Where to Begin? Auditing the Current EHR System

Transcription

1 Chapter 1 Where to Begin? Auditing the Current EHR System After implementation, allow for a period of stabilization, so physicians and employees can gain more comfort using the electronic health record (EHR). The initial major issues are worked out, and the number of patient visits or procedures returns to previous counts. Depending on your practice and how smoothly the implementation occurred, the stabilization period will last one to several months after the go-live date. When the comfort level is acceptable, begin the process of optimization with an evaluation and review of the EHR and practice operations. The EHR project team should continue to take the lead in the optimization process. The team members know the practice, the goals of the EHR, and the different departments expectations and experiences with the EHR. It may be time to add another individual or two who have become system super users. The team leader should be someone who recognizes the full potential of the EHR and how to inspire everyone to attain it. There are four steps in moving toward optimization: Step 1. Conduct a gap analysis; Step 2. Identify needed changes and change management; Step 3. Staff appropriately; and Step 4. Conduct continuous quality improvement. 1

2 2 EHR Optimization and Operations Guide FOR MEDICAL PRACTICES STEP 1: CONDUCT A GAP ANALYSIS To determine what the EHR implementation has achieved versus where you want to be, review your original goals for implementing the EHR system and identify any functions, operations, and goals that are not being met. For a baseline, you can use either the practice goals developed as part of the EHR decision and selection process or the meaningful use criteria developed by the Centers for Medicare & Medicaid Services (CMS). The EHR project team or EHR project director should lead the gap analysis. The team will be able to provide input from different departments within the practice and will also have different views and opinions for assessing the EHR functions and their status. For the first option, open up the EHR project goals, charter, or request for proposals and review the list of goals. Project goals may have included business and clinical objectives, such as increasing access to patient records, reducing transcription and medical record costs, improving staffing efficiencies, better tracking of physician orders and results, reducing the number of denied claims, and improved quality of care. Derek Kosiorek of the MGMA Health Care Consulting Group provides the following goal assessment questions: Where are you compared to where you wanted to be? What was your vision for an EHR before you implemented it? If you re not using the EHR as originally planned, what do you need to do to realize the goals? 1 During the post-implementation review, ask the following additional questions: Are physicians and staff using the EHR as envisioned, or is more training needed? Are they following the new workflow or stuck in the old ways? Are physicians doing what they should be doing, or are they doing clerical work or using workarounds?

3 CHAPTER 1 Where to Begin? Auditing the Current EHR System 3 Is the workflow reaching the ideal as it was mapped, or do changes need to be made? Are employees still writing down or printing information unnecessarily? Is after-hours time needed to catch up on work? What efficiencies are needed to accomplish work during the day? Do policies and procedures reflect the changes brought about by EHR implementation? Are they updated as needed? How are the interfaces with pharmacies, laboratories, and billing or insurance companies working? Measure this by the percentage of prescriptions and test orders sent and received electronically. Do you have appropriate staff for achieving optimization? Do you need a consultant or additional employee with skills that are currently lacking in your practice? Are charges captured and posted correctly? How is the interface with the practice management software (PMS) working? Review charges on a daily basis to ensure accurate charge capture. Are coding functions providing accurate coding? 2 Is the EHR system producing the reports you want with the data you need? Meaningful Use The second gap analysis option uses the meaningful use criteria to compare a list of goals with current status. To encourage physicians to implement EHR systems, the American Recovery and Reinvestment Act of 2009 (ARRA) directed CMS to offer incentive payments to providers who meet the meaningful use definition. Meaningful use criteria are intended to show that the EHR is implemented and used within a provider s location as more than a digitized paper record. Even if you have no interest in pursuing the CMS financial incentives, the meaningful use criteria are an excellent list of EHR functions that can serve as a baseline for comparing your current status of implementation.

4 4 EHR Optimization and Operations Guide FOR MEDICAL PRACTICES i ADDITIONAL INFORMATION For the most current information on meaningful use requirements, visit these Web sites: MGMA Government Affairs Web pages at policy; Department of Health and Human Services Health IT Web site at or The CMS Web site at If using meaningful use criteria to conduct your gap analysis, start with the Stage 1 objectives. Stage 2 criteria will encourage continuous quality improvement and the electronic exchange of health information, as well as provide requirements for e-prescribing. Stage 3 will increase the emphasis on decision support for improving outcomes along with a more robust health information exchange. Stage 2 and 3 criteria were not finalized as of this writing. 3 Many of the Stage 1 requirements (see Exhibit 1.1) do not require 100 percent compliance initially. For example, for the e-prescription criteria, 30 percent of patients must have at least one prescription ordered through the EHR function. Along with the Stage 1 criteria for EHR functions, meaningful use requires gathering and reporting data on quality of care measures. Participation from each physician within a group practice is required, but not overall practice participation. Therefore, each physician must use the EHR to record the provision of preventive and disease management services in a manner that can be extracted and reported from the EHR. This is discussed further in Chapter 9. Gap Analysis Spreadsheet Develop a spreadsheet listing the meaningful use criteria or your practice s internal EHR project goals. Columns should include current

