Electronic Health Records: Recognizing and Managing the Risks

Size: px
Start display at page:

Download "Electronic Health Records: Recognizing and Managing the Risks"

Transcription

1 Caims cinica & risk management perspectives October 2009 Eectronic Heath Records: Recognizing and Managing the Risks CME Information Sponsored by: NORCAL Mutua Insurance Company. NORCAL Mutua Insurance Company is accredited by the Accreditation Counci for Continuing Medica Education to provide continuing medica education for physicians. Method and Medium To obtain CME credit, read the enduring materia artice, and compete and return the attached activity Evauation and CME Attestation Form no ater than the expiration date indicated beow. Origina Reease Date: October 2009 Expiration Date: October 31, 2010 Learning Objectives By reviewing the cases presented in this course and impementing the risk management recommendations, you wi increase your abiity to: Adopt and adhere to eectronic communication and documentation standards. Utiize the EHR system productivey whie continuing to impement patient safety practices, such as doube-checking medication dosages, using an effective foow-up system and reviewing records for accuracy. Deveop poicies and procedures specificay reated to training in the safe use of the EHR system. Target Audience A providers Credit Designation Statement NORCAL Mutua Insurance Company designates this educationa activity for a maximum of 1 AMA PRA Category 1 Credit Ṭ M Physicians shoud ony caim credit commensurate with the extent of their participation in the activity. Discosure Poicy As an ACCME accredited provider, NORCAL Mutua Insurance Company requires panners, reviewers or authors who infuence or contro the content of a CME activity to discose financia reationships (of any amount) they have had with commercia interests associated with this CME activity during the year preceding pubication of the content. Any identified conficts of interest are resoved prior to the commencement of the activity. Discosures Individuas invoved in the panning, reviewing or execution of this activity have indicated they have no reevant financia reationships to discose. Editor Mary-Lynn Ryan Consuting Risk Management Speciaist, NORCAL Content Advisors David R. Hoey, MD Chairman, NORCAL Board of Directors Harry B. Richardson, Jr., MD Vice Chairman, NORCAL Board of Directors Wiiam R. Vetter, MD Secretary, NORCAL Board of Directors Patricia A. Daiey, MD NORCAL Board of Directors Michae Stephens NORCAL Board of Directors Newe E. Warde, PhD NORCAL Board Advisory Counci Executive Director,Rhode Isand Medica Society James Sunseri President & CEO, NORCAL Stephen M. Farber Vice President, Risk Management, NORCAL Nei Simons Vice President, Underwriting-Marketing- Poicyhoder Services, NORCAL Jane Tishkoff, Esq. Associate Vice President and Assistant Genera Counse, NORCAL Marene Nazarey, RN, MSN Manager, Risk Management, NORCAL Dustin Shaver Manager, Risk Management, NORCAL Paua Snyder, RN, CPHRM Manager, Risk Management, PMSLIC John Resetar Supervisor, Caims Department, NORCAL Panners Jo Townson Risk Management Speciaist, NORCAL Sonia Rutherford Risk Management CME Program Services Coordinator, NORCAL

2 Introduction Eectronic heath records (EHRs) hod great promise of improving patient safety and decreasing medica iabiity exposure, but their use is creating a variety of new risk management and patient safety issues. Some of these issues are directy associated with EHRs (e.g., providers disregard warnings generated by the EHR), but many of the risk concerns associated with EHRs are anaogous to probems that currenty exist in paper documentation systems. In this month s Caims Rx we present a number of shorter-than-usua case studies that exempify various aspects of unsafe EHR documentation and communication practices. The scenarios are based on NORCAL cosed caims, facts presented in appeate opinions, research findings and the observations of NORCAL Risk Management Speciaists. What many of the exampes show is that EHRs do not eiminate many of the dangerous documentation and communication practices that have historicay ed to patient injury and mapractice awsuits. Consequenty, whie it is important to address new issues that arise with EHRs, many of the risk management recommendations that appy to a paper-based documentation system remain vaid. This Caims Rx wi discuss the risks associated with various aspects of EHRs and wi provide guidance for instituting poicies and procedures designed to enhance the quaity and safety of patient care, whie diminishing professiona iabiity risk. Federa EHR Incentive Program In February of this year, President Barack Obama signed the American Recovery and Reinvestment Act (ARRA), which sets aside $17.2 biion doars of the economic stimuus package for incentive payments to Medicare and Medicaid providers who impement EHRs according to standards that are projected to be avaiabe by the end of 2009.* The payouts begin in Eary adapters who can demonstrate meaningfu use of EHRs (among other features, the system must have e-prescribing, can connect with other EHRs and can report cinica quaity measures) are eigibe for the highest reimbursement amounts. The reimbursement amount diminishes by year, up through For Medicare providers, the payout maximum is $44,000 over five years. For Medicaid it is neary $64,000 over six years. In 2015, providers who cannot demonstrate meaningfu use may have their Medicare rates diminished by 1%. This increases to 2% in 2016 and 3% in 2017 and may rise even higher in future years. Medicaid does not have a simiar penaty structure. As coud be expected, EHR vendors are aggressivey marketing their products. It can take over a year to get an EHR system up and running, so being eigibe for the 2011 stimuus payment coud be a rea chaenge for someone who waits too ong to make the initia EHR investment. It is important, however, to consider severa aspects of the incentive payment egisation before investing in an EHR for the purpose of coecting a 2011 reimbursement. For exampe, the rues coming out at the end of the year are supposed to further define meaningfu use and are expected to detai the nature of physician-to-physician data exchange requirements, describe cinica quaity measures that must be reported to the U.S. Department of Heath and Human Services (HHS) and describe the process of certification.* Despite the possibe oss of the first incentive payment, providers are urged to carefuy consider which EHR is appropriate for their practice and aow an appropriate amount of time for training and roing out the new system. CaimsRx page 2

3 Federa EHR Incentive Program (continued) EHR Impementation Resources A variety of organizations provide further information on the various aspects of converting from paper to eectronic records, incuding: Joint Commission The Joint Commission pubished Safey impementing heath information and converging technoogies, Sentine Event Aert 42, December 11, 2008, which makes patient safety recommendations reated to EHR impementation. It is avaiabe on the Joint Commission Web site at: (accessed 8/24/2009). American Academy of Famiy Physicians (AAFP) Through its Center for Heath Information Technoogy Web site, the AAFP offers advice on every step of an EHR conversion: (accessed 8/24/2009). References * Mariyn Lamar, Esq. Embracing benefits, facing risks with EHR technoogy. Presented by ASHRM on 8/4/2009. Stephen H Carson, MD. Eectronic Heath Record: Beware. San Joaquin Physicians. Summer Robert Lowes. Experts Offer EHR Advice in Light of New Federa Incentives. May 14, Avaiabe on the Medscape Web site at: (accessed 8/24/2009). Data Entry Errors EHRs may decrease errors caused by uninteigibe handwriting, but they cannot be expected to eradicate human error. Providers are encouraged to question EHR information that does not seem right (e.g., abnormay high medication dosages, radiographic images that are not consistent with the patient s anatomy, etc.) and attempt to reconcie conficting information. Saving Images in the Wrong Patient s Chart Just as an image can be misfied or ost in a paper system, it can be misfied in an eectronic one. However, as the foowing case shows, it can be ess obvious that an image has been misfied in an eectronic system. Case Study Patient #1 and patient #2 both presented to the Emergency Department (ED) compaining of abdomina pain. CT scans of the abdomen and pevis were competed for both patients. A radioogy tech mistakeny gave patient #2 s images the identification number assigned to patient #1 and upoaded the images into the Picture Archiving Computer System (PACS). A short time ater, the tech reaized his mistake and caed the on-duty teeradioogist to te him about the mistake and request that the misabeed images be deeted from the system. However, the on-duty teeradioogist did not have access to deete images from the PACS; this had to be done by the PACS administrator. The tech then corrected the abeing probem and sent the images out to the teeradioogy service for a preiminary review and resent the correcty abeed images to the PACS. Patient #1 s PACS fie now contained both his own and patient #2 s images. A few days ater the tech tod his supervisor about the misabeing, and assumed that the supervisor woud remedy the probem. Pursuant to hospita poicy, the tech shoud have immediatey contacted the PACS administrator. The teeradioogy service reported that patient #1 s CT scan was norma. Patient #2 s CT scan, however, showed a arge tumor (about the size of a grapefruit) on the patient s kidney. The service faxed the reports to the radioogy department at the hospita. (continued on page 4) CaimsRx page 3

