Unit 3 Electronic Health Records & Ancillary Functions of a Health Record PDF

Unit 3: Electronic Health Records & Ancillary Functions of a Health Record Jessica L. Hess, MPA, RHIA HEALTH SERVICES ADMINISTRATION Incomplete and Delinquent Records Let’s Review Timeframes for Medical Records H&P (30 da...

Unit 3: Electronic Health Records & Ancillary Functions of a Health Record Jessica L. Hess, MPA, RHIA HEALTH SERVICES ADMINISTRATION Incomplete and Delinquent Records Let’s Review Timeframes for Medical Records H&P (30 days prior updated with 24 hours; if not seen a provider then you need an H&P within 24 hours) OP Report (with 24 hours of surgery or ASAP) Discharge Summaries – 30 days to complete V/O & T/O – Medicare (48 hours in the absence of state law) v. Kentucky (30 days) v. General Rule of Thumb (24 hours or ASAP) Consents – prior to procedure Autopsy – (provisional 3 days) and final 60 days Health Services Administration Let’s Review the Medical Staff Who are they? – Physicians, APRN, PA What/who governs them? – CMO  CEO  BOD Medical Staff Bylaws: Let’s take a look… Health Services Administration The Role of HIM? How do these two things come together? Med Staff are aware of the Med Staff Bylaws HIM is aware of the bylaws What is HIMs responsibility? Deficiency software Health Services Administration  HSA 302 Incomplete Record Control Quantitative Analysis AKA: Discharge Analysis, Chart Analysis, Deficiency Analysis Purpose A general review for record completeness performed on 100% of all records Timing Retrospectively - Majority of the time Can be done concurrently (Concurrent Analysis) Health Services Administration  HSA 302 Incomplete Record Control Steps of Quantitative Analysis Key required documents are present All forms/entries are authenticated Flag any missing documents and authentications for each physician or provider Enter deficiencies into the chart deficiency software Health Services Administration Examples Forms/documents/consents signed Orders include: med name, dose, frequency, route, duration Vitals are documented All forms have pt name and MRN Discharge summary is completed Health Services Administration  HSA 302 Incomplete Record Control Qualitative Analysis Purpose Review to determine quality and adequacy of documentation Review to determine if documentation policies of the HCO, licensure regulations, and accreditation standards are being followed. In-depth review of a sample of records – goes beyond physician documentation Evaluates timeliness of documentation Legibility Thoroughness Health Services Administration  HSA 302 Incomplete Record Control Qualitative Analysis (continued) Can be done concurrently or retrospectively Synonymous terms for concurrent review Open record review Point-of-care review Continuous record review Synonymous term for retrospective review: Closed record review Joint Commission requires an open record review of documentation Health Services Administration Examples Writing is legible Abbreviations are approved Results are followed up with physician to assure additional orders as needed. Health Services Administration HSA 302 Incomplete vs. Delinquent Completion Time Starts at the moment of discharge Incomplete = Deficient Completion policies are established by the medical staff Health Services Administration HSA 302 Incomplete vs. Delinquent Delinquent Records Records that have fallen beyond the record completion time frame Example: Joint Commission – All records are to be completed within 30 days of discharge Hospital – All records are to be completed within 14 days of discharge Health Services Administration HSA 302 Incomplete vs. Delinquent Delinquent Records (Continued) JC Requirement Number of delinquent records cannot exceed 50% of average number of discharges Open record review helps Catch missing signatures Ensure timely dictation or written documentation occurs Most hospitals no longer check missing signatures on physician progress notes or orders retrospectively due to open record reviews Health Services Administration  Dr. Johnson gave a V/O for Ms Jones on March 15th and she was discharged on March 18th. April 8th – V/O has not been signed – (per KY law they 30 days) – incomplete/deficient Quantitative Qualitative Key required documents are present Evaluates timeliness of All forms/entries are documentation authenticated Legibility Thoroughness Incomplete/ Delinquent – past Deficient – still the timeframe within timeframe Health Services Administration HSA 302 Penalties for Delinquent Records Penalties are determined by medical staff Common Temporary suspension from medical staff No admission of new patients until delinquent records completed No posting