Document & Data Integrity in the Legal Health Record

Wednesday, April 15th , 2015 1:00 – 2:00 PM Darice Grzybowski, MA, RHIA, FAHIMA

President, H.I.Mentors, LLC

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest

Darice Grzybowski, MA, RHIA, FAHIMA, President, H.I.Mentors, LLC

Has no real or apparent conflicts of interest to report.

© HIMSS 2015

Learning Objectives Attendee should be able to: 1) Define the role of document and data integrity and its impact on the legal

health record.

2) Describe various clinical documentation and data improvement techniques and how innovation within the electronic health record environment along with utilizing best practice record management processes can assist in building a robust foundation for the legal health record.

3) Explain how the electronic documentation management system (EDMS)

plays a vital role as a component of the EHR in supporting the legal health record and ensuring document and data integrity from point of creation through use, maintenance, workflow, and archive processes.

An Introduction to the Benefits Realized for the Value of Health IT

http://www.himss.org/ValueSuite

Health IT creates five kinds of benefit to patients, healthcare providers, and communities –

These benefits can be classified into Five Steps which create value in the following areas:

S-Satisfaction

T-Treatment/Clinical

E-Electronic Information

P-Prevention & Patient Education and

S-Savings (financial and efficiencies)

Step Summary of Value Proposition for Improving Document & Data Integrity

• S - There has been a great dissatisfaction published recently in the press about EHRs. This presentation provides alternative techniques to improving end user satisfaction with the EHR

• T - When documentation is improved and more efficient for providers, improved clinical outcomes are evident for ongoing care delivery

• E - Utilizing appropriate technologies for a single ,unique, and compliant legal health record is a critical piece of the EHR picture

• P - Patients have a right to access their health record and receive a printed copy. Without a proper foundation for the LHR, this cannot be achieved effectively - this presentation demonstrates this through examples

• S - The cost of documentation and data errors as well as inefficient processing can be overwhelming to an organization - by learning techniques to improve this, a facility can save significant dollars

Therefore……

http://www.himss.org/ValueSuite

We believe that Document and Data Integrity are essential components

of creating a reliable, accurate, secure, and functional Legal Health

Record.

Yet we continue to see Electronic Health Records being implemented

which have introduced redundancy, inefficiency, risk, and added cost

into the healthcare system.

So we ask - Why has this occurred and what can be done to remediate

the problems and mitigate the outcomes?

Before We Begin – Acronym Level Setting

EHR = Electronic Health Record

EDMS = Electronic Document

Management System

LHR = Legal Health Record

HIM = Health Information

Management Department

Defining Document & Data Integrity

Document Integrity:

• The process of ensuring all paper and electronic documents are received and included into a single medical record for each episode of care and are equally accessible through a single request, and purged with a single function.

Source: “Strategies for Electronic Document and Health Record Management, AHIMA, 2014, p 177-178

Data Integrity:

• 1. The extent to which healthcare data are complete, accurate, consistent and timely.

• 2. A security principle that keeps information from being modified or otherwise corrupted either maliciously or accidentally; also called data quality.

Source: "Strategies for Electronic Document and Health Record Management", AHIMA 2014, p. 177-178

Stories of increasing provider dissatisfaction with workflow continues • Healthcare IT News (1/23/15) reports that “a coalition of 35 physician organizations led

by the American Medical Association says docs are fed up their electronic health records

and the multitude of requirements that come from the federal meaningful use program.”

• Politico (12/29/14, Allen) reports that widespread dissatisfaction with the Administration’s

“$30 billion” effort to digitize health records, combined with a “hungry new Congress,”

could pose a threat to the program. While “many believe digital health will eventually

bring huge benefits, physicians have seen few of them to date…”

• Fierce EMR March 20, 2014 reported via a Rand study that doc dissatisfaction appears

to be worsening quoting, "If practicing physicians are correct, the current state of EHR

technology has introduced several impediments to providing patient care, undermining

physician professional satisfaction.," The authors concluded, "Many of these problems--

such as the proliferation of clinical information that doctors don't trust--also should be of

great concern to patients. Patients, providers, payers, and vendors all have an interest in

improving the usability of EHRs and integrating them into clinical workflows that produce

better, more efficient care."

What are YOUR patient and family experiences?

And now…..Joint Commission Sentinel Event 54

What’s Going Wrong?

Increased provider

dissatisfaction with workflow

Data integrity issues

Documentation inconsistencies

HIPAA

violations

Labor inefficiencies

in HIM Departments

So Why Is Quality Documentation and Data So Important?

Patient Care

Research

Contract Negotiation

Quality/Utilization

Education

Physician

Credentialing

Reimbursement Certificate of Need

(Planning)

Marketing Budgeting/Resources

Historical

Documentation

Uses of Legal Health Record Data

Legal Defense – Risk Mitigation

Compliance

How Can You Tell the Symptoms of a “Sick” EHR Environment?