4 ( Data Entry Errors... continued from page 3) The next morning, the on-duty radioogist reviewed the PACS images from the night before. He disregarded the teeradioogy service reports because they did not correspond to what he saw in the PACS. Because patient #2 s scan had been competed before patient #1 s, patient #2 s images were the first series in his fie. The on-duty radioogist noted the arge tumor and dictated a note. Because patient #2 s images sti carried patient #1 s identification number, the radioogist s report was assigned to patient #1. Patient #1 was subsequenty seen by a number of speciaists for the supposed tumor on his kidney. Seven days after the CT scan, he underwent a nephrectomy. During the surgery, no mass coud be positivey identified on his kidney by his surgeons. Postoperativey, no tumor was identified in the removed kidney and pathoogy returned benign. (Pease note, once the fiing mistake was recognized, patient #2 was notified and underwent a timey and successfu nephrectomy.) Discussion A combination of system probems and communication issues ed to this patient s unnecessary surgery. It probaby never woud have occurred if the tech had either foowed the poicy of aerting the PACS administrator of his error or had had the capacity to deete an image that he had misabeed. He shoud have known that neither the teeradioogist nor his immediate supervisor woud be abe to deete images from the PACS. The probem was compounded by the radioogy department s ateration of the EHR system. In its atered state, two series of images automaticay opened up on two viewing screens one screen showing the scout fims and the other screen showing the cuts. The radioogists needed to cick on a sma button on one of the monitors marked series to see any other fims. In this case, the radioogist did not suspect any other fims were taken, so he had no reason to cick on the series button. Another probematic issue was the radioogist s faiure to ook further into why the PACS images he saw were entirey inconsistent with the fax report he received from the radioogy service. He was in the habit of disregarding the service s reports because he thought they were consistenty inaccurate. Lasty, the surgery team went through with the nephrectomy despite the surgeon recognizing that the patient s anatomy did not correspond to the CT image on the wa that showed a very arge tumor. Risk Management Recommendations If something in the EHR does not make sense, doube check it. Do not assume that the information is correct simpy because it is in the EHR. If you make a mistake in a person s record and have to depend on someone ese to correct it, go back to the patient s record to confirm that the record has been appropriatey corrected. Continuay assess whether EHR reconfigurations increase patient safety and reduce professiona iabiity risk exposure; if they don t, find aternative means to achieve needed aterations to the system. Ensure that staff and cinicians are aware of EHR poicy and that they are foowing it. Checking the Wrong Box In the foowing case, the appearance of the computer screen probaby payed a roe in the medication error. Case Study A patient presented to his primary care physician (PCP) for the treatment of headaches and episodes of atered consciousness. The PCP prescribed amitripyine at 10 mg nighty. The PCP tod the patient to escaate the dosage by 10 mg every three to four days unti the pain was reieved, but not to exceed 50 mgs without consuting him. When creating the prescription, the PCP intended to check off the 10-mg box in the computerized physician order entry (CPOE), but inadvertenty checked the 100-mg box, which was right above it. In the medication instructions section, he indicated that five pis coud be taken per night, so the patient woud not have to return to the pharmacy and pay an additiona co-pay if he utimatey needed the arger dose. Caims Rx page 4

5 The pharmacist had noticed that the dose seemed high and requested that a ca be made to the PCP prior to it being dispensed. A nurse at the PCP s office picked up the ca, and because she was very busy that day, tod the pharmacy to dispense the medication as it had been ordered she did not check the dose. Three days ater, the patient took five of the 100-mg pis together. Eary the next morning, the PCP was contacted by an emergency department (ED) physician who reported that the patient was in the ED reporting dizziness, an atered state of consciousness, an inabiity to coordinate his movements and a rapid heartbeat. He was further informed by the ED physician that the patient had taken five 100-mg amitripyine tabets. The PCP then checked the patient s record and reaized his mistake. Discussion In this case, the nurse assumed that because the dosage had come from the system, it was correct. As this case indicates, however, a typographica error can be as dangerous as iegibe handwriting. It is important to recognize probems with an EHR and attempt to get them soved so they are ess ikey to resut in treatment errors. For exampe, in this case, the provider coud contact his EHR vendor and attempt to work out a way to move the check boxes associated with dosage amounts further apart on the drug ordering screen or have a pop-up box that confirms the ordered medications before cosing out of the record. Genera Medication Transcription Risk Management Recommendations In addition to appropriatey foowing up on dosage questions (which the nurse in this case obviousy did not do), an EHR system shoud be configured to appy the risk management tactics that appy to paper records, and when such functions are not avaiabe, paperrecord tactics shoud be used in making entries in the eectronic record: Incude a brief notation of the purpose on a prescription orders (e.g., for cough), uness considered inappropriate by the prescribing physician. Record a prescription orders in the metric system except for therapies that use standard units such as insuin, vitamins, etc. Incude age and, when appropriate, weight of the patient on the prescription or medication order. Incude drug name, exact metric weight or concentration and dosage. Aways precede a decima expression of ess than one with a eading zero. Do not use a termina or taiing zero after a decima. Avoid using abbreviations incuding those for drug names (e.g., spe out unit and internationa unit rather than writing U or I.U. ; use daiy or every other day, whichever is appicabe, not q.d. or q.o.d. ). m The Institute for Safe Medication Practices (ISMP) pubishes a ist of unacceptabe abbreviations and symbos, which is avaiabe on the ISMP Web site at: (accessed 8/24/2008). Typing the Wrong Dose Athough some EHR systems fag medication doses that are abnormay high, as the previous and the upcoming case studies show, there are dosage errors that wi sip through the cracks. Case Study A 75-year-od man presented to a cardioogist s office to estabish care. He had a history of moderate pumonary hypertension, hyperipidemia, chronic gout, gaucoma, choecystectomy, and presbycusis. The patient had been taking various medications, incuding a 0.25-mg Xanax tabet prior to schedued appointments to reieve his anxiety. The medica assistant (MA) responsibe for rooming the patient took the patient s copy of his medication ist and noted that the patient was taking Xanax (aprazoam) 2-mg tabs prn in the eectronic medica record. The prescription for Xanax 2 mg tabs prn was refied at the patient s pharmacy. Three months ater, the patient presented to his ophthamoogist. Prior to the appointment, he took a 2-mg Xanax tabet to aeviate his anxiety. On his way home he fe aseep behind the whee and crashed into a tree. After the accident, the physician reviewed the (continued on page 6) Caims Rx page 5

6 ( Data Entry Errors... continued from page 5) patient s medica record and recognized that the MA had entered Xanax 2 mg tabs prn. Unfortunatey, the physician had gotten into the habit of signing off on the medica assistant s entries without reay reviewing them. Discussion The foregoing case exampe shows that caution must be used when recording patient information, even when it is captured and entered into an EHR. The physician in this case reied on an MA to accuratey transcribe the patient s medication ist into the EHR, and there was no verification process in pace. Once the origina entry made it into the patient s record, it was never reviewed. Transcription errors are often caused by cerica staff members who misunderstand an order or have difficuty reading an origina document because of iegibiity. 1 According to one study, mutifaceted intervention invoving providers and patients can significanty improve medication ist discrepancies in an eectronic medica record. Essentia interventions in the study incuded maiing etters to patients before appointments to remind them to bring a medication bottes or an updated medication ist to their cinic visit and having the patient verify the most recent medication ist in the eectronic medica record. Athough these methods significanty reduced discrepancies, they did not competey eiminate them. The study authors recommended further system designs such as medication cards and/or nurse- or software-aided coection of medication ists from patients before visits. 2 Risk Management Recommendations Ensure that a icensed heathcare professiona doube-checks medications transcribed into an eectronic medica record. Institute procedures that reguary update and reconcie patient medication ists. Mai etters prior to appointments asking patients to bring in a prescription medications and overthe-counter medications to appointments. m Generate an eectronic medication ist and compare the eectronic ist to the medication bottes whie the patient is in the office. If patients do not bring in medication bottes, enist the patient to ensure the accuracy of the eectronic medica record medication ist. m Ask the patient to compare the medication ist generated from an eectronic record with medication bottes at home. System-Assisted Documentation The issue of incompete/inaccurate documentation takes a variety of forms in the EHR arena. Functions in an eectronic record that were designed to save time have created a whoe new set of risk management issues. Case Study A 50-year-od woman presented to the ED compaining of neck and eg pain. The ED physician did his exam from the doorway of the patient s room using his tabet PC. He checked off items on the eectronic T-sheet whie he asked a few basic questions. It took him ess than one minute. Out of curiosity, an ED nurse who was present reviewed his documentation. She found that there was a comprehensive assessment documented. 3 Discussion The foregoing case study provides an exampe of documentation that uses a tempate to sef-generate certain aspects of the patient s record. This EHR function (aso referred to as an expoding note ) aows users to pu up a tempate for a particuar condition and then check boxes indicating norma or abnorma vaues or observations. An examination note in paragraph form is then produced for the EHR. In the foregoing case, the ED physician was engaging in a practice that may be considered frauduent biing by the Centers for Medicare and Medicaid Services (CMS). From a medica iabiity standpoint, if this physician s treatment came into question, it woud be difficut for him to convincingy support the adequacy of his assessment. If sef-popuating forms are used, it is important to go through the entire form and ensure that the note that has been created accuratey refects the patient s condition. Caims Rx page 6

