EHR and Health IT Consulting
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EHR and Health IT Consulting
Technical Doctor's insights and information collated from various sources on EHR selection, EHR implementation, EMR relevance for providers and decision makers
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Avoiding Legal Troubles Stemming from EHR Liabilities

Avoiding Legal Troubles Stemming from EHR Liabilities | EHR and Health IT Consulting |

I'm a big supporter of the EHR and its promise to make documenting patient care more accurate, easier, and clear. I also have a healthy respect for the dangers of the EHR — and see new dangers pop up constantly.

With all good technological tools, there are hazards that need to be recognized. The EHR can pose a liability for providers and institutions, and the legal profession is beginning to exploit this weakness in malpractice actions against providers and institutions.

Modern EHRs have a significant learning curve, and require a complete change in the process of documenting patient care. Many functions are a double-edged sword; including record cloning, automated dictation, medication dose checking, documentation templates, automatic record population, etc. The functionality of the EHR can make the job of providers much easier in generating a record, but this same functionality can introduce bad data, wrong dosages, and other errors that can harm patients.

The bottom line is that providers are ultimately responsible for what is charted in the EHR. Here are just a few examples of these new liabilities and how to avoid them.

• Scribes. Much of the charting that is done on the front end of a hospital admission is performed by the nursing and ancillary staff, or in the ER, scribes. This is very helpful in a busy inpatient and/or outpatient department, and speeds patient care and documentation. However, unless the provider verifies the accuracy and completeness of the record, significant errors can made.

• Cut and paste. The "cut and paste" function is one that is familiar to anyone using a computer in the modern age. This can interject errors, and propagate them when one does not exercise due diligence in making sure that the final record reflects the actual encounter. There are tools available which make searching for repetitive text in a record very easy. Obvious propagation of narratives and erroneous data, over and over again, is hard to defend in a court of law, and demonstrates that care was not taken. It also introduces doubt into all areas of the records being scrutinized.

• Note cloning. "Cloning" is another issue that works much like cutting and pasting. Cloning is the practice of copying an entire previous record into a new, editable record. The hazard here is obvious, and similar to the previously discussed practice of cut and paste. It goes without saying the more information and data that you "clone," the greater the risk you are going to miss something, and propagate erroneous data.

• Use of templates and macros. Macros for things such as review of systems and physical examination can really make you look bad when another provider or lawyer is reviewing your record. It is easy to miss that you called a positive physical finding negative, if you don't carefully review the record prior to finalizing it.

• Pull-down menus. Finally, clickable pre-populated components and pull-down menus can be hazardous in that it is sometimes easier to choose the wrong thing than it is to use "free text" to customize the finding or information.

On the bright side, templates for procedures help providers quickly and accurately document informed consent, indications for the procedure, the actual procedure, and the post procedure care by giving the provider a concise and complete format for documentation. The other benefit of the EHR from the provider standpoint is allowing the provider to make a more complete record in support of the level of care that is being billed.

I have to admit that in the past, I have used all the functionality of the EHR, and have made mistakes in my documentation. After studying these issues, and becoming aware of the hazards to patient safety and care, I'm much more sophisticated in my use of the functionality of the EHR. I still use macros and auto-text, but my use of cut and paste is limited to including diagnostic test reports that don't auto-populate. I never use cloning even though the functionality is still allowed in our EHR.

One of the big changes for me has been the deployment of enterprise level dictation in our EHR. Now, even though I can type 60 WPMs, I can much more rapidly and accurately dictate a unique HPI, PE, and plan, and better ensure that the record is accurate.

Take the time to understand EHR technology, and avoid the pitfalls that can be expected to increase your liability in the delivery of patient care.

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Role of Integrated EHR Technology in Solving Fragmented Care |

Role of Integrated EHR Technology in Solving Fragmented Care | | EHR and Health IT Consulting |
Authors of a recent Harvard Business Review article claim that integrated care hold the key to resolving fragmented healthcare in the United States.

Pioneering healthcare organizations demonstrate that it is now possible “the integrated-care model and accelerate its adoption more broadly and deeply across the American health care system.” This according to the Institute for Healthcare Improvement and Weill Cornell Medical College’s Kedar S. Mate, MD, and the Permanente Federation’s Amy L. Compton-Phillips, MD. Kaiser Permanente just so happens to be one of them.

Along with aligning payment with integrated care and other measures, the authors of “The Antidote to Fragmented Health Care” identify the creation of universal EHRs a means of achieving an end to fragmented care:

The lack of a single health record for each patient that clinicians from all specialties can access in both inpatient and outpatient settings is an obstacle to integrating care. In addition, patient privacy protections inhibit the sharing of health information, creating both perceived and real hurdles. Back in the 1990s, the U.S. Veterans Administration developed an electronic health record (EHR) that linked information across venues of care and provider specialties. This early work showed that linking clinicians electronically was transformational.

