When EMRs Meet Surveyors and Other Things That Go Bump in the Night

Transcription

1 When EMRs Meet Surveyors and Other Things That Go Bump in the Night Lisa Conrad, Diane E. Felix, Suzanne Sheldon 1. Introduction. (a) Presentation will NOT deal with following, which are all important factors in avoiding problems: (iii) (iv) (v) Choosing vendors; Vendor contracting issues; Initial implementation of EMR system; Inter-organization communication issues; and System security issues. (b) (c) Current prevalence of EMR in LTC. EMR contents in the long-term care setting. EMR adoption is generally considered to be more than just capturing order entries, care plans and assessments. 1 LTC EMR typically includes: (1) Computerized Physician Order Entry (CPOE); (2) Electronic Med/Tx Administration Record (emar/etar); 1 Julie Williamson, A roadmap for EMRs: strategies and starting places for long-term care, McKNIGHTS, January ,

2 (3) Progress Notes; (4) Accident and Injury Reporting; (5) Clinical Assessments; (6) Automated MDS Workflow; (7) Care Plans; (8) CNA Assignment/ADL Flow Sheets; and (9) Therapy Charting and Charge Capture. (iii) Organizations must define the EMR. (1) EMR system does NOT equal the medical record. There may be many features or reports that are technically not part of the EMR. (2) Failure to define the EMR and to understand what it includes may result in the failure to provide appropriate information to surveyors and parties who have requested/subpoenaed copies of medical records. 2. Challenges for management and legal counsel (in-house and outside). (a) Some information/records may not be included in the EMR. 2

3 Example Information from outside parties may not be included in the EMR such as physician and nurse practitioner progress notes, and labs and x-rays. Example In-house tools and monitoring records, such as neuro-check documentation, may still be maintained on paper. (b) Training (upfront and ongoing) may be insufficient, and even an optimal system and optimal training can be circumvented by the human element. Organizations may underestimate how long it takes to bring about change. Learning curves are steep and initial training typically needs to be supplemented with follow-up training. (c) Facility staff may have their own workarounds and may be maintaining an unofficial set of paper records. Corollary to Murphy s Law: Staff will spend an inordinate amount of time developing workarounds instead of asking the right people how to do something the right way. Even the most competent and well-organized organization that believes this is not happening probably has it occurring to some degree. 3

4 (iii) One study observed the following examples of nursing home staff members using workarounds with computerized order entry (COE) systems, which had intentional blocks designed to prevent ordering of excessive medication doses: To work around this block, one staff member reported intentionally selecting a medication dose in COE that did not match the physician s order simply to get the medication into the system. As the incidence of excessive dosing was encountered, licensed staff from each of the five nursing homes were most often observed entering multiple doses of the same medication to obtain the full ordered dose instead of discussing the excessive ordered dose with the pharmacist or physician. Staff discussed working around these blocks by tricking the system to get their work done. Because the underlying goal of a WA is to complete a task despite a block, WA may be seen as important problem-solving behaviors within organizations. Initially, frustrated staff who were unable to get the work done associated all blocks with the implementation of technology. The blocks led to many types of WA. 2 (iv) Facility staff may not use and understand features of the EMR system. (d) Use of templates may encourage sloppy charting practices. 2 Amy A. Vogelsmeier, MSN, RN, Jonathon R.B. Halbesleben, PhD, and Jill R. Scott-Cawiezell, RN, PhD, Technology Implementation and Workarounds in the Nursing Home, J AM MED INFORM ASSOC Jan-Feb; 15(1): , 4

5 Repetitive copying of prior entries has been a frequent issue with paper records. Cut and paste functions in EMR systems make repetitive copying even easier, which may perpetuate inaccurate information, and ultimately lead to an unreliable and perhaps even falsified record. Poorly thought out or inappropriately used templates may also encourage problematic charting. (iii) Important information, such as documentation of following up on significant changes, may get lost in template charting. (iv) A trainer for a Medicare administrative contractor recently stated that EMRs have led to cookie cutter charting. He cited the example of an audit that asked a physician's office for 17 progress notes for specific patients on a specified date. When the charts were reviewed, 15 were essentially the same. 3 (e) Staff may be careless about allowing others to use their passwords and in logging in and out of records. Automatic time-outs are advisable, but if too strict may inhibit appropriate documentation. 3 Carolyn Buppert, NP, JD, Electronic Medical Records: 18 Ways to Reduce Legal Risks, TOPICS IN ADVANCED PRACTICE NURSING EJOURNAL 2010;10(1), 5

6 Staff should be trained and periodically reminded of the risks to them and the organization of sharing their passwords. (f) Printed versions from an EMR may bear little resemblance to what can be viewed live on the system. One writer, explaining the difficulty of printing EMR to respond to a subpoena, said: Printing may have to be by all treatment notes, then all progress notes, then medications, then audit trails (which may not even be printable at all). This can result in boxes and boxes of disorganized information being produced, much of which may make virtually no sense at all. 4 If a surveyor requests paper copies of EMR information, staff dealing with the surveyor should be prepared to explain that the paper version may not be able to duplicate what clinical staff has available and has reviewed. (Better yet, have a written version of this caveat available to include with all photocopies provided to surveyors.) 4 Krystyna H. Nowik, Esq., For Lack Of A Proper "Print" Function The Difficulties In Responding To Subpoenas To Produce The EHR, LEGAL HEALTH INFORMATION EXCHANGE, March 04, 2011, 6

