ehr documentation: truth or consequences webinar

KAREO | CONFIDENTIAL @GoKareo; #KareoTip

EHR Documentation: Truth or Consequences


Your Hosts Today…

Barbara Drury,BA, FHIMSS, and President, Pricare, Inc.

Lea ChathamContent Marketing Manager, Kareo


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Our Schedule for Today…

1 Introduction & Welcome Barbara

2 EHR Documentation: Truth or Consequences

3 Discover Kareo’s Role

4 Answer Questions


Barbara Drury, BA, FHIMSS

Health information technology consultant

Speaks and writes on office-based computer systems for groups like MGMA, HIMSS, & AHIMA

Appointee to the ONC’s Technical Expert Panel on Unintended Consequences of HIT adoption

Fellow of the Healthcare Information and Management Systems Society

Serves on the HIMSS Public Policy Committee

Recipient of the December 2004 and April 2009 Spirit of HIMSS award

Barbara Drury, BA, FHIMSSPresident, Pricare, [email protected]






4 Answer Questions


Your EHR Documentation is…..

…the truth, the whole truth and nothing but the

truth! …OR

…you “nose” the rest of this story!


Talking Points

1. Who uses your EHR data

2. Assumptions about our EHR documentation

3. Sources of EHR Data

4. Shared responsibilities

5. Implications if Geppetto or Pinocchio


Direct, Point of Care Users

All Clinical Staff, based on permissions Accuracy: Human interpretation of data Accuracy: System interpretation of data

Access For data entry For clinical decision-making For orders and results among interfaced systems System of systems (labs, hospitals, HIEs,

clearinghouses, etc.)

Influenced by the system: Design Setup and options User Behavior


Who else cares?

End Users

Patients

Payers

Government

Security & Privacy

Lawyers

HIM Personnel

Vendors


EHR Data in Exchanges!

HIE (health information exchange)

Main Office

Billing, Scheduling, and EHR

HIE (RHIO, NwHIN, DIRECT, others)

Pathology Consultant

s

Research or Studies

Quest Labs

Lab Corp

Claims Clearinghou

se

Payer/Plan Eligibility

Cerner Hospital

McKesson HospitalMeditech

Hospital

External Physician

Offices

Diagnostic Centers


Typical Shared EHR Data = ROI(Release of Information, aka Request for Records)

• Referral for Specialty care: Outbound from PCP (active), Inbound to consulting Physician (passive)

• Transfer of Records: May be Outbound triggered by patient request (active) or may be Inbound (passive) to the patient’s intended new Physician.

• Legal Request: User request Inbound (passive). Release Outbound (active)

• One ‘little’ task with variations!

OUTBOUND: Actively initiated by an information creator

INBOUND: Passive recipient of information from another


PAPERWorkflow Characteristics for Information Releases (ROI) in a Provider Office

A. Care Coordination

D. Patient

YesConsent or request initiated by patient or another for Itemized Information to be Released

Yes Yes By Another Yes

YesOutbound Release of Information (ROI), Actively initiated by Provider

Yes Yes No No

YesInbound receipt of information, Passively received by Provider, by Patient, or by Another

Yes Yes No No

StaffReview of the patient-initiated or another written consent or request for release of information

Staff Staff Staff Staff

ProviderApproval of the information to be released in alignment with the written consent or request

Provider Provider EHR

StaffAssembly of the information to be released, redacting per written consent or request

EHR EHR EHR EHR

StaffFinal harmonization of the written consent or request and the assembled information prior to the release.

<gap> <gap> <gap> <gap>

Fax or mail

Protected health information is released EHR EHR EHR EHR

YesConfidentiality is dependent upon written label such as "confidential" or a similar sensitivity flag


UsuallyDetails of the workflow are addressed in Policies and procedures and are current.


Typical workflow in an all-paper

physician’s office or an EHR office

prior to Meaningful Use

Release of Information Workflow pre-EHR


“Who” is typically involved in ROI?

Information Users

PRIMARY: Point of Care Users of Medical Record Information

SECONDARY: Other Users of Medical Record Information

EXPANDED: Users of Medical Record Information

PatientSpecific care team member(s)Business ServicesPayers (private and government)AttorneysPublic HealthEHR VendorsData Repository VendorsHIE VendorsPopulation Health SurveillanceCertification/Regulatory BodiesResearchers


PAPERWorkflow Characteristics for Information Releases (ROI) in a Provider Office

A. Care Coordination

B. Transfer of Records

C. Secondary or Extended

UsersD. Patient

YesConsent or request initiated by patient or another for Itemized Information to be Released

Yes Yes By Another Yes

YesOutbound Release of Information (ROI), Actively initiated by Provider

Yes Yes No No

YesInbound receipt of information, Passively received by Provider, by Patient, or by Another

Yes Yes No No

StaffReview of the patient-initiated or another written consent or request for release of information

Staff Staff Staff Staff

ProviderApproval of the information to be released in alignment with the written consent or request

Provider ProviderProvider and

AdvisorsEHR

StaffAssembly of the information to be released, redacting per written consent or request

EHR EHR EHR EHR

StaffFinal harmonization of the written consent or request and the assembled information prior to the release.


