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PRACTICAL  PITFALLS  OF  THE  ELECTRONIC  MEDICAL  

RECORD STEVE  WAXMAN  MD,  JD,  FCLM  ACLM  57TH  ANNUAL  MEETING  

FEBRUARY  25,  2017  

DISCLOSURES

Mid-­‐America  Kidney  Stone  AssociaMon-­‐Shareholder  

TERMINOLOGY

Ø  Electronic  Medical  Records  (EMRs)  

Ø  Electronic  Health  Records  (EHRs)  Ø  Personal  Health  Records  (PHRs)  Ø  Hospital  Based  Systems  

Ø  Office  Based  Systems  

VENDORS

Ø  Meditech  

Ø  Cerner  Ø  McKesson  

Ø  Epic  Systems  

Ø  Siemens  Healthcare  

Ø  VistA-­‐Veterans  Affairs  Ø  AHLTA-­‐U.S.  Military  

Ø  And  Hundreds  More  

HEALTH  INFORMATION  TECHNOLOGY  LEGISLATION

Ø  American  Recovery  and  Reinvestment  Act-­‐-­‐-­‐ARRA  

Ø  Health  Insurance  Portability  and  Accountability  Act-­‐-­‐-­‐HIPAA  Ø  Health  InformaMon  Technology  For  Economic  and  Clinical  Health-­‐-­‐-­‐HITECH  

Ø  Affordable  Care  Act-­‐-­‐-­‐ACA  Ø  FDA  Safety  and  InnovaMon  Act-­‐-­‐-­‐FDASIA  

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Stage  1:    Meaningful  use  criteria  focus  on:  

Stage  2:  Meaningful  use  criteria  focus  on:  

Stage  3:    Meaningful  use  criteria  focus  on:  

Electronically  capturing  health  informaMon  in  a  standardized  format   More  rigorous  health  informaMon  exchange  (HIE)   Improving  quality,  safety,  and  efficiency,  leading  to  improved  

health  outcomes  

Using  that  informaMon  to  track  key  clinical  condiMons  

Increased  requirements  for  e-­‐prescribing  and  incorporaMng  lab  results   Decision  support  for  naMonal  high-­‐priority  condiMons  

CommunicaMng  that  informaMon  for  care  coordinaMon  processes  

Electronic  transmission  of  paMent  care  summaries  across  mulMple  seangs   PaMent  access  to  self-­‐management  tools  

IniMaMng  the  reporMng  of  clinical  quality  measures  and  public  health  informaMon   More  paMent-­‐controlled  data   Access  to  comprehensive  paMent  data  through  paMent-­‐

centered  HIE  

Using  informaMon  to  engage  paMents  and  their  families  in  their  care       Improving  populaMon  health  

MEANINGFUL  USE EMR  USAGE  IN  U.S.  AS  OF  2015

Ø  Hospitals-­‐90%  Stage  2  (Meaningful  Use)  

Ø  Offices-­‐87%  Had  Any  EMR  

Ø  Offices-­‐54%  Had  Basic  EMR  

Ø  Offices-­‐41%  PaMents  Could  Download  Their  Own  Medical  Record  

Ø  Offices-­‐19%  Could  E-­‐Send  Their  Record  to  a  3rd  party  

Ø  Already  Way  Past  Being  the  First  One  to  Adopt-­‐Don’t  Want  to  be  the  Last  to  Adopt-­‐PenalMes  

Ø  Technology  Constantly  Advancing-­‐Hard  Enough  Keeping  Up  With  Advances  In  Medicine  

Ø  It  Is  Very  Expensive  Ø  Now  Add  the  Epidemic  of  Hacking  and  IdenMty  Theh    

COMPUTERIZED  PHYSICIAN  ORDER  ENTRY  (CPOE)

Ø  Standardized  Order  Sets-­‐Reviewed  and  Approved  by  Medical,  Nursing  and  Pharmacy  Staffs  

Ø  Orders,  Sets  and  Protocols  Consistent  with  NaMonally  Recognized  and  Evidence  Based  Guidelines  Ø  Periodic  and  Regular  Review  by  Medical,  Nursing  and  Pharmacy  Staffs  

Ø  Hospital  Commiiees  Determine  the  ConMnuing  Usefulness  and  Safety  

Ø  Dated,  Timed  and  AuthenMcated  in  the  EMR  

Ø  Must  have  Robust  Training  and  Real  Time  Support  24/7  

Ø  Must  Ensure  “Workarounds”  by  Providers  Do  Not  Compromise  PaMent  Safety  or  Validity  of  EMR  

CONTENT  IMPORTING  TECHNOLOGIES  (CIT)

Ø  PotenMal  Problems  During  an  Audit  

Ø  Progress  Notes  with  Physical  Exams  Nearly  IdenMcal  on  Subsequent  Visits-­‐Over  Time  or  Changes  in  Dx  

