BULLETIN LifeWays Community Mental Health Electronic Medical Record Bulletin October 2014

Transcription

1 BULLETIN LifeWays Community Mental Health Electronic Medical Record Bulletin October 2014 Dear LEO Users, In an effort to offer your more information on the EMR, the monthly LEO Bulletin has been signi icant revised. We have heard your feedback on how helpful the it is to receive written noti ication of EMR system changes. We have also learned how this bulletin serves as a primary communication channel to our end users, and therefore wanted to spruce it up. The bulletins will now include educational content to remind you of some basic features of LEO, a spotlight topic to provide direct education on a key area, an overview of both planned and implemented system changes, and links to helpful websites related to health information technology. Aside from this change, we have many other developments to share. We have successfully recorded a test training on the LEO system using new software, which means users will have access to recorded trainings that they can view from their desk. The goal is to have a library of pre recorded trainings available on various forms and modules. We are also convening our irst EMR Change Control Committee after the new year. This will provide users with a voice and role in the system change management process, so you can tell us on what s needed for the EMR reach its full potential. We hope you enjoy this new edition! Kindest regards, Nikki Adkins Director of Quality Improvement & Technology Services LifeWays In This Issue EMR Change Control Committee EMR Website Virtual Trainings Spotlight: Security October System Changes Data Quality Report

2 User Manuals Did you know that LEO includes 43 User Manuals and technical resource documents? Please access the Help button in the header of LEO for assistance. Change Control Committee LifeWays plans to host an EMR Change Control Committee beginning in January The membership of this group will include a diverse set of users from providers and LifeWays. The scope of work includes: Strategic Enhancements Training Development Data Integrity & Standards Change Management & Evaluation The irst meeting is tentatively scheduled for Tuesday, January 6, 2015 from 2:00 PM 3:30 PM in the LifeWays Pine Room. A call for participants will begin in November/December 2014 to secure one representative from providers and programs. If you have questions, please contact Nikki Adkins. LifeWays EMR Website LifeWays maintains an EMR page on our public website where you can access: Historical EMR Bulletins LEO Training Environment Data Completeness Reports In the future! Recorded Trainings Please visit this page anytime you are looking for EMR information: Help Desk The LEO community is growing and we have lots of experts in the ield! Please reach out to your peers and colleagues if you need help. There is also a LEO Help Directory in the Help button that includes which staff at LifeWays can assist you by topic area. If you are still having dif iculties, contact the Help Desk at (517) You may also submit a ticket for technical assistance using the Help Desk Module within LEO. LEO Messages LEO has an internal Message system that works just like e mail to communicate with other users of the system. This is a secured system to where consumer speci ic information can be shared for the purpose of treatment coordination, payment or operations. However, it is advised that the LEO Message system is NOT used for general e mails that are not consumer speci ic. Communication not consumerspeci ic should be conducted through the LifeWays primary e mail system (@lifewayscmh.org).

3 Blank Prints Do you need a blank version of the forms in LEO for attaching to procedures or using in the ield when you are without a computer? Visit the Blank Prints menu in LEO for a full list of forms that can be generated as blank prints in PDF format. Clinical Dashboard Did you know that there s a clinical dashboard in LEO for easy access to your favorite areas? Check it out! To ind it in LEO, visit Staff To Do List / Clinical Dashboard. From one place you can access: Clinical Statistics Messages Quick Action Links My Case Load Recently Accessed Consumers Today s Appointments Virtual Trainings Beginning November 2014, LifeWays will provide virtual trainings on various aspects of the LEO system. The trainings will be scheduled live or offered through a pre recording. Details on the training topic will be sent out in advance. Registration is not required. LifeWays will be using a new software product GoToMeeting to host the training. Tentative Training Topics: To Do Items Unsigned Documents Provider Administrator Medical Records Data Errors Reporting Services Incident Reports Training is always available through our IT Help Desk. To request a training or report training suggestions, please contact the Help Desk at (517)