7 A practice referred to as coning can resut in simiar documentation inaccuracies. Coning refers to copying information from an earier exam and pasting the information into the record for a current exam. This can occur in the same patient s chart or between different patients. Athough it is considered appropriate to copy a compex medica history from an earier exam, providers shoud not use coned content for a patient s history of a present iness, the exam or the medica decision-making process and particuary not for a different patient. 4 Using the EHR to document treatment that did not occur or to inappropriatey cone notes diminishes the integrity and usefuness of the medica record. Providers are under pressure to see as many patients as possibe whie keeping the customer satisfied. It is important to remember that the primary function of an EHR is to manage data it does not repace compex decision-making or face-to-face contact with the patent. Whie taking advantage of time-saving features provided by an EHR might be tempting, the issue of patient safety shoud remain centra. Breach of Confidentiaity of Medica Information The breach of confidentiaity of medica information happens with paper medica records. EHRs, however, aow for a eve of breach that is inconceivabe at the paper-record eve. Case Study 5 An MA observed her sister-in-aw enter an examination room. Against cinic poicy, the MA accessed the patient s medica record and discovered that the patient had requested testing for sexuay transmitted diseases because she had a new sex partner. She aso earned that the patient was diagnosed with a sexuay transmitted disease. Later that week, the MA and her sister created a MySpace page that incuded the patient s picture and the sexuay transmitted disease information from her medica record. Discussion The foregoing case exampe was taken directy from a 2009 Minnesota Appeate Court opinion. It exempifies the ease with which a person with bad intentions can access an eectronic medica record and pubicize confidentia information. Even individuas with benign intentions technicay vioate patient privacy when they casuay browse through patient records for no medica purpose. Having a security poicy that incudes password usage is a first ine of defense against unauthorized access to patient medica information. Unfortunatey, a password aone does not protect confidentiaity when the password hoder is untrustworthy or has poor judgment. There is probaby no fai safe way to keep medica information confidentia, but there are ways to make it more difficut for cinicians and staff members to inappropriatey access information, incuding: 6 Add additiona ayers of access restrictions (for exampe, in addition to a password, the person accessing the record must have a particuar job or must be part of a particuar team of providers). Impement two-factor user authentication add a second, physica proof for access. (A bank ATM card is an exampe of a widey used form of two-factor authentication. It requires the combination of a PIN and a vaid card for access.) Put protocos in pace that define which staff members need access to the EHR and the eve of access that is appropriate. Do not aow password sharing. Change passwords frequenty. Review audit reports weeky or monthy to show who has accessed the medica records, during which hours and for which functions. Create a medica information confidentiaity poicy. Consistenty discipine peope who vioate confidentiaity poicies. Because technoogy continues to become more sophisticated, it is important to reguary reevauate the appicabiity of security protocos. Communicate reguary with vendors and IT staff to ensure state aw and HIPAA heath information confidentiaity compiance. 7 Caims Rx page 7

8 Curbside Consutations Emai conversations between providers add a new dimension to the risks associated with curbside consutations. Case Study A 64-year-od uninsured man was under the care of a famiy practitioner for mutipe heath issues, incuding an aortic murmur, high bood pressure, high choestero and diabetes. A CT scan reveaed an aortic thrombus. The physician emaied the scan and report to a friend who was a vascuar surgeon, asking for treatment recommendations. The surgeon recommended that an angiogram be performed to further evauate the thrombus. The physician repied back that the patient was uninsured and that an additiona test woud be too expensive. As an aternative, the surgeon suggested the patient be paced on warfarin. The physician cut and pasted the surgeon s recommendation from the ater emai into the patient s medica record. Based on the vascuar surgeon s recommendation, he initiated warfarin therapy at 2.5 mg per day. He conducted routine Prothrombin Time (PT) and Internationa Normaized Ratio (INR) testing. After five months of therapy, the patient s dose was set at 10 mg per day. One repeat CT scan was done after four months of therapy, reveaing that a thrombus was sti present at the same ocation. The patient coud not afford additiona testing, so the physician never ordered another CT scan. Two years after the patient had started on warfarin a series of unfortunate events ed to him dying shorty after being hospitaized for warfarin overdose. Discussion Paintiff s experts were critica of both the famiy practitioner and vascuar surgeon for the patient being paced on anticoaguation therapy without a forma consutation. They beieved that, at a minimum, a vascuar surgeon needed to review the patient s medica records and fims to give an opinion regarding the patient s condition. The vascuar surgeon had no idea that his casua recommendation woud become part of the patient s chart. It was additionay disturbing to find that his initia recommendation for an angiogram did not get pasted into the patient s chart. Risk Management Recommendations Formay consut with speciaists when necessary and document consutations in the patient's chart. Recognize that informa consutations are based on incompete information and take pace without the benefit of review or examination of the patient. Do not repace a forma consutation with a curbside consut. When emaiing coeagues, reaize that correspondence may become part of the patient s medica record. Labe the emai with a statement regarding whether you are providing a forma consutation. Inadequate EHR Training Inadequate training can increase iabiity risk, diminish patient safety, decrease productivity and resut in user frustration. Intensive training on the EHR is particuary important during transition from a paper record, but it is aso necessary on an ongoing basis to ensure user competency. As the foowing case shows, a heathcare entity must not ony ensure empoyee EHR competency, but it shoud aso ensure the EHR competency of independent contractors who use the system. Case Study On Juy 1, 2006, the patient, a 45-year-od man with a history of thyroid cancer, presented to the ED compaining of groin pain. A chest x-ray and a CT scan of the abdomen and pevis were ordered. Radioogist #1 reported that the chest x-ray showed a 3-4-mm noduar opacity in the eft upper obe of the ung, which he thought might be a sma granuoma. Radioogist #2 noted a 9-mm pumonary nodue in the eft ower obe of the ung on the CT Scan. Due to a series of miscommunications, these resuts were entered directy into the patient s eectronic record and his PCP was never informed of the resuts. Months ater, radioogist #3 interpreted another chest x-ray and noted a faint noduar density in the eft upper obe of the ung. Radioogist #3 thought this was equivoca and so informed the PCP. After speaking with radioogist #3, the PCP ogged onto the radioogy department s Web site. He brought up the patient s Juy 1 Caims Rx page 8

9 chest x-ray, but coud not see any irreguarities. He then attempted to access the Juy 1 abdomina CT images, but he had troube manipuating the icons. He was, however, abe to access the abdomina CT report. Because much of the upper obe overaps the ower obe, the PCP assumed that the nodue mentioned in the CT report was the upper obe density that radioogist #3 had tod him was equivoca. Three years ater the patient was diagnosed with ung cancer in the ower eft obe, where the density had been identified three years earier. Discussion This caim was compicated by the fact that the hospita was transitioning to an eectronic medica record system. Unfortunatey, the PCP did not obtain training on the system. His inabiity to fuy access his patient s information contributed to his faiure to adequatey foow up on the 2006 chest x-ray and CT scan resuts. Risk Management Recommendations Have a transition pan in pace that is reaistic and adequatey communicated to any provider who treats patients at your faciity or refers patients to your faciity for testing or treatment. Provide adequate training and technica support. m If providers are expected to use an eectronic medica record system, make avaiabe training opportunities with ongoing support. Ensure heathcare team member EHR proficiency. m Conduct audits and foow-up on identified weaknesses. m Provide refresher courses as necessary. Provide an environment where heathcare team members fee empowered to request assistance. Reguary assess and monitor errors and near misses. Evauate the cause of the probems and address them. 7 Faiure to Check EHR or Emai Inbox A probem minimay reated to the eectronics of communication, but more reated to an individua s persona practice, is not reguary checking one s EHR and emai inbox for test resuts. The issue is akin to not deaing with an inbox overfowing with paper. An interesting recent study found that having an EHR that deivers a test resuts via emai in offices without adequate foow-up processes actuay can increase the chance that a physician wi not receive significant resuts. In other words, in a paper-system office with inadequate foow-up processes, the chances of a test resut being noticed on a physician s desk are greater than are the chances of that test being discovered in a physician s EHR or emai inbox. 8 If your practice is using the EHR or emai for test resut deivery, it is important to have a poicy in pace that describes how frequenty providers must check their inboxes and the process by which resuts are then communicated to the various parties who need to see them. For a more detaied discussion about test resut communication, see the May 2009 Caims Rx entited Faiure to Appropriatey Communicate Abnorma Test Resuts, which is avaiabe on the NORCAL Web site at: may_09.pdf (accessed 8/25/2009). (continued on page 10) Caims Rx page 9