Ø  MulMple  PaMents  with  Exactly  the  Same  Findings  

Ø  Extraordinarily  Long  and  Detailed  Progress  Notes  Not  Necessary  to  Address  the  Problem  

COPY  AND  PASTE

Ø  Good  For  Things  Like  a  Pathology  Report    Ø  Standard  DescripMon  of  a  Procedure-­‐-­‐-­‐i.e.  Vasectomy  or  Informed  Consent  for  Radical  Prostatectomy  

Ø  Bad  When  ImporMng  Material  That  is  Inaccurate  or  Not  PerMnent  to  the  New  Encounter  

Ø  Also  Bad  When  Copied  Material  is  Not  Properly  Edited  to  Accurately  Reflect  the  Current  Encounter  

Ø  “Note  Bloat”  Makes  it  Tougher  to  Find  Clinically  Relevant  InformaMon  Related  to  Current  Visit  

Ø  Unnecessary    Loading  of  Detailed  InformaMon  From  the  Past  Lessens  Credibility  of  the  Note/Provider  

Ø  Ugly  When  >  50%  of  Providers  note  is  Copy/Paste.  Metadata  &  Plagiarism  Sohware  Picks  This  Up    Easily  

Ø  Different  From  Specialty  Offices  Which  May  See  a  Large  Number  of  Similar  CondiMons  

PRE-­‐POPULATION  AND  INFORMATION  PULLED  FORWARD

Ø  Demographics  

Ø  Past  Surgical  History  Ø  Past  Medical  History  

Ø  Meds  

Ø  Allergies  Ø  Review  of  Systems  Update  

Ø  Pressures  to  Aggressively  Code  Ø  Limit  the  Types  of  Data  to  Pull  Forward-­‐Demographics  and  Relevant  Info/Procedures/Reports,  etc.  

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TEMPLATES  AND  AUTOMATED  TEMPLATES Ø  Good  in  That  They  Facilitate  Uniformity  and  Ease  of  Retrieval    

Ø  Need  Room  to  Free  Text  and  Personalize  the  Encounter  

Ø  Problems  Arise  When:  

Ø  The  Note  Appears  to  be  “Canned”  Ø  Default  Seangs  are  Normal  or  “Auto  negaMve”  

Ø  Was  Every  Item  Examined?    

Ø  Were  they  All  Really  Normal?  

Ø  Looks  Bad  When  Caught  Red  Handed-­‐Normal  Neuro  Exam  on  Paraplegic  PaMent  

Ø  Upcoding    or  Overcoding?  

FREE  TEXT  AND  DRAGON

Ø  Allows  the  Provider  to  “Personalize”  the  Note  Ø  Templates  Should  Be  Adjustable  

Ø  Some  Templates  are  Designed  to  Capture  a  Level  of  Code  Rather  Than  Address  the  Problem  

Ø  Need  Complete  CollecMon  of  InformaMon  to  Achieve  Each  Level  of  Code  

Ø  However,  Is  the  Problem  Appropriate  to  JusMfy  the  Level  of  Care?  

Ø  i.e.-­‐-­‐-­‐DocumenMng  More  Intensive  Services  Than  Were  Reasonable  and  Necessary  Under  the  Circumstances.  Level  5  for  Minor  LaceraMon  or  Ankle  Sprain  

Ø  AuthenMcaMon-­‐Diagnosis  Codes,  Level  of  Complexity  and  Care,  Is  It  Correct?-­‐  Is  It  Warranted?  

Ø  Machine  Generated  Level  of  Care  Code?,  Frequent  Use  of  Time  Spent  With  PaMent  Override  to  Increase  Code  

CLONING

Ø  Suspicious  When  Every  Entry  in  EMR  is  the  Same  or  Similar  to  the  Previous  Entries  

Ø  Between  Entries  of  the  Same  PaMent  or  Between  Entries  of  Different  PaMents  

Ø  Similar  is  OK  if  Record  Accurately  Reflects  Clinical  SituaMon—i.e.-­‐Cold,  Flu,  GastroenteriMs  

Ø  Medicare  Audit-­‐True  Cloning-­‐MisrepresentaMon  of  Medical  Necessity  Requirement  of  Services  

Ø  Office  of  Inspector  General  (OIG)-­‐-­‐Over  documentaMon-­‐InserMng  False  or  Irrelevant  DocumentaMon  

Ø  Concern  Over  EMR-­‐Facilitated  Entries  That  Generate  Extensive  DocumentaMon  With  a  Single  Click  of  a  Checkbox  

USER  INTERFACE  ISSUES

Ø  Menus  and  Checkboxes  

Ø  Risk-­‐”Adjacency  Error”  Checking  the  Item  Next  to  the  Intended  Item  

Ø  Concern-­‐Structuring  the  Menu  Lists  by  Forcing  Choices  of  More  RemuneraMve  Services  or  CreaMng  False  DocumentaMon  

Ø  More  Time  Spent  Face  to  Face  with  Laptop  Means  Less  Time  Face  to  Face  With  PaMent  

Ø  When  to  Document/Dictate  into  the  Note?  

