Post on 17-Dec-2015
Copy That: Are You In Compliance?
Diana Warner, MS, RHIA , CHPS, FAHIMADirector, HIM Practice Excellence, AHIMA
Agenda
• Identify benefits and risks of using copy and paste functionality
• Identify auditing best practices• Examine how to define, support, and
execute best practices • Describe how information
governance applies to the integrity of the health record
Reported Errors Make Headlines• American Medical News: EHRs:
“Sloppy and paste” endures despite patient safety risk
• EHR Intelligence: EHR patient notes: What’s wrong with cloning, anyway?
Risks
• Information Integrity– Inaccurate data– Redundant information– Inability to identify original source of
data– Propagation of inaccurate data
Copy and Paste Challenges• Outdated histories• Outdated labs• Entire chart note• Taking credit for interpretations • Attributions not documented • Spelling errors, formatting issues
Inappropriate Use
• Erroneous Error – 2 charts open at one time
• Provider – copied and pasted the office visit into the next 10 visits
• 60 page chart note• Chart note documentation not
unique to visit• Bill multiple times for one procedure
Appropriate Use
• Demographics • Medications • Allergies • Problems • Labs and treatment or therapies
Healthcare Fraud
• Fraud is defined as an “intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, to the entity or to some other party”
Fraud and Abuse• Included in OIG 2012 Work Plan• “worded alike, or similar to other
entries”• Inconsistent documentation affects
coding and quality reporting• Volume of information does not
equal quality information• Pattern of inaccurate reporting may
be considered abuse
Auditing for Compliance
• Lawsuits• Risk Management– Organizational level– Vendor level
• Procedures
Develop an Audit Plan• How and when audits will be conducted • Who will perform the audits • Frequency for performing the audit • Time period covered by the audit • How the sample size is determined • Describe the outcome indicators • How will copy functionalities within the
record are identified • A corrective action plan based on findings
Create A Work List• Can a copy event be identified
retrospectively? • Is an appropriately detailed audit log
generated when a copy event occurs in the course of documentation?
Understand EHR Functions and Features• Is information copied forward
distinctive?• Audit trails included in EHR system• Blocks of content should be
individually authenticated• Identify re-authenticated information
Current Organizational Status
Discovery Phase• Policies and Procedures• Current Practices– Risk and Mitigating Factors
• Ongoing oversight – Education programs– Training programs– Auditing programs
Organizational Questions• Is there an alternative to copying data in the
EHR?• Who is responsible for ensuring that all copy
policies and procedures are enforced?• Who will perform ongoing audits of provider
documentation for appropriate use of copy?• How are errors identified and corrected?• What audit trails are available?
More Questions• Does the organization know how its
systems copy functions can be used within the EHR?
• Has the organization identified how copy will be utilized within the EHR?
• Has the medical staff approved copy policy and procedures?
• Does the organization have a process for identifying and mitigating unacceptable functions or uses?
Alternatives• Dictation or transcription • Voice recognition • Medical Scribes • Citing
– Active problems from problem list – Current medication from medication list – Allergies – Current labs
Additional Alternatives
• Templates – Drop down menus – Check boxes
• Macros – Phrases that are used routinely and can be populated
automatically
Education
• Review organizational policies on copy/paste in documentation
• Review sanction policy• Review audit policy• Train user on EHR workflow for
accepted copy and paste entries
Information Governance
• Information is an asset• Manage integrity through an
enterprise information management (EIM) program
How to Maintain Integrity• Commitment to conduct business and provide
care in an ethical manner • Purchasing systems that have capabilities to
prevent or discourage fraudulent activity • Implementing and following policies,
procedures, and system functions to prevent fraud
• Ensure the end product is compliant with all billing, coding, documentation, regulatory, and payer guidelines
• Ensuring documentation integrity in the record is a fundamental practice.
Information Governance
There is an increasing need to ensure healthcare information is trustworthy and actionable