10 ( Faiure to Check EHR or Emai Inbox... continued from page 5) Patient-Physician Emai Correspondence Guideines The use of emai is becoming more common between providers and their patients. Various medica associations have pubished guideines for physician-patient eectronic communication. Incuded beow are a combined seection of emai correspondence recommendations from the American Medica Association and the Caifornia Medica Association:* Estabish a turnaround time for messages. Use an automatic repy function to acknowedge receipt of the patient s message and to warn patients against emaiing regarding urgent matters. Inform patients about the information privacy and security imitations of emai. Inform patients about who (other than the provider) is responding to emais. Retain and integrate eectronic and/or paper copies of emai communications with patients in their medica record. Estabish poicies that deineate the types of transactions (prescription refi, appointment scheduing, etc.) and sensitivity of subject matter (HIV, menta heath, etc.) that are permitted in emai correspondence. Te patients to indicate their main objective (e.g., prescription refi, biing issues) in the subject ine of the message. Instruct patients to incude their name, insurance pan, and patient identification number either in the subject ine or in the body of the message. Inform patients when their request has been competed. Instruct patients to use an autorepy feature to acknowedge receipt of the provider s message. Deveop emai retention, archiva and retrieva poicies and procedures. Do not send group maiings where recipients are visibe to each other; use a bind-copy emai function. End each emai message with the provider s fu name, contact information, reminders about medica information security and warnings about emai communication for emergencies. Request that patients send concise messages. If emai messages from a patient become engthy, confusing or if the correspondence is proonged, ask the patient to discuss the issue in person or on the teephone. Advise patients that abiding by the emai poicies is a condition of continued emai communication. Because emai becomes part of the medica record, and even if deeted it remains on the system, providers are encouraged to utiize the same conventions that woud be empoyed for any other patient communication. For exampe, avoid anger, sarcasm, harsh criticism, and ibeous references; use proper grammar; and check speing. Resources * AMA Guideines for Physician-Patient Eectronic Communications. Avaiabe on the AMA Web site at: member-groups-sections/young-physicians-section/advocacy-resources/guideines-physician-patient-eectronic-communications.shtm (accessed 8/24/2009). Physician Web sites, internet advice and emai. CMA On-Ca Document #0823. January Avaiabe on the Caifornia Medica Association Web site at: (accessed 8/24/2009). Caims Rx page 10

11 Turning Off the System s Warning Messages Case Study Isaac, et a. performed a retrospective anaysis of 233,537 medication safety aerts generated by 2,872 cinicians in Massachusetts, New Jersey, and Pennsyvania who used a common eectronic prescribing system. From January 1, 2006, through September 30, 2006, the system warned physicians neary 230,000 times about potentia drug interactions. Ninety percent of the time the physicians who received these warnings proceeded as if the aert had not appeared. 9 Discussion Most EHRs offer medication aerts. The objective of these aerts is to warn the person prescribing or ordering a medication of potentia adverse drug interactions, aergic reactions, etc. Unfortunatey, EHR aert technoogy has not deveoped to the point of fu utiity. As the study above indicates, a majority of physicians turn off or routiney override the aert function because it adds itte vaue to them or their patients. As the technoogy catches up to the needs of the peope who must use it, providers are encouraged to be cautious when disabing or overriding a system s aert functionaity. In the event of mapractice itigation arising from a medication error, the record of aerts that have been turned off or seectivey overridden may be difficut to expain to a judge or jury, especiay when heeding an ignored warning coud have prevented the patient s injury. 10 Risk Management Recommendations Work with vendors to create an aert system that is as usabe as possibe. Deveop a system of aerts that aows cinicians to determine their urgency and reevancy. Review which aerts are overridden and determine whether these need to be hard stops (aerts that cannot be overridden). Document the decision-making process. 7 If you do not use the aert system of an EHR, use an aternative system for determining whether the patient woud be exposed to aergy or drug interaction risks. Document the resut of your efforts. Faiure to Obtain Buy-in from Every Member of the Heathcare Team Some providers wi not make the change to EHR, regardess of the incentives offered or the penaties assessed. What is an individua decision for one, however, can affect an entire group s recordkeeping practice. There are vaid arguments on both sides of the EHR impementation debate, but if the impementation decision has been made and one or more providers refuse to use it, the issue cannot be ignored. Note-taking foowed by ater transcription can ead to deays and/or inaccuracies. Some practices have managed this situation by assigning a scribe to a physician who either cannot or wi not use an EHR. Athough this woud obviousy be an expensive way to manage the situation, it highights the fact that there are creative ways to work around buy-in probems. Concusion Because of the compexity of the many soutions and options avaiabe and the unique needs of each practice, panning, research and training are critica to the successfu conversion from paper to eectronic records. Providers are encouraged to impement and appropriatey update poicies and procedures that address the iabiity and patient safety risks that are particuar to these new and constanty improving technoogies, whie continuing to appy risk management strategies that have been effective in a paper-based system. Caims Rx page 11

12 CPOE (Computerized Physician Order Entry) Risks Identified in a Recent Study A 2005 JAMA artice discusses a study that focused on medication errors faciitated by CPOE in a major urban tertiary-care teaching hospita with 750 beds, 39,000 annua discharges, and a widey used CPOE system operationa there from 1997 to The authors found that the CPOE system at this hospita faciitated 22 types of medication errors, as iustrated by the foowing: Physicians reied on the CPOE dispays to determine the minima effective or usua doses, but those doses were based on the pharmacy s warehousing and purchasing decisions, not on cinica guideines. For exampe, where a usua dosage was 20 or 30 mg, the pharmacy woud stock 10-mg doses, which resuted in 10-mg units being dispayed on the CPOE screen. Physicians then ordered 10-mg doses for patients, mistakeny beieving that it was the usua dosage. Physicians ordered increased or decreased doses of medications without discontinuing current dose because they mistakeny beieved that ordering the new dose woud automaticay discontinue the current dose in the system. Physicians ordered medications that were associated with a particuar procedure or test, but if the procedure or test was canceed, the system did not automaticay cance the medication. Consequenty, patients received unnecessary medications. Because medication charting was cumbersome and the screen dispays were fragmented, immediate orders and give as needed medications (P.R.N.) were often not entered into the system and not canceed as directed. This resuted in patients receiving unintended doses. Because reapprova stickers were paced in the paper chart and physicians primariy used the CPOE to order antibiotics, unintentiona gaps occurred in patient antibiotic therapy. The CPOE required physicians to identify diuents for administering antibiotics, but the physicians were not aware of interactions between some diuents and antibiotics. This generated precipitates and other probems. Aergy information was deayed because physicians ignored warnings and depended on pharmacists for checking drug aergies. Physicians seected the wrong patient record because the names were cose together, the font was sma, every screen did not contain the patient s name and patients were isted aphabeticay, instead of by teams or rooms. The wrong medication was ordered because the patient s medication information was not synthesized on one screen. Getting a of the medication information sometimes necessitated going through 20 screens. Because a physician was not ogged out of a patient s record, the patient whose record was sti active got a medication intended for a different patient. Because the EHR canceed preoperative orders and required numerous steps to activate orders foowing surgery, postsurgica medication was deayed. Caims Rx page 12