Documentation Inconsistency:

• Problem List Carryover

• Copy and Paste Proliferation

• Consultant-itis

• Diagnosis of the Day

• Fragmented Information Flows

(i.e. Orders)

• Reconciliation Roulette

Data Integrity Issues:

• Duplicate Medical Record Numbers

• Uncontrolled Patient Status/Type Changes

• Forgotten Forms Control & Management

• Release of Information from a Dynamic Template

• Missing Master Patient Index Control

• Who’s Watching the Master Data Dictionary?

But wait…..there’s more!

HIPAA Violations:

• Enabling the Ability to Access, Without the Need to Know

• Identifying the Original and Only the Original Sir

• Accessing the Original, and Only the Original, Ma’am

• Filling the Recycling Bins

• Source of Record Release

• Do you Know Where Your Records Are?

Labor Inefficiencies in HIM:

• Are you adding vs. decreasing staff?

• Are clean up and audit activities taking center stage?

• How do you know you are reading a complete chart? (Coding/$ Impact)

• Record Retention & Purging Nightmares

• Release of Information Runaround

• Lack of focus on Concurrent Documentation Deficiency resolution

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required for charts, graphs, etc.

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How Can We Use Technology and Process Innovation to Improve Documentation and Data Integrity?

17

Differentiating the Patient Care Focused EHR vs. the Discharged LHR

• The Patient Care Focused EHR:

– Input Focused Documentation

– Longitudinal

– Discrete Data Driven

– Utilizes Templates for Documentation

– Dynamic in Nature

– Single Source of Truth for Data Entry

• The Discharged Legal Health Record:

– Output Focused for Long Term Document Management and Retention

– Episodic

– Forms and Document Driven

– Single Source for the Complete Record (integrated w Scanned & Workflow Documents

– Stable/Static Post Discharge “Permanent” Record

– Tells the ‘Story’ of the patient in readable, Chronological Sequenced Order

These are designed for different

functional purposes, are symbiotic,

yet require different technologies!

Tips for Improving Document Integrity

• Reduce Hybrid electronic fragmentation by ensuring your facility has a robust Level 3 electronic document management solution in place acting as your Legal Health Record (not just scanning tacked onto an EHR)

• Transform the role of the HIM Director from “Legal Guardian of the Record” to “Chief Information Governance” officer to provide enterprise-wide guidance on electronic document and health record management principles

• Complete a full Forms/Document Inventory from an Output Based perspective (printable) assuring input and output views are matched

Tips for Improving Document Integrity (continued)

• Complete a full Health Record Inventory if still in a paper/electronic hybrid environment

• Institute an (Electronic) Forms control policy and committee

• Perform daily reconciliation on complete discharge record (electronic) received and transferred into the EDMS from the EHR

• Implement a Clinical Documentation Improvement program that stops focusing on reimbursement and starts to link documentation with compliance, legal, and supports standardized language terminologies to support computer assisted coding

Tips for Improving Data Integrity

• Ensure the Level 3 EDMS is supported by full workflow functions including record completion/signature, coding & abstracting queues, release of information functionality, master patient index linkage, and retention/full purge from a single point functionality

• Create a master data dictionary for use in designing templates and output based permanent documentation forms

• Treat data (and documentation problems) as a key quality indicator

• Create Order Sets that are linked to reason for order (the ‘why’)

Tips for Improving Data Integrity (continued)

• Corrections and revisions to data are clearly visible to the end user and not ‘hidden’ in versioning documents

• Utilize documentation based protocols for determining patient status from the Emergency Department

• Perform periodic five point compliance audits: Order, Documentation/Results, Coding, Billing, Reimbursement

• Promote centralized access and release post-discharge

Summary: Five Steps and Benefits of Sound Document and Data Integrity for the Legal Health Record – Your WIIFM

• Decreased complaints from clinicians and patients

• Mitigate risk and potential litigation problems

• Optimize coding accuracy and improve legitimate reimbursement with better capture and design of clinical documentation – i.e. Present on Admission, Core Measures, Hospital Acquired Conditions, Observation Status, etc.

• Improve workflow for clinicians and HIM staff for improved productivity and satisfaction

• More meaningful information and better compliance with Meaningful Use standards (turnaround time for patient requests, ability to provide patient access to a clean record, etc.)

But Wait – there’s more……..

• Improved Interoperability of data

• Clean mergers of organizations

• Compliance with Record Retention programs

• Building a good foundation for advanced functionality i.e. Computer Assisted Coding, Biometric reporting/documentation

• Implementation of new EHRs (when we stop jumping off the cliff like the lemmings……)

For more information on document and data integrity to support the legal health record you can download the following white paper:

“Forging a Path to the True Legal Health Record”

by Darice M. Grzybowski, MA, RHIA, FAHIMA, H.I.Mentors, LLC

http://bit.ly/1FQrwGF

Questions? Thank You!

Darice Grzybowski, MA, RHIA, FAHIMA

AHIMA Academy Approved ICD-10-CM/PCS Trainer/Ambassador

Author “Strategies for Electronic Document & Health Record Management”

(AHIMA 2014)

https://www.ahimastore.org/ProductDetailBooks.aspx?ProductID=17550

President, H.I.Mentors, LLC

One Westbrook Corporate Center, Ste. 300

Westchester, Illinois 60154

Twitter: dariceg1

www.himentors.com

info@himentors.com

Phone: 708-352-3507