø QuesMon-‐Was it Reasonable and Necessary to Evaluate Those Organ Systems?
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RECOMMENDATIONS TO IMPROVE CODING
Ø EMR Generates a Suggested Code and Preliminary RecommendaMon-‐Provider Can Accept or Edit
Ø EMR Suggests Diagnosis Codes Which Provider Can Accept or Edit
Ø Coding Teams Are Ubiquitous in Hospitals and Offices Today
Ø Diagnosis Coding Drives Hospital Reimbursement
Ø Crucial That The Charge Capture System Only Bills For Services Rendered and Not All Things Ordered
Ø Now The Move Towards DocumenMng Outcomes As Reimbursement Will Be Tied to That Metric
EMR
Ø ConnecMvity to Other EMRs
Ø Labs and Imaging Results
Ø Viewing Images
Ø Addendum to the Note
Ø EdiMng the Note Ø Tampering With The Note-‐Screen Shots-‐Metadata
Ø EducaMng The Provider-‐Improve Competence-‐Crah The CharMng To Your PracMce
Ø ArMficial Intelligence, Clinical Decision Making, Diagnosis and Coding Assistance
NOTIFICATION OF RESULTS ORDERED
Ø Labs Ø Imaging
Ø Cultures Ø Specimens to Pathology
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COMMUNICATIONS WITH OTHER PROVIDERS
Ø Office Notes and Labs and Imaging From Referring Providers
Ø Consultant Notes From Specialists
Ø ConfirmaMon That Referral was Received by Other Office and Appointment was Made
Ø NoMficaMon That PaMent Could not be Reached or Missed Their Appointment
SCANNING INFORMATION INTO THE EMR
Ø ConverMng From Paper to Electronic IniMally
Ø What to Import and What not to Import?
Ø Entering Received Results –Labs, Imaging and Clinic Notes, DictaMon
Ø Reviewing Newly Received Data Prior to it Being “Filed”
NOTIFICATION TO PATIENTS OF RESULTS
Ø Who is Responsible to “Ask For” vs. “NoMfy” the PaMent of All Test Results?
Ø List or “Tickler File” of PaMents Who Have Pending Test Results
Ø Who is Looking For and NoMfying the PaMents?
Ø Are They Knowledgeable of What is “Normal” and “Abnormal”?
Ø Memorializing the Acknowledgement and NoMficaMon to the PaMent of the Test Results
Ø MemorializaMon of the Plan of Treatment or Follow-‐Up
Ø MemorializaMon of PaMent Discussions Regarding Treatment Plan or Informed Consent
CONCLUSIONS
Ø Technology ConMnues to Advance and Improve
Ø The EMR Has Already Improved The Storage of PaMent Data
Ø The EMR Has Improved PaMent Safety
Ø The EMR Will ConMnue to Alter the Provider-‐PaMent RelaMonship
Ø EMRs Are Not Foolproof-‐Will Always Have Human Errors and Systems Errors
Ø Certain Aspects of EMRs Can Open Providers Up to Increased Liability
Ø Providers Should Tailor The EMR to Their Own Unique PracMce Habits
REFERENCES
Ø Electronic Health Records: How to Avoid Digital Disaster. Susan R. Gering. 16/Mich. St. U. J. Med. & L. 297 Ø Challenges With The Electronic Medical Record. Robert H. Ossoff, Christopher D. Thomason, Julie Appleton.
12 No. 6 J. Health Care Compliance 51 Ø Electronic Medical Records: A PrescripMon for Increased Medical MalpracMce Liability? Blake Carter. 13 Vand.
J. Ent. & Tech L. 385
Ø Electronic Medical Record DocumentaMon: Inherent Risks and Inordinate Hazards. Timothy P Blanchard, Margaret M. Manning. 2016 Health L. Handbook
Ø Electronic Medical Records and E-‐Discovery: With Every New Technology Come New Challenges. Jeffrey L. Masor. 5 HasMngs Sci. & Tech L. J. 245
Ø The Legal Challenge of IncorporaMng ArMficial Intelligence Into Medical PracMce. Amanda Swanson, Fazal Khan. 6 J. Health & Life Sci. L. 90
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THANK YOU
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