4 User IDs and Passwords Take a moment to consider how secure is your login and password? This is your #1 responsibility in protecting con idential information. Consider these secure password practices: Keep password secure and con idential to all others. Create strong passwords using alpha, numeric and special characters. Change the password completely when prompted by the system or if security has been compromised. Spotlight Topic: Security Acceptable Use of the EMR LifeWays plans to implement an acceptable use agreement that all users will be required to sign initially and annually. The purpose of the agreement is based in security policies to ensure that users are informed of and agree to the acceptable uses of the EMR. Areas that will be covered include: LEO is property of LifeWays LEO is strictly used for job related purposes All information in LEO is con idential Access to information must be minimum necessary User ID and passwords must not be shared Unauthorized access is prohibited Actions in LEO are audited User Setup and Permissions New users are setup by the LifeWays IT Help Desk or by a Provider Administrator at the provider agency. This is a highly privileged function and high ethical standards and practices must be applied in this role. The administrator that is setting up permissions shall always operate in a minimum necessary position and not give unnecessary permissions. Lock the computer workstation when stepping away from your device every time. This can be done by using Ctrl Alt Delete and then selecting Lock this Computer. Do not share password with others. Do not write down the password. Do not allow others to log in as you. Do not allow other people to watch you type your password. Do not save your password in your internet browser. Passwords are set to expire every 90 days in the EMR. If you forgot your password, you can use the link Forgot My Password on the login screen to reset it and obtain a temporary password. If you have been locked out due to too many unsuccessful attempts, you will need to contact the IT Help Desk at to reset you account. Physical Controls Users are responsible for maintaining the physical security of their workstation that is used to access the EMR and protected health information. This includes: Immediately locking the device when not in use. Closing doors when away from the of ice where the device is located. Placing devices out of site when traveling (e.g. truck of car). Password protecting the device for user authentication. Being aware of the immediate surroundings and

5 risks. Minimum Necessary Rule Users are created with very speci ic access to areas in the EMR based on their position and function. It is expected that the user access only the minimum information that is necessary to complete their job function. The actions carried out by users in the EMR are logged and recorded. This includes all attempts to read, write and delete data. LifeWays reserves the right to review the audit trails to determine if the access level is necessary and appropriate. Audit trail reports are available to LifeWays System Administrators on the IT team. Access to Records Users are granted access to case records in LEO based on their af iliation with a service location. LifeWays or the designated Provider Administrator is responsible for assigning the user to a location and grating functional access. Location assignments must be done with great care and caution. Users shall not be assigned to locations in which they are not employed. Once assigned to a speci ic location by LifeWays or the Provider Administrator, the user will have access to the consumer records that are assigned to that location. Case records within the assigned location must be accessed on a need to know basis. Simply having access to the ile does not grant the user rights to review protected health information. Once the case is closed, the provider and assigned staff will have limited view only access to the case in LEO for a period of 90 days. The 90 day window is intended to provide the user with limited access in order to complete inal claims submission and clinical documentation activities. After the 90 day period, the system will automatically restrict access to the record and the user is forbidden from accessing the consumer s electronic medical record. If future access of the record is required (e.g. court request, SSA documentation), the IT Help Desk can grant temporary view only access upon request. Users leaving the agency must have their LEO account inactivated on the day of termination. This can be performed by the IT Help Desk or Provider Administrator. Questions? Nikki Adkins Director of Quality Improvement & Technology Services LifeWays CMH (517) Nikki.Adkins@lifewayscmh.org References: LifeWays Operating Procedure Electronic Medical Record Management U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) U.S. Health Information Technology for Economic and Clinical Health Act of the American Recovery and Reinvestment Act of 2009 Termination of Access It is expected that users complete a discharge summary immediately when it is known that their organization will no longer serve the case; a discharge summary will close out permissions. The IT team may request a discharge summary from the provider to properly close from the case. LifeWays reserves the right to conduct an administrative closure of agencies or users to remove access to a case record when there is a period of inactivity. The purpose is to minimize case access to only users that are authorized for service delivery and are activity serving the case.

