When EMRs Meet Surveyors and Other Things That Go Bump in the Night February 2012 Lisa Conrad, RN, RAC-CT; Diane Felix, JD; Suzanne Sheldon, RN, JD 1 Issues which are important, but that we won t be dealing with in this short presentation Choosing vendors Vendor contracting issues Initial implementation of EMR system Inter-organization communication issues System security issues 2 1
What is an EMR (Electronic Medical Record)? EMR very simply is the electronic record of information about an individual s health care that is created, gathered, managed and consulted by caregivers in a single health care organization. 3 How is that different from an EHR (Electronic Health Record)? EHR is the aggregate electronic record of healthrelated information on an individual that is created and gathered by multiple health care organizations. 4 2
EMR vs. EHR 5 Assessing Nationwide Adoption Varying Definitions of HIT/EHR if defined at all Many surveys state-specific Varying sample sizes Not able to be generalized nationwide Estimates range from low 1-14% to a high of 18-47% Most using HIT to meet federal requirements Clinical applications minimally used 6 3
A rose is a rose. But one EMR system isn t going to be the same as the next. An EMR in acute care setting won t have the same components as one in a long-term care setting. In-house counsel and facility management should be alert to this when dealing with outside counsel who may be more familiar with acute care EMR systems. 7 What is in a typical LTC EMR? An organization may start with automated MDS and Care Planning, but that s not enough to = EMR 8 4
Other typical LTC EMR ingredients MDS Workflow Care Plans CNA Assignment and ADL Flow Sheets Therapy Charting and Charge Capture 9 The EMR does not = The Medical Record Almost certainly there will be reports and information that are a part of the medical record, but that are not part of the EMR. Each organization needs to define and understand what is and is not in the EMR to make sure that it provides the right information to outside consumers. 10 5
11 Examples of information that may not be included in the EMR Physician and Nurse Practitioner Progress Notes Hospice Care Plans and Progress Notes Labs and X-Rays In-house Tools and Monitoring Records, such as Neuro-Check Documentation 12 6
EMRs Present Multiple Challenges for LTC Management and Legal Counsel 13 Some challenges are simply new versions of old problems Planning and training for surveys Training needs Cookie cutter or sloppy charting Specific concerns: cutting and pasting, wrong chart, spelling, abbreviations Incomplete or inappropriate production of records to outside users 14 7
Other challenges are new ones Printed information from an EMR that looks very different from what is viewed live on the system Outside users unfamiliar with and even hostile to the idea of EMRs Workarounds and unofficial paper records used by staff Staff lending passwords and not logging out EMRs will differ from organization to organization 15 Challenge: Live View doesn t necessarily translate to printed page This is a particular problem with outside users surveyors, their supervisors and others in survey agencies, and lawyers requesting records. Surveyors who aren t specific about their concerns may get only the first layer of data, which may lead to their assuming that s all there is. Organizations need to think about how to assure that paper records being produced capture the care that s been given. 16 8
17 Looks Different! 18 9
Challenge: Surveys Not only are surveyors not your friends, they aren t in the business of assisting you in showing that you are in compliance. You have the burden of making sure that your systems and staff can demonstrate your measures to achieve compliance and quality care. 19 Challenge: Surveys cont d Training and preparing for surveys needs to take into account the new twists that EMRs bring to the process. See Checklist to Prepare for EMR Use in Surveys. 20 10
Which Report(s) Does the Surveyor Need? 21 Challenge: Surveys cont d Although CMS has recognized the important and necessary role of EMR in LTC, not all surveyors are enthused. Be aware of what CMS has published about EMR and the survey process 22 11
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25 Challenge: Surveys cont d The 2009 CMS Survey and Certification Letter also directed surveyors to look at whether EMR use is consistent with Medicare Conditions of Participation for instance: Are computer screens showing clinical information left unattended and readily visible to residents and visitors? Are passwords publicly posted? 26 13
Challenge: Surveys cont d Facility management should be familiar with these EMR features and their role in preparing for surveys and responding to surveyor questions. Over-riding / audit trails. Meta Data reports. Clinical Dashboards for monitoring care. 27 28 14
