Electronic Medical Record Overview

Transcription

1 Electronic Medical Record Overview Saturday, January 31, 2015 POMA District VIII Winter Seminar Farmington, PA Presented by: Paula Snyder, RN, CPHRM Regional Manager, Risk Management DISCLAIMER The information contained herein and presented by the speakers is based upon sources believed to be accurate at the time they were referenced. The speakers are not engaged in rendering legal or professional services other than risk management. If legal advice is required, the services of an attorney should be sought. This document was designed for discussion purposes only and is not intended to present detailed information on our analysis and findings. It is incomplete and not intended to be used without the accompanying oral presentation and discussion. Learning Objectives This presentation will support your ability to: Identify potential risks with using an EMR. Apply risk management strategies to promote patient safety and reduce medical liability risks associated with EMR use. January 29 February 1,

2 EMR The Changing Landscape Care Liability Workflow Accountability Communication Data Potential EMR Benefits Improved documentation Improved follow-up Improved communication and access to information Decreased errors in prescribing and dispensing medications Records won t be lost in event of disaster Potential Risk Issues with EMRs User Issues Incorrect use of system Communication issues Insufficient training HIPAA/Security issues January 29 February 1,

3 Potential Risk Issues with EMRs System Issues Faulty templates Ineffective workflow processes HIPAA/security issues EMR Related Malpractice Claims 22% due to system failure 20% due to incorrect information in EMR 16% due to hybrid systems or problems with EMR conversion 10% due to pre-populating or copy/paste CRICO Study, 2013 BEST PRACTICES January 29 February 1,

4 Documentation Scanning Consistent workflow for lab reports, etc Abnormal results Train staff on scanning policies and procedures Periodic chart audits AHIMA Position on Copying/Pasting The use of copy/paste functionality in EHRs should be permitted only in the presence of strong technical and administrative controls Users of copy/paste functionality should weigh the efficiency and time savings benefits it provides against the potential for creating inaccurate, fraudulent or unwieldy documentation. American Health Information Management Association, March 28, 2014 Documentation Copy & Paste/Templates Choose templates wisely Copy and paste policy Staff training Review entries before signing off/closing Periodic chart reviews EMR audit trail January 29 February 1,

5 Case Study Medication Reconciliation 2014 State Volunteer Mutual Insurance Company (SVMIC). Video vignette used by permission of SVMIC. Case Study Medication Reconciliation Discussion Where did this go wrong? What went right? Risk Management Recommendations Medication Reconciliation Standardized Workflow Verification Correct discrepancies Admission Inpatient transfer Discharge January 29 February 1,

6 Prescribing from an EMR April 2013 study on Rx errors via EMR Errors decreased from 24.6% to 3.8% in the two years post-implementation Limited alerts to drug allergys Used capital letters to distinguish similar med abbreviations from each other Changed dispense field from text to dropdown A Long-Term Follow-Up Evaluation of Electronic Health Record Prescribing Safety by EL Abramson, et al. Journal of American Medical Informatics Association, April 11, 2013 Prescribing from an EMR Use caution with drop-down boxes or prepopulated dosages Understand how your system handles offlabel uses of medications Adjust EMR alerts One chart open at a time Interface with outside systems appropriately Alerts & Warnings Do not bypass alerts without a process Document rationale any an alert is bypassed Consider limiting alerts to those of high severity January 29 February 1,

7 Data Security & Integrity Staff Unique username/password for each person NEVER share passwords with other staff Define standards/timeframe for when patient encounters must be signed off and locked Close patient s record when data entry or review in completed NEVER leave a computer unattended without being locked Data Security & Integrity Administration Create appropriate levels of access restrictions Ensure that screens are not visible to public Encryption and HIPAA-required security Create a back-up and disaster recovery plan Ensure that your EMR can produce an audit log Security Policies Develop a confidentiality and security policy Educate staff Notify patients Develop a policy to deal with employees who access patient information without a legitimate business reason to do so January 29 February 1,

8 Additional Resources MyNORCAL (policyholder-only website) March 2014 Claims Rx: Why You Should Optimize Your EHR System EHR articles (including sample worksheets, tools) American Health Information Management Association (AHIMA) website has sample policies and procedures for members at SAFER EHR Guides contain self assessments, worksheets and tips to optimize use of EHRs Q&A CONTACT INFORMATION Paula Snyder, RN, CPHRM Regional Manager, Risk Management NORCAL Mutual Medicus, NORCAL, PMSLIC January 29 February 1,