13 CPOE (Computerized Physician Order Entry) Risks Identified in a Recent Study (continued) Because of system crashes and maintenance, drug ordering was deayed. If a patient was moved whie the system was down, medications went to the new patient in the patient s former room. A cumbersome interface made contemporaneous drug administration recording difficut, resuting in drug administration being charted at the end of the shift and consequenty providing physicians with inaccurate information about when the medication was administered. Based on their findings, the authors made the foowing recommendations: Do not direct cinica actions with CPOE if it causes patient care to deteriorate. Examine the technoogy to determine if it is working effectivey. Fix the technoogy if it is counterproductive. When a medication error occurs, ook for the weakness in the way the system works instead of assuming the error was the resut of human error. Expect and pan for revisions and quaity improvement. Reference Koppe R., et a. Roe of Computerized Physician Order Entry Systems in Faciitating Medication Errors. JAMA. 2005;293(10): Endnotes 1 Leape LL, Bates DW, Cuen DJ, et a. Systems anaysis of adverse drug events. JAMA. 1995;274: Varkey P, Cunningham J, Bisping S. Improving Medication Reconciiation in the Outpatient Setting. The Joint Commission Journa on Quaity and Patient Safety. May Voume 33 Number 5. 3 Case study based on Tempated Charting The Sippery Sope to Frauduent Documentation, Friday, October 12, Avaiabe on the ERMurse Bog at : (accessed 8/24/2008). 4 Compiance Risks Grow with Eectronic Medica Record Systems. (accessed 8/24/2009). 5 Case study based on Yath vs. Fairview Cinics, et a. 767 N.W.2d 34; 2009 Minn. App. LEXIS 117 (2009). 6 HIPAA Security Guidance for Remote Use. Avaiabe on the U.S. Department of Heath and Human Services Web site at: (accessed 8/24/2009). 7 Safey impementing heath information and converging technoogies. Sentine Event Aert 42, December 11, Avaiabe on the Joint Commission Web site at: (accessed 8/24/2009). 8 Casaino R, et a. Frequency of Faiure to Inform Patients of Cinicay Significant Outpatient Test Resuts. Arch Intern Med. 2009;169(12): Isaac T, Weissman S, Davis R, Massagi, Cyruik A, Sands D, Weingart S. Overrides of Medication Aerts in Ambuatory Care. Arch Intern Med. 2009;169(3): Shay E. Eectronic heath records in itigation. Pubished September Avaiabe on the Physician s News Digest Web site at: (accessed 8/24/2009). Caims Rx page 13

14 A Bright Invention from NORCAL Introducing MyCME from NORCAL Mutua. Review our wide array of risk management resources and services. Register for and compete CME courses at your convenience. Submit your Attestation Form onine. Print transcripts and certificates everything from one easy-to-navigate website. Our passion protects your practice Learn more at or ca , ext 2244.

15 560 Davis Street, Suite 200 San Francisco, CA Prsrt. Std U.S. Postage PAID Permit #751 San Diego Inside... Eectronic Heath Records: Recognizing and Managing the Risks Caims cinica & risk management perspectives October 2009 New CME Podcast avaiabe at Now you can earn CME credit wherever you are with Compex Regiona Pain Syndrome a new CME podcast avaiabe excusivey from NORCAL Mutua. Go to and cick on podcast to downoad and isten to this new CME activity NORCAL Mutua Insurance Company. Reproduction permissibe with written permission and credit. Direct inquiries to: NORCAL Mutua Insurance Company Risk Management Department 560 Davis Street, Suite 200 San Francisco, CA (800) The information in this pubication is obtained from sources generay considered to be reiabe; however, accuracy and competeness are not guaranteed. The information is intended as risk management advice. It does not constitute a ega opinion, nor is it a substitute for ega advice. Lega inquiries about topics covered in this pubication shoud be directed to your attorney. Guideines and/or recommendations contained in this pubication are not intended to determine the standard of care, but are provided as risk management advice. Guideines presented shoud not be considered incusive of a proper methods of care or excusive of other methods of care reasonaby directed to obtain the same resuts. The utimate judgment regarding the propriety of any specific procedure must be made by the physician in ight of the individua circumstances presented by the patient. Visit NORCAL Mutua on the Internet at 687J-RM

16 Caims Rx Evauation and CME Attestation Form Eectronic Heath Records: Recognizing and Managing the Risks Reease Date: October 2009 Expiration Date: October 31, 2010 In order to receive CME credit,* you must fi out this form in its entirety and return it to NORCAL Mutua by the expiration date above. For instant access to your CME certificate, go to og-in to MyNORCAL and cick on MyCME. You may access this enduring materia and submit the form eectronicay. Aternativey, you can mai or fax this (paper) form to receive your CME certificate in 7-10 business days. Name: Address: Phone: Emai: NORCAL Mutua poicy number (Required for CME credit): *Receipt of CME credit is imited to NORCAL poicyhoders. Target Audience: A providers. 1. Educationa Outcomes: Overa, degree to which the materia presented is appicabe in your practice setting: Not appicabe Very appicabe 2. Appication of Risk Management Strategies By providing risk management and patient safety-based strategies, this CME activity is designed to reduce your risk exposure associated with the impementation and utiization of an EHR system. To demonstrate your abiity to appy or utiize the risk management recommendations herein, pease seect the strategies you pan to impement or currenty utiize in your practice (mark the box yes or no for each): Risk Management Strategies Yes No Ensure you/your staff members and cinicians are aware of and abide by EHR poicies and procedures. In emai exchanges with patients and other providers, utiize proper grammar and punctuation and avoid anguage that is not considered appropriate within physician/patient communications. Remain vigiant regarding patient foow-up; do not rey soey upon EHR features. Review records for accuracy, paying specia attention to possibe errors reated to auto-popuate features. Work with your EHR vendor to design an aert system that is meaningfu, and one that minimizes inappropriate or fase aerts that might condition users to routiney override or ignore warnings. 3. Other Strategies to Minimize Risk The October Caims Rx focuses on the physician risks associated with the use of an EHR system. Risks that can be associated with the use of an EHR system incude: inaccurate data entry; unauthorized access; disregard of warnings; iabiity via emai consutations; inadequate training; and faiure to foow up on abnorma ab vaues. Recognizing that physician users pay an integra part in the success of an EHR system, we addressed the risk areas of communication, foow-up and documentation at the provider eve. However, system changes that promote quaity and risk management must take pace as we for the physician behaviora change to continue successfuy. For additiona information, pease visit our Web site at or contact the Risk Management Department at (800) , ext Was this activity free of commercia bias? Yes No CME Attestation I attest that I participated in this CME activity and caim credits (use quarter hour increments) of AMA PRA Category 1 Credit TM up to a maximum of one credit (hour). Signature Date (mm/dd/yy) You may submit this form onine at Or you can mai or fax it to: Attention: Risk Management, NORCAL Mutua Insurance Company, 560 Davis Street, Suite 200, San Francisco, CA 94111, Fax: (415)

Early access to FAS payments for members in poor health

Early access to FAS payments for members in poor health Financia Assistance Scheme Eary access to FAS payments for members in poor heath Pension Protection Fund Protecting Peope s Futures The Financia Assistance Scheme is administered by the Pension Protection

More information

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services

A Description of the California Partnership for Long-Term Care Prepared by the California Department of Health Care Services 2012 Before You Buy A Description of the Caifornia Partnership for Long-Term Care Prepared by the Caifornia Department of Heath Care Services Page 1 of 13 Ony ong-term care insurance poicies bearing any

More information

Australian Bureau of Statistics Management of Business Providers

Australian Bureau of Statistics Management of Business Providers Purpose Austraian Bureau of Statistics Management of Business Providers 1 The principa objective of the Austraian Bureau of Statistics (ABS) in respect of business providers is to impose the owest oad

More information

professional indemnity insurance proposal form

professional indemnity insurance proposal form professiona indemnity insurance proposa form Important Facts Reating To This Proposa Form You shoud read the foowing advice before proceeding to compete this proposa form. Duty of Discosure Before you

More information

READING A CREDIT REPORT

READING A CREDIT REPORT Name Date CHAPTER 6 STUDENT ACTIVITY SHEET READING A CREDIT REPORT Review the sampe credit report. Then search for a sampe credit report onine, print it off, and answer the questions beow. This activity

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these

More information

ELECTRONIC FUND TRANSFERS. l l l. l l. l l l. l l l

ELECTRONIC FUND TRANSFERS. l l l. l l. l l l. l l l Program Organization = Number "1060" = Type "123342" = "ETM2LAZCD" For = "502859" "TCCUS" "" Name "WK Number = Name "First "1001" = "1" Eectronic = "1001" = Financia "Jane Funds Doe" Northwest Xfer PG1

More information

Internal Control. Guidance for Directors on the Combined Code

Internal Control. Guidance for Directors on the Combined Code Interna Contro Guidance for Directors on the Combined Code ISBN 1 84152 010 1 Pubished by The Institute of Chartered Accountants in Engand & Waes Chartered Accountants Ha PO Box 433 Moorgate Pace London

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES About ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account. Some of

More information

Human Capital & Human Resources Certificate Programs

Human Capital & Human Resources Certificate Programs MANAGEMENT CONCEPTS Human Capita & Human Resources Certificate Programs Programs to deveop functiona and strategic skis in: Human Capita // Human Resources ENROLL TODAY! Contract Hoder Contract GS-02F-0010J

More information

Annual Notice of Changes for 2016

Annual Notice of Changes for 2016 Easy Choice Best Pan (HMO) offered by Easy Choice Heath Pan, Inc. Annua Notice of Changes for 2016 You are currenty enroed as a member of Easy Choice Best Pan (HMO). Next year, there wi be some changes

More information

DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS

DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS DOING BUSINESS WITH THE REGION OF PEEL A GUIDE FOR NEW AND CURRENT VENDORS TABLE OF CONTENTS INTRODUCTION... 1 GOVERNANCE... 1 COMMONLY PURCHASED GOODS AND SERVICES... 1 HOW TO REGISTER YOUR COMPANY...