6 requested to move to LEO documentation for MST progress notes; customizing a form to meet the MST elements. 6. MST Discharge Form Providers have requested to include MST elements in the Life Ways discharge to meet MST program requirements. Test System Changes Plan Stage De inition: Process of identifying customer needs and desired outcomes. 1. UM Clinical Record Review Tool Form is being inalized by MSHN and will be programmed into LEO for UM to conduct their routine clinical record reviews and communicate improvement opportunities to the service provider. 2. Access Follow Up Queue Queue will be created to place follow up requests in a queue based on certain values in a form. Design Stage De inition: Creating the architecture of the requested enhancement. 1. Crisis Plan Workgroup changes are being inalized to move towards a standardized crisis plan that is used by all providers and the Access Center for enhanced coordination. 2. Treatment Plan Lean PCP changes are being designed to improve the content and low of the treatment plan form. 3. Treatment Plan Addendum Lean PCP changes are being designed to improve the content and low of the treatment plan form. 4. MST Intake Assessment Changes are being designed to the intake assessment to capture the MST elements and streamline the process. 5. MST Weekly Progress Note Providers have Stage De inition: Reviewing and testing the proposed change to ensure that it meets the customer expectation, usually in a simulated environment. 1. RN Monitoring Note RN staff providing monitoring and vital sign services (Integro) will use a new form that documents progress and populates the vital sign area of the medical chart for enhanced data collection. 2. Residential Assessment (aka PC/CLS worksheet) Users are testing the new residential assessment in the development system and providing feedback on inal changes before move to production system. 3. Formal Review Users are reviewing the changes made to the formal review based on the Lean PCP project. 4. Pre Plan for PCP Meeting Users are reviewing the changes made to the pre plan based on the Lean PCP project. 5. Secondary Provider Summary of Progress Users are reviewing the new form created based on recommendations from the Lean PCP project. Deploy Stage De inition: Transitioning to real time use of the change in the production environment. 1. User Acceptable Use Agreement Users will be required to sign an annual acceptable use agreement within the LEO system to attest to proper use of the EHR. 2. Medication Delivery Services (MDS) Monthly/Treatment Team Review (Advanced Care) New form has been approved and deployed to the production system. Training has occurred with Advanced Care team. Treatment team members can review the note to determine how the consumer is progressing with med drop services. Path to access form: Medication Delivery Services / MDS Treatment Team Review 2. CEHR Patient Portal Consumers can now access a Patient Portal that allows them to view basic information and send a message to their pri

7 mary case holder. Instructions are attached to this bulletin. 3. Consumer Budget Reports Budgets can be printed for the consumer during the treatment plan process. This is to inform them of the potential cost of services. Path to access form: Treatment Plans Menu / View and Develop Consumer Treatment Plans / Search for Consumer Name / Treatment Plans / Print Consumer Budget Report Improve Stage De inition: Evaluation of the effectiveness of the system for continuous improvement and value. 1. Authorizations: Due to Security Enhancements the Early Termination and Voiding of Authorizations will no longer be available to Providers. Your request must be made via a helpdesk submission by Supervisor or by contacting the LifeWays Utilization Management Department. The Authorization request process has not changed. 2. Lab Orders: Pregnancy Test Serum and Urine have been added to the Rapid Lab Orders within the Medical Chart section of LEO. 3. Financial Determinations are being scanned into the All Scanned Documents location and per the Life Ways Eligibility Specialist these documents should be scanned into the appropriate section of LEO known as the Financial Determination section. If you have any questions regarding the Financial Determination process please contact Brenda Lewis, Network Eligibility Specialist at Discussions within LEO charts must be used with Caution as IT cannot delete part of the Discussion if a response was made on the wrong consumer. The entire Discussion must be deleted and staff will need to re enter the appropriate information in a chart note. 5. Add Medication to Drug Catalog Providers please submit your requests for the Catalog to Deana Yates Life Ways Physicians Manager II, or Caitlyn Yanakeff LifeWays Physicians Manager I. Questions? Nikki Adkins Director of Quality Improvement & Technology Services LifeWays CMH (517) Nikki.Adkins@lifewayscmh.org

8 Data Quality Report LifeWays and its provider network are required to report certain demographic data elements to the Michigan Dept. of Community Health on the consumers we serve. These demographic elements are submitted through a QI File each month and have certain completeness standards and quality checks that are mandated by the Department. To assist you in meeting these expectations, we have created a Data Requirement Technical Guideline and Data Quality Report Card. LifeWays highly recommends designating a person at your agency with the responsibility to manage the Data Quality Control module within LEO, which will identify critical areas that need your immediate attention. Click here to open the Data Requirement Technical Guideline. Pending October 2014 Data Quality Completeness Report. Questions? Sally Vainner Database Administrator LifeWays (517) Contact Us LifeWays CMH Jackson Of ice 1200 N West Avenue Jackson, MI Hillsdale Of ice 25 Care Drive Hillsdale, MI Help Desk (517) Administration (517) Visit us on the web at Additional Resources HealthIT.gov HHS Health Information Privacy LEO System Michigan Health Information Network (MiHIN) Michigan Health IT LifeWays EMR Web Page: leoelectronicmedicalrecord.html LifeWays LEO Training Environment: EMR Procedure: images/07_01_03_electronic_medical_record_management.pdf Data Integrity Standards for EMR Records: images/ LEO_Quality_and_Integrity_Standards_for_Electronic_Medical_Records_Rev_ pdf Use of Disclosures of PHI Procedure: images/07_02_06_use_and_disclosures_of_protected_health_information.pdf