Avoiding Medical Malpractice Workshop April 25, 2015 (GEN-A95)

Transcription

1 2015 User Conference Avoiding Medical Malpractice Workshop April 25, 2015 (GEN-A95) Presented by: Susan J. Kressly, MD, FAAP Medical Director, Office Practicum General Workshop

2 Learning Objectives Understand how use of your EHR can hurt or help you in a malpractice case Realize the importance of understanding how OP works under the hood Identify at least 2 pitfalls to avoid to protect yourself Identify at least 2 goals for using OP according to best practices to be better prepared in the event of a malpractice inquiry 2015 Office Practicum User Conference

3 Disclaimer* *I am NOT a lawyer. Information in this presentation does not constitute legal advice Office Practicum User Conference

4 EHR

5 Common EHR Error Gender Mismatch NOT OP!!!! 2015 Office Practicum User Conference

6 Understanding Your EHR Log ins/security/passwords/administrative users oh my How does your office workflow integrate with OP? Documentation matters! 2015 Office Practicum User Conference

7 Let s take a closer look

8 Please explain to the jury how Nurse Ratchet entered data into the EHR when she was on vacation in the Caribbean for a week?

9 Security/Passwords 2015 Office Practicum User Conference

10 Best Practices Do NOT share logins/passwords Do NOT write down logins/passwords Consider using strong password functionality Do NOT allow users to be simultaneously logged in to more than one workstation Set a reasonable timed logout 2015 Office Practicum User Conference

11 Why Does it Matter? The audit trail logs EVERYTHING you do Who signed in when, on which computer and for how long What they did when they were signed it Changed records and what the record said before and after changes Audit logs are DISCOVERABLE and malpractice attorneys ask for them as well as your documentation 2015 Office Practicum User Conference

12 You can run, but you can t hide... from the audit trail.

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14 Doctor, tell us how you though that it was reasonable that your office received no imported lab results for two weeks in the middle of cold & flu season?

15 Workflow Matters: Labs. Do you get lab results via an interface, on papers, both? Do you have a written workflow? Does everyone follow it? How do you know if your lab interface goes down? What do you do when a provider is on vacation? Who notifies the patient and how do you document it? Do you track outstanding labs? 2015 Office Practicum User Conference

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17 Beware the Outlier

18 He wants you to believe that he spends tens of thousands of dollars on an EHR, went to countless hours of training and he doesn t know what is in the template that he used and signed?

19 Documentation Pitfalls to Avoid Missing information Conflicting information Putting key information where it isn t seen or can t be used appropriately for decision support Using shortcuts/templates without knowing what they say Not reviewing information Ignoring alerts or using meaningless override reasons 2015 Office Practicum User Conference

20 2 month old Girl with Failure to Thrive You use the FTT template and include newborn history What s missing here? How could that put you at risk? 2015 Office Practicum User Conference

21 Best Practices Agree where in the chart all users will put newborn screen information (scan?, NB hx, lab test?) Have a practice protocol for tracking down missing screens 2015 Office Practicum User Conference

22 Standing Reminders Standing order for staff to obtain NB screen on tasks attached to 1 week well visit template Requires staff to track outstanding tasks Transfer in at 1 month? 2015 Office Practicum User Conference

23 What else is a risk for this patient? Where s the reminder for a hip ultrasound or documentation of result? What is your practice protocol for communication? 2015 Office Practicum User Conference

24 What s wrong with this picture? Conflicting Information

25 Key Data Entry Not Used Appropriately

26 Have you ever looked at the data audit?

27 Using Templates Know what the template says Preview before you finalize 2015 Office Practicum User Conference

28 Alerts 1 2

29 Alerts continued 3 4

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31 Audit Reasons Are recorded Defaults are editable 2015 Office Practicum User Conference

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33 Report Criteria Must know what sections are included into notes Edit per practice preferences 2015 Office Practicum User Conference

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35 Well Visit Physical Exam Detailed vs School Exam School Exam is what gets put on default forms Currently can only be edited within the context of the visit before note is finalized 2015 Office Practicum User Conference

36 Detailed Exam vs School Exam

37 Good Habits Sanity check chart at every touch No longer can review/preview before information gets sent out (portal or HIE) Chart as complete and up-to-date as possible 2015 Office Practicum User Conference

38 You absolutely should understand that my client is a doctor! Doctors are very smart. She absolutely can remember what happened years ago to her patient that was one of 27 she saw that day. Of course it is reasonable for her to change her note and add information 5 years after the visit.

39 Finalizing Notes Have good practice habits Finalize prior to leaving for the day Use addenda if needed Archive un-finalized notes regularly 2015 Office Practicum User Conference

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41 Questions? 2015 Office Practicum User Conference

42 2015 Office Practicum User Conference We want your feedback!