Fax or mail

Protected health information is released EHR EHR EHR EHR

YesConfidentiality is dependent upon written label such as "confidential" or a similar sensitivity flag


UsuallyDetails of the workflow are addressed in Policies and procedures and are current.


Workflow Characteristics for Information Releases (ROI) in an EHR Meaningful Use Physician Office

EHR ROI: Human, EHR System, and ???

Most importantly, do you KNOW what is or has been released by the EHR?


And while you weren’t looking…..

Electronic

Footprint

… Metadata, aka Evidence


“159” Entered at: 11:17:10

Data: What you see (or not)

159 90Logged in User ID: bdruryUser Logged in Time: 11:05:32

“90” entered at: 11:16:02Device ID: wacnx3400-5

“195” entered at: 111558

Range alert: High ValueAlert Time: 11:16:06Alert Action: acknowledged“195” Deleted at: 11:16:47


Possible Sources of “159”

• Device or User in your exam room

• Device or User in your office

• Another Device with a unique calibration and time stamp

• PHR submitted by patient or representative

• Directly by the physician entering into EHR

• Through an HIE from another EHR

• Verbally from patient or representative

• From separate system, i.e. Surescripts

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Data TimeHeight 08:00:11Weight 08:00:11Smoking History 08:00:11Temp 99.3 08:00:11Chief Complaint 08:00:11Resp 18 08:00:11Pain "8" 08:00:11BP 136/89 08:01:47Pulse 74 08:02:55Assment SKIN 08:03:38Assment NEURO 08:04:44Lab Order 08:11:51Send to lab name 08:11:51Result Due Date 08:11:51Pulse 69 08:46:31Pain "0" 08:46:31Next appointment 08:46:31Appt Reason 08:46:31EHR Signed 09:55:29 Real time? Near-real-time? Or hours later?

Operations and/or Evidence

Staff probably wrote info on a paper form. Subsequently went to a monitor to enter what

was on the paper form. System saved at "08:00:11". Not possible to actually 'enter'

disparate data simultaneously.

Staff could have written info on paper and entered at four different times. Also possible,

that the time stamp actually reflects the original times when the data was collected AND entered.

Real time? Near-real-time? Or hours later?

Real time? Near-real-time? Or hours later?

Which Story Does the Data “tell”?


Talking Points







Assumptions Often Made:

A. The EHR (data) is accurate

B. The view presented is complete

C. It’s “my record”

D. The data tells a coordinated story

E. The system does (or does NOT collect) data

F. The EHR vendor is responsible


A. The EHR (data) is accurate

We never make entry errorsNo one else ‘used’ the erroneous dataEHR vendors understand HIM principlesThe system has archive and purge toolsThe system reflects the truth of care process

RFP

GI


B. The View is complete

No known allergies

5 Wishes, copy, w/spouse


C. It’s “my record”

Signer wins, no other authors matterMake me the author, removes any othersAll authors essential for proper useOthers not necessary for proper use It’s better than nothing!

MDs

MDs


D. Data Tells Coordinated Story

Interfaces between systems are thoroughly tested

Users in one area (billing) never edit data from another area (ICDs, CPTs)

HIEs and PHRs appropriately integrate inbound data with all/any provenance

Patient correctly and accurately participates in data collection

Barbitol

Phen/penta


E. The system does (not) collect…

Each EHR has different on-board tools with different ‘handles’

Audit log optional—often separate data base and server

Access log, disclosure log as defined by MU (does not equal “audit log”)

Permission levels to preserve metadata integrity

Electronic footprint available only through e-discovery or forensics.


F. The EHR Vendor is Responsible (NOT!)

Contractually, EHR vendor is indemnified by user and disclaims any responsibility.

Contractually, EHR user agrees to update all clinical logic and represents that he/she is an expert EHR user.

From the HITECH regulations, “tools such as clinical decision support and drug interaction checking must be ‘on’ but should not be relied upon.”


Talking Points







No Magic to Data Creation•Data = the “answer” to an item or question

•Structured (codes or format) or unstructured (free text)?

•How often must this data be created?

•How much does this data change?

•When is it most efficient to create data?

•How will the data be used later?

•What tools does your EHR use “most” of the time to create “most” of the data?


Data Creation Methods

Type

Dictate

Handwriting Rec

Drop down lists

Buttons/Boxes

Virtual key pad

Digital Device

System Creates

+- /+- /+

--

- /+

Add NOK

--

+-/+-/+--+

Blood Pressure

+-

+/--

- /+--

+/-

Start Time

+/-+/-

+/-+/-+/-++

+/-

Problem Diagnosis

--


Using the Data Later

Type

Dictate

Handwriting Rec

Drop down lists

Buttons/Boxes

Virtual key pad

Digital Device

System Creates

YesYesYesYesYesYes

Display?