of surgeries for the individual (or the group) Levying of fines per incomplete record per day Health Services Administration HSA 302 Penalties for Delinquent Records If suspended more than 30 days for delinquent records: Must reapply to medical staff Suspension reported to the National Practitioner Databank (NPDB) and state medical board Health Services Administration HSA 302 Notification of Physicians First notice - Reminder Reminder that there are incomplete records to be completed Usually a count: # to dictate, # to sign Normally, sent weekly Second notice – Warning Letter Listing of delinquent or near delinquent records Penalties for non-completion Health Services Administration HSA 302 Notification of Physicians Third notice – Suspension Letter Prepared by HIM director Sent by Administration or Chief of Medical Staff or Chair of Medical Record Committee (physician) Delineates the suspension penalty applied Fourth notice – Intent to Remove Letter Notice of potential removal from medical staff and the implications of that Sent by Administration or Chief of Medical Staff Health Services Administration HSA 302 Notification of Physicians Fifth notice – Dismissal Letter Sent by Administration or Chief of Medical Staff Notification of medical staff revocation Health Services Administration Electronic Health Records: Why Convert?  HSA 302 Definitions Electronic Health Record (EHR) A computerized record of health information that is maintained in a manner that facilitates the sharing of information among a variety of authorized entities Electronic Medical Record (EMR) A computer-based health record in which an HCO’s information about one patient is stored Health Services Administration  HSA 302 Definitions Personal Health Record (PHR) A computerized or paper-based health record maintained and updated by an individual about himself or herself This is not the same as Patient Portal Health Information Technology (HIT) The use of technology to manage patient health care information Health Services Administration  HSA 302 Why Go Electronic? Decreased Medical Errors To Err is Human: Building a Safer Health System (1999) Between 44,000 and 98,000 medical error deaths per year Today: 210,000-440,000 medical error deaths per year Increased Savings VA saved Flagging of drug interactions approximatel Verify medications and doses y 4.64 billion from preventing ADEs Health Services Administration  HSA 302 Why Go Electronic? Increased Communication Misfiled or lost documents Incomplete or inaccurate information Illegible records Health Services Administration  HSA 302 Legibility Accoun ts about 7 for deaths ,000 annual ly. Health Services Administration  HSA 302 Why Go Electronic? Coordination of Care Sharing of information Quickly provide care Sharing information with patients (PHR) Health Services Administration  HSA 302 Why Go Electronic? Data Compilation Quick Health Services Administration  Health Information Exchanges  HSA 302 A Little History…The move to electronic Office of the National Coordinator (ONC) for HIT HHS – Department of Health and Human Services Implementing a nationwide health information system Supports meaningful use (MU) of technology Created in 2004 by Order of President George W. Bush Health Services Administration ARRA American Recovery and Reinvestment Act $19 Billion for HIT Health Services Administration  HSA 302 HITECH Act Health Information Technology for Economic and Clinical Hea lth Act (2009) Signed into law by President Barack Obama Part of the American Recovery and Reinvestment Act HHS to establish programs for health care Quality, safety, efficiency through HIT Promotes wide spread adoption of EHRs Authorizes Meaningful Use (MACRA – Medicare Access and CHIP Reauthorization Act) payments Health Services Administration  HSA 302 Health Information Exchange (HIE) Collection of health records Used for patient care KHIE (Kentucky Health Information Exchange) Pronounced kay-hi Enables safe, secure electronic exchange of patient health information among participating providers and organizations throughout the state RHIO (Regional Health Information Organization) NeKY RHIO Pronounced Ree-oh Health Services Administration  HSA 302 KHIE Established in Aug 2009 Cabinet for Health and Family Services Funding from CMS and ARRA $9 million Health Services Administration  HSA 302 KHIE Goals Statewide adoption of an eHIE National adoption of an eHIE What they do Participating providers – sharing information Intermediary for public health Immunizations Surveillance Cancer Cases Health Services Administration KHIE Exchange Health Services Administration Public Health Reporting Health Services Administration  HSA 302 