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these

More information

NCH Software MoneyLine

NCH Software MoneyLine NCH Software MoneyLine This user guide has been created for use with MoneyLine Version 2.xx NCH Software Technica Support If you have difficuties using MoneyLine pease read the appicabe topic before requesting

More information

Avaya Remote Feature Activation (RFA) User Guide

Avaya Remote Feature Activation (RFA) User Guide Avaya Remote Feature Activation (RFA) User Guide 03-300149 Issue 5.0 September 2007 2007 Avaya Inc. A Rights Reserved. Notice Whie reasonabe efforts were made to ensure that the information in this document

More information

Order-to-Cash Processes

Order-to-Cash Processes TMI170 ING info pat 2:Info pat.qxt 01/12/2008 09:25 Page 1 Section Two: Order-to-Cash Processes Gregory Cronie, Head Saes, Payments and Cash Management, ING O rder-to-cash and purchase-topay processes

More information

Example of Credit Card Agreement for Bank of America Visa Signature and World MasterCard accounts

Example of Credit Card Agreement for Bank of America Visa Signature and World MasterCard accounts Exampe of Credit Card Agreement for Bank of America Visa Signature and Word MasterCard accounts PRICING INFORMATION Actua pricing wi vary from one cardhoder to another Annua Percentage Rates for Purchases

More information

Accreditation: Supporting the Delivery of Health and Social Care

Accreditation: Supporting the Delivery of Health and Social Care Accreditation: Supporting the Deivery of Heath and Socia Care PHARMACY E F P T O L P E D P E C M F D T G L E F R Accreditation: Supporting the Deivery of Heath and Socia Care June 9, 2015 marks Word Accreditation

More information

PREFACE. Comptroller General of the United States. Page i

PREFACE. Comptroller General of the United States. Page i - I PREFACE T he (+nera Accounting Office (GAO) has ong beieved that the federa government urgenty needs to improve the financia information on which it bases many important decisions. To run our compex

More information

How to deal with personal financial problems

How to deal with personal financial problems How to dea with persona financia probems D I S P U T E R E S O L U T I O N Introduction Heping you face the future with confidence In 2014, the eve of consumer debt in the UK grew to reach a seven-year

More information

INDUSTRIAL AND COMMERCIAL

INDUSTRIAL AND COMMERCIAL Finance TM NEW YORK CITY DEPARTMENT OF FINANCE TAX & PARKING PROGRAM OPERATIONS DIVISION INDUSTRIAL AND COMMERCIAL ABATEMENT PROGRAM PRELIMINARY APPLICATION AND INSTRUCTIONS Mai to: NYC Department of Finance,

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow some of which may not appy your account Some of these may

More information

l l ll l l Exploding the Myths about DETC Accreditation A Primer for Students

l l ll l l Exploding the Myths about DETC Accreditation A Primer for Students Expoding the Myths about DETC Accreditation A Primer for Students Distance Education and Training Counci Expoding the Myths about DETC Accreditation: A Primer for Students Prospective distance education

More information

Teamwork. Abstract. 2.1 Overview

Teamwork. Abstract. 2.1 Overview 2 Teamwork Abstract This chapter presents one of the basic eements of software projects teamwork. It addresses how to buid teams in a way that promotes team members accountabiity and responsibiity, and

More information

Qualifications, professional development and probation

Qualifications, professional development and probation UCU Continuing Professiona Deveopment Quaifications, professiona deveopment and probation Initia training and further education teaching quaifications Since September 2007 a newy appointed FE ecturers,

More information

Key Features of Life Insurance

Key Features of Life Insurance Key Features of Life Insurance Life Insurance Key Features The Financia Conduct Authority is a financia services reguator. It requires us, Aviva, to give you this important information to hep you to decide

More information

Frequently Asked Questions

Frequently Asked Questions Community Heathcare Organisations Report & Recommendations of the Integrated Service Area Review Group Frequenty Asked Questions 1. What are Community Heathcare Services? Community Heathcare Services are

More information

Preschool Services Under IDEA

Preschool Services Under IDEA Preschoo Services Under IDEA W e don t usuay think of Specific Learning Disabiities in connection with chidren beow schoo age. When we think about chidren age birth to six, we think first of their earning

More information

On-Line Banking Application

On-Line Banking Application OnLine Banking Appication 1st Name: SSN/Tax ID #: Work Phone: City born in: Fax: Mother's Maiden Name: Emai Address: 2nd Name: SSN/ax ID#: Work Phone: City born in: Fax: Mother's Maiden Name: Emai Address:

More information

A short guide to making a medical negligence claim

A short guide to making a medical negligence claim A short guide to making a medica negigence caim Introduction Suffering from an incident of medica negigence is traumatic and can have a serious ong-term impact on both the physica and menta heath of affected

More information

The BBC s management of its Digital Media Initiative

The BBC s management of its Digital Media Initiative The BBC s management of its Digita Media Initiative Report by the Comptroer and Auditor Genera presented to the BBC Trust s Finance and Compiance Committee, 13 January 2011 Department for Cuture, Media

More information

Immunisation of healthcare and laboratory staff

Immunisation of healthcare and laboratory staff 12 of heathcare and aboratory staff Heath and safety at work Under the Heath and Safety at Work Act (HSWA) 1974, empoyers, empoyees and the sef-empoyed have specific duties to protect, so far as reasonaby

More information

Chapter 3: JavaScript in Action Page 1 of 10. How to practice reading and writing JavaScript on a Web page

Chapter 3: JavaScript in Action Page 1 of 10. How to practice reading and writing JavaScript on a Web page Chapter 3: JavaScript in Action Page 1 of 10 Chapter 3: JavaScript in Action In this chapter, you get your first opportunity to write JavaScript! This chapter introduces you to JavaScript propery. In addition,

More information

Network/Communicational Vulnerability

Network/Communicational Vulnerability Automated teer machines (ATMs) are a part of most of our ives. The major appea of these machines is convenience The ATM environment is changing and that change has serious ramifications for the security

More information

Leadership & Management Certificate Programs

Leadership & Management Certificate Programs MANAGEMENT CONCEPTS Leadership & Management Certificate Programs Programs to deveop expertise in: Anaytics // Leadership // Professiona Skis // Supervision ENROLL TODAY! Contract oder Contract GS-02F-0010J

More information

Introduction the pressure for efficiency the Estates opportunity

Introduction the pressure for efficiency the Estates opportunity Heathy Savings? A study of the proportion of NHS Trusts with an in-house Buidings Repair and Maintenance workforce, and a discussion of eary experiences of Suppies efficiency initiatives Management Summary

More information

AA Fixed Rate ISA Savings

AA Fixed Rate ISA Savings AA Fixed Rate ISA Savings For the road ahead The Financia Services Authority is the independent financia services reguator. It requires us to give you this important information to hep you to decide whether

More information

NCH Software FlexiServer

NCH Software FlexiServer NCH Software FexiServer This user guide has been created for use with FexiServer Version 1.xx NCH Software Technica Support If you have difficuties using FexiServer pease read the appicabe topic before

More information

NCH Software Express Accounts Accounting Software

NCH Software Express Accounts Accounting Software NCH Software Express Accounts Accounting Software This user guide has been created for use with Express Accounts Accounting Software Version 5.xx NCH Software Technica Support If you have difficuties using

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these

More information

SNMP Reference Guide for Avaya Communication Manager

SNMP Reference Guide for Avaya Communication Manager SNMP Reference Guide for Avaya Communication Manager 03-602013 Issue 1.0 Feburary 2007 2006 Avaya Inc. A Rights Reserved. Notice Whie reasonabe efforts were made to ensure that the information in this

More information

ICAP CREDIT RISK SERVICES. Your Business Partner

ICAP CREDIT RISK SERVICES. Your Business Partner ICAP CREDIT RISK SERVICES Your Business Partner ABOUT ICAP GROUP ICAP Group with 56 miion revenues for 2008 and 1,000 empoyees- is the argest Business Services Group in Greece. In addition to its Greek

More information

LADDER SAFETY Table of Contents

LADDER SAFETY Table of Contents Tabe of Contents SECTION 1. TRAINING PROGRAM INTRODUCTION..................3 Training Objectives...........................................3 Rationae for Training.........................................3

More information

Business Banking. A guide for franchises

Business Banking. A guide for franchises Business Banking A guide for franchises Hep with your franchise business, right on your doorstep A true understanding of the needs of your business: that s what makes RBS the right choice for financia

More information

Ricoh Healthcare. Process Optimized. Healthcare Simplified.