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ALERTS,  PROMPTS,  AND  WARNINGS

Ø  Alert  FaMgue-­‐DesensiMzed  to  Alerts-­‐Either  Ignored  or  Silenced  Ø  Clinical  Decision  Support  (CDS)-­‐Review  CDS  Prompts  Annually-­‐Update  and  Edit  Prompts-­‐Weed  Out  

Irrelevant  Ones  and  Reinforce  the  CriMcal  Ones  

Ø  Access  and  NavigaMon  Controls-­‐Don’t  Want  Too  Many  PaMent  Charts  Open  at  Same  Time-­‐  Prevent  Puang  Notes  or  Orders  Into  the  Wrong  Chart  

Ø  Search  and  Retrieval  Capability-­‐Design  and  Modify  Systems  to  Facilitate  Ease  of  Access  to  Providers  

Ø  User  “Unfriendly”  Systems  Lead  to  Increased  Risk  of  FrustraMon  and  Errors  and  PotenMal  PaMent  Harm  

PROVIDER  AWARENESS  OF  OTHER  DATA  IN  EMR

Ø  Screen  Shots  of  What  the  Provider  Viewed  

Ø  Results  Visible  in  One  Program  But  Not  in  Another  

Ø  Provider  Not  Aware  of  Data-­‐Labs/Radiology  Results/Other  Providers  Notes  in  the  EMR  

Ø  Changes,  Corrected  Results  and  CriMcal  Results-­‐Knowing  The  Results  Were  Seen  and  Acted  Upon  By  The  Provider  

Ø  Are  All  The  FuncMonaliMes  Being  UMlized  In  the  EMR-­‐Lab  Tab/Radiology  Tab  

Ø  EMRs-­‐You  Get  What  You  Pay  For-­‐And  None  are  Cheap  

AUTHENTICATION  ISSUES

Ø  Log-­‐in  Controls  Ø  User  IdenMty  Ø  Medical  Record  AuthenMcaMon  

Ø  Providers  With  Same  Last  Names  Geang  Each  Others  Results  

Ø  Privacy,  Security,  Unauthorized  Release  of  Medical  InformaMon  

Ø  Increased  Liability  for  Providers  and  Hospital  for  Improper  Use  of  EMR  

Ø  If  Provider  Relies  on  EMR  RecommendaMons  and  There  is  Injury-­‐Are  Hospital  and  Vendor  also  Liable?  

CLINICAL  DECISION  SUPPORT  (CDS)  FUNCTIONALITY

Ø  Recommend  Course  of  AcMon  Ø  Warn    Ø  Assist  Ø  Advise  Ø  Applying  Treatment  Guidelines  Using  Evidence  Based  Sources  Ø  Algorithms—”Cook  Book  Medicine”?  Ø  AutomaMc-­‐Rules  Based  Prompts  or  Surveillance  Alerts  

Ø  On-­‐Demand-­‐Allows  Physician  to  Ask  For  Assistance  Ø  Hard  Stops-­‐Prevent  an  Error  Which  Could  be  Injurious  Ø  But  SMll  Must  Allow  a  ConMngency  For  Non-­‐Standard  Orders  

CODING  AND  BILLING  SUPPORT  FUNCTIONALITY

Ø  Concern-­‐Geared  to  Maximize  Reimbursement  

Ø  Encourage  Providers  to  Pad  the  EMR  DocumentaMon  to  JusMfy  Greater  Reimbursement  

Ø  Sohware-­‐Accuracy  and  Reliability  of  the  Recommended  Coding  is  ProblemaMc  

Ø  ImplementaMon  Policies  and  Procedures  Adopted  by  the  Providers  

Ø  Programs  Cannot  Evaluate  the  Medical  Necessity  of  the  Elements  Listed  in  the  EMR  

Ø  QuesMon-­‐Was  it  Reasonable  and  Necessary  to  Evaluate  Those  Organ  Systems?  

