EHR Documentation Perspectives from Informatics and the Law

Transcription

1 EHR Documentation Perspectives from Informatics and the Law Lynn Choromanski, PhD, RN-BC Nursing Informatics Specialist Gillette Children s Specialty Healthcare MN Chapter NAN April 30, 2013 bjectives 1) Define the problem of copying and pasting information into the EHR using research and industry standards. 2) Describe 2 alternative approaches to reduce duplicate documentation in patient records by highlighting an example of an orthopedic case study. 3) Recognize 2 risk areas in the use of EHR that might result in Board of Nursing (BN) or court action against your nursing license. Define the Problem Copy and Paste : common word processing function Cloning Carrying forward Pulling forward Historic information

2 Pros and Cons Pros Efficiency Decreases data entry errors Items which rarely change should not have to be entered each time Prevents other work arounds which might be more dangerous Cons Slower Increases error rate from retention of old information Likelihood that rare changes will not be captured Work arounds might be considered innovative rthopedic Case Study 6 y.o. female undergoes a single event multi level surgery (SEMLS) to correct an orthopedic condition secondary to cerebral palsy n admission to pre-op area the patient s baseline CMS is assessed (observation and/or report) Documentation of baseline allows nurse to detect change in CMS status early which might indicate compartment syndrome Need to easily compare baseline to current status Baseline does not change it should carry forward with each new assessment Documentation Screen Examples

3 Workflow Issues Research findings: Hammond et al (2003) 9% of progress notes contained copied material (40 word string), 10% of charts had high risk copying. Dramatic increase in copying from 6 in 1995 to 2200 instances in Weir et al (2003) 20% of notes contained copied text Thielke, Hammond, Helbig (2008) 3% physical exams had evidence of copying, 25% notes in charts had evidence of copying Research (continued) Donnell et al (2008) 90% providers used copy/paste on inpatient notes, those notes contained inconsistencies and outdated information (71%), <25% felt these errors impacted patient care Siegler & Adelman (2009) problem lists never change, house staff copy others notes and errors, loss of the narrative (patient s story) Holden (2011) qualitative survey identified a host of concerns copy-and-pasted notes do not provide new information Nursing Research Kossman (2006) EHR preferred over paper, concern for overuse of checkboxes and copy and paste. Leads to laziness in charting if the selection is not in the pick list do I free text or just pick the closest thing.

4 Workflow Issues (continued) Ability to turn off copy and paste functionality Compromised credibility of the record External requirements: how will insurance companies handle information that appears to be unchanged auditing becomes more difficult; what is the truth Financial implication: reimbursement could be impacted Legal questions might arise Clearly defined policies against copy and paste in the electronic record have not been established at some major insurance providers No national policy exists for CMS (Dimick, 2008) Alternatives EHR rules which can capture acuity of patient, identify the employee performing the documentation and time frame which could reasonably allow a copy/paste action Carry forward information Patient specific: items that rarely change such as language spoken, eye color, religion Visit specific: items which rarely change during a visit such as cast location, presenting problem Shift specific: items which rarely change in a typical 8-12 hour shift such as level of consciousness, activity status Never carry forward information Alternatives (continued) Redesign nursing documentation agreed upon standard of what is minimally required If it is ordered you did it unless otherwise noted Charting by exception Care plan driven documentation Worse, better, the same (work on this being done in Finland)

5 References Dimick, C. (2008). Documentation bad habits. J Ahima, 79, Hammond, K. W., Helbig, S. T., Benson, C. C., & Brathwaite-Sketoe, B. M. (2003). Are electronic medical records trustworthy? observations on copying, pasting and duplication. AMIA Annual Symposium Proceedings,, Holden, R. J. (2011). Cognitive performance-altering effects of electronic medical records: An application of the human factors paradigm for patient safety. Cognition, Technology & Work, 13(1), Kossman, S. P. (2006). Perceptions of impact of electronic health records on nurses' work. Studies in Health Technology and Informatics, 122, 337. Donnell, H. C., Kaushal, R., Barrón, Y., Callahan, M. A., Adelman, R. D., & Siegler, E. L. (2009). Physicians attitudes towards copy and pasting in electronic note writing. Journal of General Internal Medicine, 24(1), Siegler, E. L., & Adelman, R. (2009). Copy and paste: A remediable hazard of electronic health records. American Journal of Medicine, 122(6), 495. Thielke, S., Hammond, K., & Helbig, S. (2007). Copying and pasting of examinations within the electronic medical record. International Journal of Medical Informatics, 76, S122-S128.