7 (g) Outside users (e.g. surveyors and plaintiffs attorneys) may have varying levels of experience with EMR (ranging from experienced, to what is this? ) and may even be hostile. Example Plaintiff s attorney questions integrity of EMR information. Example Surveyor says: I hate EMR systems. I will only look at information on paper. (iii) Even if the onsite surveyor is familiar with EMRs in general, he or she may assume that your system is the same as the last EMR the surveyor dealt with. (iv) Even if the surveyor is familiar with EMRs in general and your system in particular, that surveyor s supervisor or other decision-makers in the regulatory system likely will not be as familiar. Consider what copies from your system will look like to a supervisor who may not have any understanding of your organization s system. (h) Various issues are popping up in different regions during surveys, and those issues are likely to change as more facilities adopt EMRs and more surveyors become familiar with them. Software support may be only technical and may not include clinical support and workflow, which may make it more difficult to 7

8 get assistance with troubling situations from the vendor in the midst of a survey. (j) If an organization produces inconsistent responses to record requests, complications will follow. Example: A facility responds to two different record requests from same law firm with copies of charts that did not contain same types of information. Example: Facility staff provides information on two different residents to surveyors tracking same care issue and the data provided doesn t include the same types of information. (This is more likely to occur if the organization has failed to define the EMR.) (k) For outside counsel when you ve seen one EMR system, you haven t seen them all! 3. Recommendations to meet the challenges (a) Knowledge is power. Identify who inside or outside the facility is accountable for the system knowledge who s the go-to person to find out what the system can and cannot do? Ask about parallel paper records being maintained unofficially. 8

9 (iii) Ask about workarounds what are staff doing when the EMR system seems to make their jobs more difficult? (iv) Find out how the organization s EMR system tracks alterations and modifications to the records. (b) Assure that organization has policies covering issues such as: Defining what the medical record includes; Dealing with discovery requests; 5 (iii) Backing up the system (and checking periodically to assure that the back up is working); (iv) (v) Use of passwords; Modifying records; (c) Planning and training for surveys should anticipate issues relating to EMRs. Review CMS 2009 Survey & Certification Letter 6 concerning surveying facilities that use EHRs. [See Attachment A.] In particular, note: (1) Surveyors responsibility: Surveyors will cooperate and work with facilities that use EHR. During the entrance conference surveyors will establish with the 5 Id. 6 Surveying Facilities That Use Electronic Health Records (EHR), S&C-09-53, Centers for Medicare & Medicaid Services, Survey and Certification Group, Aug. 14, 2009, 9

10 facility the process they will follow in order to have unrestricted access to the medical record. 7 (2) Paper copies: (A) (B) Electronic access to records will not eliminate the need for a surveyor to print a paper copy or to request a paper copy of certain parts of certain records. However, the surveyor shall make reasonable efforts to avoid, where possible, the printing of entire records. The surveyor should print or request a paper copy of only those parts of records that are needed to support findings of noncompliance, unless protocols for particular types of surveys require otherwise, e.g., copying complete medical records to be submitted for an EMTALA physician review. 8 If the facility is unable to provide direct print capability to the surveyor, the provider must make available a printout of any record or part of a record upon request in a timeframe that does not impede the survey process. Undue delays in the production of records are unacceptable. 9 (3) Surveyor s access to records: (A) (B).(A) provider must grant access to any medical record, including access to EHRs, when requested by the surveyor. If access to an EHR is requested by the surveyor, the facility will (a) provide the surveyor with a tutorial on how to use its particular electronic system and (b) designate an individual who will, when requested by the surveyor, access the system, respond to any questions or assist the surveyor as needed in accessing electronic information in a timely fashion. 10 Each surveyor will determine the EHR access method that best meets the need for that survey. 7 Id. at 3. 8 Id. at 3. 9 Id. at Id. 10

11 During the entrance conference in a facility using EHRs the survey team must request that the facility, provide a terminal(s) where the surveyors may access records. 11 (C) Whenever possible, the facility must provide surveyors electronic access to records in a read-only format or other secure format to avoid any inadvertent changes to the record. 12 (4) Confidentiality and HIPAA issues: (A) (B) Surveyors are not responsible for assessing compliance with the HIPAA Privacy and Security Rules.... The surveyors responsibility is to assess compliance with the provider or supplier-specific requirements for maintaining the content and confidentiality of the medical record. Surveyors instead are to focus on how the EHR system is being used in the facility, and whether that use is consistent with the Medicare CoPs or CfCs. For example, are computer screens showing clinical record information left unattended and readily observable or accessible by other patients/residents or visitors? Are there documents publicly posting passwords, which would be evidence of noncompliance with both confidentiality and medical record authentication requirements? Is there evidence to support a complaint allegation that facility staff shared information obtained from an EHR with unauthorized individuals? 13 Steps to take in advance of surveys: (1) Make sure the EMR software is set up to prevent surveyors from looking at records that they shouldn t 11 Id. 12 Id. 13 Id. at3. 11

12 access, such as your incident reports and QA committee notes. 14 (2) Plan to have a password assigned to surveyors. (3) Plan for one or more computer terminals to be available for surveyors to work with. (4) Plan ahead to have one or more designated individual to assist surveyors with EMR. (5) Plan ahead to have a tutorial for the surveyors on your organization s EMR. (6) Consider having a written orientation tool prepared for the surveyors, covering key aspects of your system. Include a warning that printed versions will not necessarily duplicate the information the surveyor is seeing on the screen. (7) Consider specific hot button topics and how records available from your organization s EMR will demonstrate your compliance (or noncompliance). (A) Examples: pressure sores, Coumadin therapy, falls. (d) Organization staff and management should be alert to possibility that legal counsel may not be familiar with their particular EMR system. 14 Don t Get Tripped Up During Your Next Survey: Simple Tips Help You Avoid Missteps, LTC SURVEY & COMPLIANCE ALERT, Vol. 13, No. 7, 2011, at p