NeKY RHIO Goals Enhancing the use of EHR and HIE technologies Billing, HIPAA, IT workforce training, meaningful use Improving care coordination in rural health settings Kentucky Rural Health Information Technology Network (KRHIT) Reducing disparities for medically underserved persons in rural KY. Health Services Administration Data Sources and Functions of Medical Records  HSA 302 Principal Functions of the HR Administrative information Demographic data Financial data Clinical data This is primary data!!!! Health Services Administration  HSA 302 Ancillary Functions of the HR Accreditation, Licensure, and Certification Research Education Risk Management and Incident Reporting Morbidity and Mortality Reporting NVSS- National Vital Statistics System (CDC) This is secondary data!!!! Health Services Administration  HSA 302 Lets Think About This You are a CFO and you want to know how many patients are Medicare Patients at your facility. - Without a MPI at the facility you would have to sort though a large number of charts to find the information you are looking for - With a MPI you would pull a report and you would be able to see the number of patients who have a particular type of insurance Health Services Administration  HSA 302 Lets Think About This You are a manager and you want to know how many patients developed a certain type of infection while in your facility at. - Without a disease index at the facility you would have to sort though a large number of charts to find the information you are looking for - With a disease index you would just have to look up a diagnosis and you would be able to see the number of patients for a given time Health Services Administration  HSA 302 Internal vs External Reporting of information Internal External Local State Federal Lets look at an example! Health Services Administration  HSA 302 The Flu KAR requires facilities who have a confirmed case of influenza to report to the CHFS (KY Disease Surveillance) on a weekly basis CDC Epidemiologist look for patterns What would happen if we didn’t have a reporting mechanism? What would happen if the data reported wasn’t good quality data? Think about the flu shot, how do researchers pick the strains in the shot? Health Services Administration  HSA 302 Why is This Data Important? Government Funding/Grants Prevention Guidance Treatments Health Services Administration Living in an Electronic World  HSA 302 Systems Working Together Interoperability The ability of two different systems to exchange information. Health Services Administration  HSA 302 Various Applications of an EHR Administrative and Financial Ancillary Clinical – Lab Radiology Specialty Clinical – ED, Surgery, L&D Core Applications –Nursing notes, H&P Health Services Administration  HSA 302 Administrative and Financial Applications MPI –Demographic MRN -> Link between the patient, MRN, visits HIM Encoders Natural Language Processing Computer Assisted Coding Abstracting Billing Transcription Chart deficiency management QI RHIA vs RHIT Health Services Administration  HSA 302 Natural Language Processing Computational linguistics or text mining Converting unstructured data to structured data by using algorithms or statistical methods (520)-956-8474 605-23-1987 NLP includes dictation and CAC This technology is sophisticated enough to understand the spoken word and correctly classify them ICD-10 coding Health Services Administration  HSA 302 Computer Assisted Coding Uses NLP to scan charts and identify codes Coder verifies codes Benefits: Productivity Consistent Barriers: Costs Potential increase in errors Lack of standards in the industry Health Services Administration  HSA 302 Core Clinical Applications Results Management Point-of-care Documentation Work stations On Wheels (WOW) Medication Management Computerized Provider Order Entry (CPOE) eMAR E-prescribing (e-RX) Pyxis Messaging Clinical Decision Support (CDS) Health Services Administration  HSA 302 Ancillary Clinical Applications Laboratory Radiology Report – CT/MRI/X-ray report PACS - Picture Archiving and communication systems Pharmacy Dietary Health Services Administration  HSA 302 Connecting Patients Patient Provider Portal (MyChart ex of EPICs Patient Portal) Personal Health Records _ paper or electronic Connected to the Portal (tethered) Separate Health Services Administration  HSA 302 Information Portability IPads Smart Phones Security of Mobile Health Health Services Administration  HSA 302 Changing HIM with EMR File Room Activities Incomplete Record, Deficiency, and Chart Completion Release of Information Chart Reviews Coding, Abstracting and Billing Transcription Documentation Imaging Health Services Administration THE END!