Ricoh Healthcare. Process Optimized. Healthcare Simplified. Ricoh Heathcare Process Optimized. Heathcare Simpified. Rather than a destination that concudes with the eimination of a paper, the Paperess Maturity Roadmap is a continuous journey to strategicay remove

More information

Income Protection Solutions. Policy Wording

Income Protection Solutions. Policy Wording Income Protection Soutions Poicy Wording Wecome to Aviva This booket tes you a you need to know about your poicy, incuding: what to do if you need to caim what s covered, and expanations of some of the

More information

Older people s assets: using housing equity to pay for health and aged care

Older people s assets: using housing equity to pay for health and aged care Key words: aged care; retirement savings; reverse mortgage; financia innovation; financia panning Oder peope s assets: using housing equity to pay for heath and aged care The research agenda on the ageing

More information

Health Savings Account 2013 2014 reference guide

Health Savings Account 2013 2014 reference guide Heath Savings Account 2013 2014 reference guide Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist of sections and topics

More information

CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS

CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS Dehi Business Review X Vo. 4, No. 2, Juy - December 2003 CONTRIBUTION OF INTERNAL AUDITING IN THE VALUE OF A NURSING UNIT WITHIN THREE YEARS John N.. Var arvatsouakis atsouakis DURING the present time,

More information

Niagara Catholic. District School Board. High Performance. Support Program. Academic

Niagara Catholic. District School Board. High Performance. Support Program. Academic Niagara Cathoic District Schoo Board High Performance Academic Support Program The Niagara Cathoic District Schoo Board, through the charisms of faith, socia justice, support and eadership, nurtures an

More information

Income Protection Options

Income Protection Options Income Protection Options Poicy Conditions Introduction These poicy conditions are written confirmation of your contract with Aviva Life & Pensions UK Limited. It is important that you read them carefuy

More information

NCH Software Warp Speed PC Tune-up Software

NCH Software Warp Speed PC Tune-up Software NCH Software Warp Speed PC Tune-up Software This user guide has been created for use with Warp Speed PC Tune-up Software Version 1.xx NCH Software Technica Support If you have difficuties using Warp Speed

More information

SABRe B2.1: Design & Development. Supplier Briefing Pack.

SABRe B2.1: Design & Development. Supplier Briefing Pack. SABRe B2.1: Design & Deveopment. Suppier Briefing Pack. 2013 Ros-Royce pc The information in this document is the property of Ros-Royce pc and may not be copied or communicated to a third party, or used

More information

Business schools are the academic setting where. The current crisis has highlighted the need to redefine the role of senior managers in organizations.

Business schools are the academic setting where. The current crisis has highlighted the need to redefine the role of senior managers in organizations. c r o s os r oi a d s REDISCOVERING THE ROLE OF BUSINESS SCHOOLS The current crisis has highighted the need to redefine the roe of senior managers in organizations. JORDI CANALS Professor and Dean, IESE

More information

Advanced ColdFusion 4.0 Application Development - 3 - Server Clustering Using Bright Tiger

Advanced ColdFusion 4.0 Application Development - 3 - Server Clustering Using Bright Tiger Advanced CodFusion 4.0 Appication Deveopment - CH 3 - Server Custering Using Bri.. Page 1 of 7 [Figures are not incuded in this sampe chapter] Advanced CodFusion 4.0 Appication Deveopment - 3 - Server

More information

CUSTOM. Putting Your Benefits to Work. COMMUNICATIONS. Employee Communications Benefits Administration Benefits Outsourcing

CUSTOM. Putting Your Benefits to Work. COMMUNICATIONS. Employee Communications Benefits Administration Benefits Outsourcing CUSTOM COMMUNICATIONS Putting Your Benefits to Work. Empoyee Communications Benefits Administration Benefits Outsourcing Recruiting and retaining top taent is a major chaenge facing HR departments today.

More information

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider.

Welcome to Colonial Voluntary Benefits. Thank you for your interest in our Universal Life with the Accelerated Death Benefit for Long Term Care Rider. Heo, Wecome to Coonia Vountary Benefits. Thank you for your interest in our Universa Life with the Acceerated Death Benefit for Long Term Care Rider. For detai pease ca 877-685-2656. Pease eave your name,

More information

INDUSTRIAL PROCESSING SITES COMPLIANCE WITH THE NEW REGULATORY REFORM (FIRE SAFETY) ORDER 2005

INDUSTRIAL PROCESSING SITES COMPLIANCE WITH THE NEW REGULATORY REFORM (FIRE SAFETY) ORDER 2005 INDUSTRIAL PROCESSING SITES COMPLIANCE WITH THE NEW REGULATORY REFORM (FIRE SAFETY) ORDER 2005 Steven J Manchester BRE Fire and Security E-mai: manchesters@bre.co.uk The aim of this paper is to inform

More information

ADVANCED ACCOUNTING SOFTWARE FOR GROWING BUSINESSES

ADVANCED ACCOUNTING SOFTWARE FOR GROWING BUSINESSES ADVANCED ACCOUNTING SOFTWARE FOR GROWING BUSINESSES Product Features 1. System 2. Saes Ledger Unimited companies with password protection User security Muti-user system: 1 user comes as standard, up to

More information

Learning from evaluations Processes and instruments used by GIZ as a learning organisation and their contribution to interorganisational learning

Learning from evaluations Processes and instruments used by GIZ as a learning organisation and their contribution to interorganisational learning Monitoring and Evauation Unit Learning from evauations Processes and instruments used by GIZ as a earning organisation and their contribution to interorganisationa earning Contents 1.3Learning from evauations

More information

medical injury a claimant s guide

medical injury a claimant s guide medica injury a caimant s guide The ega caims process is not a simpe one and cinica negigence caims are amongst the most compex. We have over three decades of experience representing patients and recovering

More information

History of Stars and Rain Education Institute for Autism (Stars and Rain)

History of Stars and Rain Education Institute for Autism (Stars and Rain) History of Education Institute for Autism () Estabished:: March 15. 1993 in Beijing Founder:: Ms. Tian Huiping (mother of a boy with autism) STARS AND RAIN was founded in 1993 by a parent and is China

More information

Online Security. Savings

Online Security. Savings Onine Security Savings What is onine security? This booket is designed to make you aware of some of the atest threats that exist when managing your money onine so you can protect your money in the same

More information

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l

ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES. l l. l l. l l ELECTRONIC FUND TRANSFERS YOUR RIGHTS AND RESPONSIBILITIES The Eectronic Fund Transfers we are capabe of handing for consumers are indicated beow, some of which may not appy your account Some of these

More information

Key Features of the Term Assurance (with options) For use in business protection planning

Key Features of the Term Assurance (with options) For use in business protection planning Key Features of the Term Assurance (with options) For use in business protection panning Term Assurance (with options) Key features The Financia Conduct Authority is a financia services reguator. It requires

More information

The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT

The Productive Therapist and The Productive Clinic Peter R. Kovacek, MSA, PT The Productive Therapist and The Productive Cinic Peter R. Kovacek, MSA, PT Format Interactive Discussions among equa peers Constructive argument Reaity Oriented Mutua Accountabiity Expectation Panning

More information

IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM

IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM The New Jersey Department of Human Services Division of Deveopmenta Disabiities 1 IMPLEMENTING THE RATE STRUCTURE: TIERING IN THE FEE-FOR-SERVICE SYSTEM Eizabeth M. Shea Assistant Commissioner Thomas S.

More information

Pay-on-delivery investing

Pay-on-delivery investing Pay-on-deivery investing EVOLVE INVESTment range 1 EVOLVE INVESTMENT RANGE EVOLVE INVESTMENT RANGE 2 Picture a word where you ony pay a company once they have deivered Imagine striking oi first, before

More information

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com

Benefits That Count. Colonial Life is the proud sponsor of SHRM s Annual Employee Benefits Survey. coloniallife.com Benefits That Count Coonia Life is the proud sponsor of SHRM s Annua Empoyee Benefits Survey cooniaife.com 1 Dear Empoyer: Randa C. Horn President & CEO Coonia Life & Accident Insurance Company 1200 Coonia

More information

DECEMBER 2008. Good practice contract management framework

DECEMBER 2008. Good practice contract management framework DECEMBER 2008 Good practice contract management framework The Nationa Audit Office scrutinises pubic spending on behaf of Pariament. The Comptroer and Auditor Genera, Tim Burr, is an Officer of the House

More information

Quality Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM

Quality Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM Quaity Monitor HEALTH QUALITY ONTARIO 2012 REPORT ON ONTARIO S HEALTH SYSTEM This report is a too for driving a cuture of quaity, vaue, transparency and accountabiity throughout the heath system in Ontario.