Yes

+/-

+/-No

-/+YesYes

+/-

Count?

Yes

+/-

YesYesYesYesYesYes

E-Discovery?

Yes

Yes


Data Provenance or Metadata“Provenance” is:

User, date and time, Includes a legal signerNot too hard to see or find

“Metadata” is:Data about the dataGoes beyond “provenance”Actions by user and by systemOld answer, new answerIncludes permissionsIncludes privacy tagsLimited to admin usersUsed to re-construct ‘the story’Increases storage costs and litigation costs


Talking Points






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It takes two to tango!

•Is the functionality available? (the System Design)

•Are you using it? (the Setup Options)

•Are you using it appropriately? (the User’s Behavior)

•Is it executing as you expect? (the System)

THE USER

THE EHR


Shared Responsibilities (or not):

EHRs: Multi-dimensional primary and secondary data:

1. Software Design

2. Set-up Options, Implementation

3. Operations, User Behaviors


Software Design Risks

• System built views (too small, usability, hidden sections)

• Changes to master templates impact previously closed records that used that template

• Unclear system ‘cues’ such as “Close”, “Save”, “Lock”, “Final”, “Sign”, “Done”

• Amendment or version process and subsequent views and outputs

• Non-standardized formats, structured or unstructured data, SOAP or unique, CCD or CCR as data or PDF, etc.

• Errors that are acceptable to the vendor with safety or evidence implications


Risk Issues related to Documentation Quality, Reliability, Truth

Why don’t we?

B Budget: Many of these decisions have a cost.

T Technology: Complexity beyond capabilities.

S Safety: Not obvious.

E Evidence: Overlooked.


Scanning without adding pertinent data to activate clinical rules

Turning tools off such as ‘audit logging’

Turning off ‘charge-pass’ (using paper tickets that may contradict EHR)

Not setting up chart-specific privacy to mirror patient consents

Over customization = user confusion, data gaps

Scribe role versus user logins

Katrina-proof options

Fail to update all EHR software

Permit ‘auto’ use of WNL for ROS/PE

Fail to establish an electronic chart retirement process

S B

E BB T

S E

S EE T

B TB T

S EE T

Risk Issues, cont.


Workflow and EHR Use (and Users)

• TimelinessReal time, Near real time, within xx hours or daysBest practice or more efficient

• Sequence or order of desired workflow

• Routine/primary responsible ‘author’ Operationally and legally

• Secondary consequences of workflow: Completeness for the next user Represents ‘truth’ of care process in outputs Represents ‘truth’ of care process in evidence


Work-arounds and Testing Tasks • Confirm ‘what’ e-information for what purposes

• Confirm ‘how’ the EHR gathers the appropriate data

• Affirm through testing that the EHR is including or excluding appropriately based on purposes

• Affirm through testing how the e-information is received (what, format, accuracy, completeness, HIPAA compliant)

• Revise technology and workflow to incorporate system ‘silos’ into the complete clinical record.

• Train physicians and staff on documentation for all purposes

• Update Procedures & Policies to reflect EHR uses


Talking Points







What You Can Do to Minimize Surprises• Review before you sign

• View before you share

• Do ask and do tell if logic or truth seem confusing or mis-represented by data

• Actively participate and don’t assume

• HITECH was a job stimulus bill, not a patient safety or data quality initiative

• Embrace the electronic technology but wear your seatbelt at all times!

• Ultimately, the EHR Software is NOT responsible – You are!


• Shared prioritiesSmall bites that are prioritized, not all at onceIncrementally more difficult or comprehensive

goalsReward, celebrate, identify the ‘stick’Constantly ‘look’ at EHR data in all it’s versions– On the screen

– Printed

– Pdf copies to each other

– Reports (CQMs, PQRS, MU, production)

• Value the act of monitoring the story of your patient’s care, not just the act of data creation

EHR Data = Moving Target, but….


What are your users doing in the EHR?

Will the ‘proof’ be in the EHR as you expect or hope?


What’s the ‘right’ answer?

Please describe to:__(choose one)_____, the due diligence that you took in choosing,

training, using and monitoring this EHR?

- Patient- Clinical User- EHR Vendor- CMS, payer- Records- Quality efforts- HIPAA Officer- Defense Attorney- Plaintiff Attorney- Jury


Why did Pinocchio’s nose get longer?

• Confused

• Stress

• Didn’t know what was right and what was wrong

…..words often associated with an EHR implementation!


Your EHR Documentation should pass the “Geppetto” test

…the truth, the whole truth and nothing but the

truth!






4 Answer Questions


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EHR Documentation: Truth or Consequences

ehr documentation: truth or consequences webinar

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