5 CHAPTER 1 Where to Begin? Auditing the Current EHR System 5 Exhibit 1.1 Meaningful Use Criteria Stage 1 Objectives for Physicians and other Eligible Professionals Measure criteria Core Objectives 1 Use Computerized Provider Order Entry (CPOE) for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines >30% 2 Implement drug-drug and drug-allergy interaction checks Enabled 3 Generate and transmit permissible prescriptions electronically (erx) >40% 4 Record the following patient demographics: preferred language, gender, race, ethnicity, and date of birth >50% 5 Maintain an up-to-date problem list of current and active diagnoses >80% 6 Maintain active medication list >80% 7 Maintain active medication allergy list >80% 8 Record and chart changes in vital signs: height, weight, and blood pressure. Calculate and display BMI. Plot and display growth charts for children 2 20 years, including BMI. >50% 9 Record smoking status for patients 13 years old or older >50% Objective met: Yes or No Department or individual responsible for objective Date to achieve objective (continued on next page)

6 6 EHR Optimization and Operations Guide FOR MEDICAL PRACTICES Stage 1 Objectives for Physicians and other Eligible Professionals Measure criteria 10 Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule One rule 11 Report ambulatory clinical quality measures to CMS or, in the case of Medicaid, the States Successfully report to CMS 12 Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies), upon request >50% 13 Provide clinical summaries for patients for each office visit >50% 14 Capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically One test 15 Protect electronic health information created or maintained by the certified EHR technology through the implementation of appropriate technical capabilities Conduct or review security risk analysis Objective met: Yes or No Department or individual responsible for objective Date to achieve objective

7 CHAPTER 1 Where to Begin? Auditing the Current EHR System 7 Menu Set: Select 5 measures including 1 from Population Health The other 5 measures defer to Stage 2 1 Implement drug formulary checks Enabled 2 Incorporate clinical lab-test results into EHR technology as structured data >40% 3 Generate lists of patients by specific conditions to use for quality One list improvement, reduction of disparities, research or outreach 4 Send reminders to patients per patient preference for preventive/ follow >20% up care 5 Provide patients with timely electronic access to their health information >10% (including lab results, problem list, medication lists, allergies) within four business days of the information being available to the EP 6 Use certified EHR technology to identify patient-specific education >10% resources and provide those resources to the patient if appropriate 7 The EP who receives a patient from another setting of care or provider >50% of care or believes an encounter is relevant should perform medication reconciliation. 8 Provide summary of care record for each transition of care to another >50% setting of care or referral to another provider 9 Population Health: Capability to submit electronic data to immunization One test registries or immunization information systems and actual submission in accordance with applicable law and practice 10 Population Health: Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice One test Source: Centers for Medicare & Medicaid Services, EHR Incentive Programs, Eligible Professional Meaningful Use Table of Contents Core and Menu Set Objectives, (accessed November 8, 2011).

8 8 EHR Optimization and Operations Guide FOR MEDICAL PRACTICES status (met or unmet), who is tasked with meeting the criteria or goal, and when your practice plans to meet the goals. If using meaningful use criteria, start with the Stage 1 objectives listed in Exhibit 1.1. Exhibit 1.2 suggests where in the patient-flow process it is appropriate to incorporate functions that support the meaningful use criteria. Exhibit 1.2 Organizing Meaningful Use Tasks by Steps in Patient Flow Medications list* Reminders* Demographics Vitals Smoking Medication allergies Medication reconciliation* CPOE prescriptions Drug-drug interaction Formulary* e-prescribe Problem list Medications Clinical decision support Lab results integration* Patient electronic copy Clinical summary Patient electronic access Patient education* Quality measures Electronic interchange capability Referral summary* Immunizations* Syndromic data* Privacy and security * Menu set measures Patient Provider Check- Post- Pre-Visit Registration Intake Encounter Out Visit Cindy Dunn, RN, FACMPE. Used with permission.