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RECOMMENDATIONS  TO  IMPROVE  CODING

Ø  EMR  Generates  a  Suggested  Code  and  Preliminary  RecommendaMon-­‐Provider  Can  Accept  or  Edit  

Ø  EMR  Suggests  Diagnosis  Codes  Which  Provider  Can  Accept  or  Edit  

Ø  Coding  Teams  Are  Ubiquitous  in  Hospitals  and  Offices  Today  

Ø  Diagnosis  Coding  Drives  Hospital  Reimbursement  

Ø  Crucial  That  The  Charge  Capture  System  Only  Bills  For  Services  Rendered  and  Not  All  Things  Ordered  

Ø  Now  The  Move  Towards  DocumenMng  Outcomes  As  Reimbursement  Will  Be  Tied  to  That  Metric  

EMR  

Ø  ConnecMvity  to  Other  EMRs  

Ø  Labs  and  Imaging  Results  

Ø  Viewing  Images  

Ø  Addendum  to  the  Note  

Ø  EdiMng  the  Note  Ø  Tampering  With  The  Note-­‐Screen  Shots-­‐Metadata  

Ø  EducaMng  The  Provider-­‐Improve  Competence-­‐Crah  The  CharMng  To  Your  PracMce  

Ø  ArMficial  Intelligence,  Clinical  Decision  Making,  Diagnosis  and  Coding  Assistance  

 

NOTIFICATION  OF  RESULTS  ORDERED

Ø  Labs  Ø  Imaging  

Ø  Cultures  Ø  Specimens  to  Pathology  

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COMMUNICATIONS  WITH  OTHER  PROVIDERS

Ø  Office  Notes  and  Labs  and  Imaging  From  Referring  Providers  

Ø  Consultant  Notes  From  Specialists  

Ø  ConfirmaMon  That  Referral  was  Received  by  Other  Office  and  Appointment  was  Made  

Ø  NoMficaMon  That  PaMent  Could  not  be  Reached  or  Missed  Their  Appointment  

SCANNING  INFORMATION  INTO  THE  EMR

Ø  ConverMng  From  Paper  to  Electronic  IniMally  

Ø  What  to  Import  and  What  not  to  Import?  

Ø  Entering  Received  Results  –Labs,  Imaging  and  Clinic  Notes,  DictaMon  

Ø  Reviewing  Newly  Received  Data  Prior  to  it  Being  “Filed”  

NOTIFICATION  TO  PATIENTS  OF  RESULTS

Ø  Who  is  Responsible  to  “Ask  For”  vs.  “NoMfy”  the  PaMent  of  All  Test  Results?  

Ø  List  or  “Tickler  File”  of  PaMents  Who  Have  Pending  Test  Results  

Ø  Who  is  Looking  For  and  NoMfying  the  PaMents?  

Ø  Are  They  Knowledgeable  of  What  is  “Normal”  and  “Abnormal”?  

Ø  Memorializing  the  Acknowledgement  and  NoMficaMon  to  the  PaMent  of  the  Test  Results  

Ø  MemorializaMon  of  the  Plan  of  Treatment  or  Follow-­‐Up  

Ø  MemorializaMon  of  PaMent  Discussions  Regarding  Treatment  Plan  or  Informed  Consent  

CONCLUSIONS

Ø  Technology  ConMnues  to  Advance  and  Improve  

Ø  The  EMR  Has  Already  Improved  The  Storage  of  PaMent  Data  

Ø  The  EMR  Has  Improved  PaMent  Safety  

Ø  The  EMR  Will  ConMnue  to  Alter  the  Provider-­‐PaMent  RelaMonship  

Ø  EMRs  Are  Not  Foolproof-­‐Will  Always  Have  Human  Errors  and  Systems  Errors  

Ø  Certain  Aspects  of  EMRs  Can  Open  Providers  Up  to  Increased  Liability    

Ø  Providers  Should  Tailor  The  EMR  to  Their  Own    Unique  PracMce  Habits    

REFERENCES

Ø  Electronic  Health  Records:  How  to  Avoid  Digital  Disaster.    Susan  R.  Gering.  16/Mich.  St.  U.  J.  Med.  &  L.  297  Ø  Challenges  With  The  Electronic  Medical  Record.  Robert  H.  Ossoff,  Christopher  D.  Thomason,  Julie  Appleton.  

12  No.  6  J.  Health  Care  Compliance  51  Ø  Electronic  Medical  Records:  A  PrescripMon  for  Increased  Medical  MalpracMce  Liability?    Blake  Carter.  13  Vand.  

J.  Ent.  &  Tech  L.  385  

Ø  Electronic  Medical  Record  DocumentaMon:  Inherent  Risks  and  Inordinate  Hazards.  Timothy  P  Blanchard,  Margaret  M.  Manning.  2016  Health  L.  Handbook  

Ø  Electronic  Medical  Records  and  E-­‐Discovery:  With  Every  New  Technology  Come  New  Challenges.  Jeffrey  L.  Masor.  5  HasMngs  Sci.  &  Tech  L.  J.  245  

Ø  The  Legal  Challenge  of  IncorporaMng  ArMficial  Intelligence  Into  Medical  PracMce.  Amanda  Swanson,  Fazal  Khan.  6  J.  Health  &  Life  Sci.  L.  90  

 

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THANK  YOU