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31 Challenge: Surveys cont d It s critical to make sure that appropriate staff can use and explain to surveyors how they use EMR features. Clinical decision-making tools. Prompts when charting is outside the normal ranges or parameters. Drug allergy and dosage cross-checks. 32 16
Challenge: Training Needs Once is not enough. Organizations underestimate how long it takes to bring about and maintain change. 3-Legged Stool: People, Process, Technology. Often focus is on the Technology, and the People and Process legs don t get enough attention. 33 Challenge: Cookie Cutter Entries, Sloppy Charting Not a new problem, but automated system makes it easier to copy a prior entry, which may mean that current and appropriate information doesn t get charted. May lead not only to inaccurate records, but problems with supporting claims for reimbursement. 34 17
35 Challenge: Appropriate Responses to Record Requests Example: Law firm requesting medical records for two different residents gets copies with different components. Example: Surveyor requesting records on pressure sore treatments gets records with varying levels of detail for various residents. 36 18
Challenge: Workarounds and Unofficial Paper Records What s a workaround? Wikipedia: a bypass of a recognized problem in a system typically a temporary fix. pressure on a workaround may result in later system failures. 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. 37 Challenge: Workarounds cont d A 2007 study referenced in this session s written materials provided numerous examples of this phenomenon related to medication administration and safety practices. Even organizations with well-supervised and welltrained staff should assume that workarounds are in use. 38 19
Challenge: Unofficial paper records cont d Unofficial paper records are not unique to facilities with EMRs. Staff may use paper cheat sheets or back-up notes with EMRs, especially if they are suspicious of the system or concerned about delays in accessing information. Especially in early stages of EMR implementation, staff may be printing many records. This should lessen with increased trust and familiarity with the system, but is unlikely to completely stop. 39 Recommendations to Meet the Challenges Find the go-to person (inside or outside the facility) who knows what the system can and cannot do. Ask about records still maintained on paper officially and unofficially. Ask what staff are doing when the EMR system makes their jobs difficult. (What workarounds are they using?) Find out how the EMR system tracks alterations and modifications to the records. 40 20
Assure your organization has policies covering: What the medical record includes. Dealing with record requests and litigation discovery requests. Backing up the system, and making sure the back up is working. Using passwords. Modifying records. 41 Checklist to Prepare for EMR Use in Surveys Assure EMR is set up so surveyor won t have inappropriate access (eg, QA Committee notes, incident reports) and has read-only access. Make one or more computer terminals available for surveyors to work at, and arrange for surveyors individual passwords. Designate one or more individuals to assist surveyors with EMR, and to coordinate producing any printed copies requested by surveyors. Maintain a file copy of all printed records provided to surveyors, during or after the survey. 42 21
43 Checklist to Prepare for EMR Use in Surveys cont d Remind staff of: (i) confidentiality concerns with information that can be seen by others on monitors and tablets, (ii) need to protect passwords, and (iii) ease with which surveyors can monitor when information is recorded vs. when care reportedly was provided. Provide a written warning along with any printed copies, which alerts surveyors (and others in the survey agency who may review the information later) to the fact that printed versions won t necessarily duplicate information the surveyor is seeing on the system. Review how your EMR will demonstrate compliance (or noncompliance) with hot button issues such as pressure sores, falls and Coumadin therapy Speakers Contact Information Suzanne Sheldon Director of Risk Management and Corporate Compliance Lutheran Senior Services 1150 Hanley Industrial Ct. St. Louis, MO 63144 (314) 446-2577 (314) 446-2550 (Fax) Ssheldon@LSSLiving.org Diane E. Felix Partner Armstrong Teasdale LLP 7700 Forsyth Blvd., Suite 1800 St. Louis, MO 63105 (314) 342-8001 (314) 612-2243 (Fax) dfelix@armstrongteasdale.com Lisa Conrad, RN, RAC-CT Director System Integration Optimus EMR, Inc. 17802 Skypark Circle, Suite 105 Irvine, CA 92614 (888) 617-2457, ext. 227 lconrad@optimusemr.com 44 22