More information

Normalization of Database Tables. Functional Dependency. Examples of Functional Dependencies: So Now what is Normalization? Transitive Dependencies

Normalization of Database Tables. Functional Dependency. Examples of Functional Dependencies: So Now what is Normalization? Transitive Dependencies ISM 602 Dr. Hamid Nemati Objectives The idea Dependencies Attributes and Design Understand concepts normaization (Higher-Leve Norma Forms) Learn how to normaize tabes Understand normaization and database

More information

Health Savings Account 2014-2015 reference guide

Health Savings Account 2014-2015 reference guide Heath Savings Account 2014-2015 reference guide www.seectaccount.com Information at your fingertips This ist of chapters and page numbers wi hep you find the information you need quicky. A detaied ist

More information

NatWest Global Employee Banking Eastwood House Glebe Road Chelmsford Essex England CM1 1RS Depot Code 028

NatWest Global Employee Banking Eastwood House Glebe Road Chelmsford Essex England CM1 1RS Depot Code 028 To appy for this account, the printed appication must be competed and returned together with any necessary supporting documentation to the foowing address: NatWest Goba Empoyee Banking Eastwood House Gebe

More information

Bite-Size Steps to ITIL Success

Bite-Size Steps to ITIL Success 7 Bite-Size Steps to ITIL Success Pus making a Business Case for ITIL! Do you want to impement ITIL but don t know where to start? 7 Bite-Size Steps to ITIL Success can hep you to decide whether ITIL can

More information

Income Protection Solutions. Policy Wording

Income Protection Solutions. Policy Wording Income Protection Soutions Poicy Wording Wecome to Aviva This booket tes you a you need to know about your poicy, incuding: what to do if you need to caim what s covered, and expanations of some of the

More information

Chapter 3: e-business Integration Patterns

Chapter 3: e-business Integration Patterns Chapter 3: e-business Integration Patterns Page 1 of 9 Chapter 3: e-business Integration Patterns "Consistency is the ast refuge of the unimaginative." Oscar Wide In This Chapter What Are Integration Patterns?

More information

How to Cut Health Care Costs

How to Cut Health Care Costs How to Cut Heath Care Costs INSIDE: TEN TIPS FOR MEDICARE BENEFICIARIES What is one of the biggest financia surprises in retirement? Heath care costs. It s a growing concern among many Medicare beneficiaries,

More information

HAVE YOU EMBRACED THE NEW E-DISCOVERY RULES OR ARE YOU JUST HOPING YOU WON T HAVE TO DEAL WITH THEM?

HAVE YOU EMBRACED THE NEW E-DISCOVERY RULES OR ARE YOU JUST HOPING YOU WON T HAVE TO DEAL WITH THEM? J U N E 2 0 0 9 N E V A D A L A W Y E R HAVE YOU EMBRACED THE NEW E-DISCOVERY RULES OR ARE YOU JUST HOPING YOU WON T HAVE TO DEAL WITH THEM? BY JOHN L. KRIEGER, ESQ. The amendments to the Federa Rues of

More information

(David H T Lan) Secretary for Home Affairs

(David H T Lan) Secretary for Home Affairs Message We sha make every effort to strengthen the community buiding programme which serves to foster among the peope of Hong Kong a sense of beonging and mutua care. We wi continue to impement the District

More information

Setting Up Your Internet Connection

Setting Up Your Internet Connection 4 CONNECTING TO CHANCES ARE, you aready have Internet access and are using the Web or sending emai. If you downoaded your instaation fies or instaed esigna from the web, you can be sure that you re set

More information

... HSA ... Health Savings Account. Custodial. (includes self-direction)

... HSA ... Health Savings Account. Custodial. (includes self-direction) HSA Heath Savings Account Custodia (incudes sef-direction) ADDITIONAL INFORMATION Purpose This Organizer contains documents necessary to estabish a Heath Savings Account (HSA) It meets the requirements

More information

Federal Financial Management Certificate Program

Federal Financial Management Certificate Program MANAGEMENT CONCEPTS Federa Financia Management Certificate Program Training to hep you achieve the highest eve performance in: Accounting // Auditing // Budgeting // Financia Management ENROLL TODAY! Contract

More information

STRATEGIC PLAN 2012-2016

STRATEGIC PLAN 2012-2016 STRATEGIC PLAN 2012-2016 CIT Bishopstown CIT Cork Schoo of Music CIT Crawford Coege of Art & Design Nationa Maritime Coege of Ireand Our Institute STRATEGIC PLAN 2012-2016 Cork Institute of Technoogy (CIT)

More information

Oracle. L. Ladoga Rybinsk Res. Volga. Finland. Volga. Dnieper. Dnestr. Danube. Lesbos. Auditing Oracle Applications Peloponnesus

Oracle. L. Ladoga Rybinsk Res. Volga. Finland. Volga. Dnieper. Dnestr. Danube. Lesbos. Auditing Oracle Applications Peloponnesus N o r w e g i a n S e a White 60ûN ATLANTIC OCEAN UNITED KINGDOM Rio Douro Hebrid Bay of Biscay Garonne Faroe Isands Shetand Isands Orkney Isands North Loire ine Rhone Rhine Po Ebe Adriatic Batic Guf of

More information

3.3 SOFTWARE RISK MANAGEMENT (SRM)

3.3 SOFTWARE RISK MANAGEMENT (SRM) 93 3.3 SOFTWARE RISK MANAGEMENT (SRM) Fig. 3.2 SRM is a process buit in five steps. The steps are: Identify Anayse Pan Track Resove The process is continuous in nature and handed dynamicay throughout ifecyce

More information

WEBSITE ACCOUNT USER GUIDE SECURITY, PASSWORD & CONTACTS

WEBSITE ACCOUNT USER GUIDE SECURITY, PASSWORD & CONTACTS WEBSITE ACCOUNT USER GUIDE SECURITY, PASSWORD & CONTACTS Password Reset Process Navigate to the og in screen Seect the Forgot Password ink You wi be asked to enter the emai address you registered with

More information

Gerald F. Danaher, DDS, Past President of

Gerald F. Danaher, DDS, Past President of Dateine VOLUME A NEWSLETTER FOR -INSURED PHYSICIANS & FACILITIES Case Study: Setting a 2 Disastrous Case with Sef Insured Co-Defendants New Website 5 Reeased Surprise Visits from 6 Government Investigators

More information

A practical guide to personal financial advice Finding the right financial adviser and advice that works for you. Getting advice

A practical guide to personal financial advice Finding the right financial adviser and advice that works for you. Getting advice A practica guide to persona financia advice Finding the right financia adviser and advice that works for you Getting advice About ASIC The Austraian Securities and Investments Commission (ASIC) reguates

More information

Group Income Protection. Technical Guide

Group Income Protection. Technical Guide Group Income Protection Technica Guide Aviva By choosing Aviva, part of the UK s argest insurance group, you benefit from our financia strength. Together with miions of customers wordwide you can fee certain

More information

Budgeting Loans from the Social Fund

Budgeting Loans from the Social Fund Budgeting Loans from the Socia Fund tes sheet Pease read these notes carefuy. They expain the circumstances when a budgeting oan can be paid. Budgeting Loans You may be abe to get a Budgeting Loan if:

More information

Corporate Governance f o r M a i n M a r k e t a n d a i M C o M p a n i e s

Corporate Governance f o r M a i n M a r k e t a n d a i M C o M p a n i e s Corporate Governance f o r M a i n M a r k e t a n d a i M C o M p a n i e s 23. Corporate governance towards best-practice corporate reporting John Patterson, PricewaterhouseCoopers LLP Reporting is

More information

NCH Software BroadCam Video Streaming Server

NCH Software BroadCam Video Streaming Server NCH Software BroadCam Video Streaming Server This user guide has been created for use with BroadCam Video Streaming Server Version 2.xx NCH Software Technica Support If you have difficuties using BroadCam

More information

Driving Accountability Through Disciplined Planning with Hyperion Planning and Essbase

Driving Accountability Through Disciplined Planning with Hyperion Planning and Essbase THE OFFICIAL PUBLICATION OF THE Orace Appications USERS GROUP summer 2012 Driving Accountabiity Through Discipined Panning with Hyperion Panning and Essbase Introduction to Master Data and Master Data

More information

The guaranteed selection. For certainty in uncertain times

The guaranteed selection. For certainty in uncertain times The guaranteed seection For certainty in uncertain times Making the right investment choice If you can t afford to take a ot of risk with your money it can be hard to find the right investment, especiay

More information