In addition to the example of the VA and its Veterans Health Information Systems and Technology Architecture (VistA) EHR, the authors highlight the positive experiences of EHR end-users at Kaiser Permanente:

Kaiser Permanente has an EHR that is shared by primary care doctors and specialists who work in hospitals and offices and is also used by nurses, pharmacists, physical therapists, and nutritionists. Their ability to collaborate electronically with patients in their homes and with each other using tools such as electronic consultation has fundamentally changed the way medicine is practiced at KP.

While these examples do make a case for integrated EHR technology, they are short on details about the two EHR technologies being used by providers at the VA and Kaiser Permanente.

Kaiser Permanente is using an Epic EHR although it is one that bears the marks of its own optimizations and enhancements. As noted in a report earlier today, the costs of implementing and maintaining an Epic EHR “are significantly higher than comparable competitor products, and, in at least one study, did not produce savings for payers” based on research published in the Journal of the American Medical Informatics Association. Not all healthcare organizations have these kinds of financial resources at their disposal or the expertise necessary for running this EHR technology effectively.

The example of the VA should raise additional doubts about the concept of a universal EHR. Without taking the Phoenix scheduling fiasco into account, the VA is facing significant pressure from Congress to modernize its EHR platform and achieve interoperability with the Department of Defense’s platform, when one is finally chosen.

The longstanding lack of interoperability between the two departments continues to be an obstacle preventing the records of DoD patients moving seamlessly into the VA’s EHR platform. And even with billions of dollars in funding from the federal government, no solution is in sight.

The EHR marketplace is full of players with products capable of supporting a provider’s pursuit of meaningful use and other financial incentives and still health information exchange varies by region and interoperability remains elusive. Technology is only one component of the authors’ vision of integrated care, but it is much more complicated than they demonstrate.

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ONC Should Decertify Products that Block EHR Interoperability |

ONC Should Decertify Products that Block EHR Interoperability | | EHR and Health IT Consulting |
Congress attempts to further EHR interoperability by asking the ONC to decertify EHRs that don’t meet data sharing standards.

Congress has instructed the ONC to “take steps” to decertify EHR products that actively block the sharing of information or the interoperability of health IT systems in the 2015 omnibus appropriations bill.  The $1.1 trillion spending bill, which has a number of health IT implications, asks the Office of the National Coordinator to ensure the integrity and value of the Certified EHR Technology (CEHRT) program to healthcare providers and to the taxpayers whose dollars are invested in the EHR Incentive Programs.

The language in the bill firmly directs the ONC to meet Congressional expectations about the future of interoperability in the healthcare industry.

“The Office of the National Coordinator for Information Technology (ONC) is urged to use its certification program judiciously in order to ensure certified electronic health record technology provides value to eligible hospitals, eligible providers and taxpayers,” Congress says.

“ONC should use its authority to certify only those products that clearly meet current meaningful use program standards and that do not block health information exchange. ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use.”

This is not the first time that questions have arisen about the seeming laxity of some provisions of the EHR certification requirements.  Earlier this summer, the Health IT Now Coalition posed the same query to the ONC: if federal and industry roadmaps focus so sharply on the need for widely-adopted data standards, health information exchange, and the fluid transfer of data across the healthcare continuum, why are providers still being encouraged to purchase EHR software that doesn’t allow them to achieve these goals?

“Taxpayers have paid $24 billion over three years to subsidize systems that block health information in a program Congress created to share health information,” said Joel White, Executive Director of Health IT Now, at the time.  “We call on HHS and Congress to use their authority to investigate business practices that inhibit or prohibit data sharing in federal incentive programs. We also call on HHS to work to decertify systems that require additional modules, expenses, and customization to share data.”

While the omnibus bill may have done little to satisfy critics on either side of the aisle, the Congressional injunction to speed interoperability by withdrawing certifications from EHRs based on closed, proprietary technologies may go a long way towards cheering up health IT pundits over the holiday season – even if it brings no small amount of anxiety to the healthcare providers who have already invested heavily in EHR technology that may come on the certification chopping block.

If a number of products are decertified, will the ONC provide any type of compensation for healthcare organizations that will be required to purchase new technologies in order to continue to meet meaningful use criteria?  Will those organizations be eligible for extensions or exemptions as they try to adopt new software and reengineer their processes accordingly?  How will significant changes to the certification process affect the timelines for Stage 3 of the EHR Incentive Programs?

Congress has asked the ONC to produce a report on the interoperability landscape, the challenges to industry-wide data exchange, and its plans to retool the certification process, in which some of those answers may be revealed.  “The report should cover the technical, operational and financial barriers to interoperability, the role of certification in advancing or hindering interoperability across various providers, as well as any other barriers identified by the Policy Committee,” the omnibus says, and must be delivered no later than 12 months from now.

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Effects of Interoperability on Health Data Privacy Policies |

Effects of Interoperability on Health Data Privacy Policies | | EHR and Health IT Consulting |

Interoperability enables healthcare providers to make the most well-informed decisions for individual patients, but it introduces the potential for sensitive patient health data to become compromised if the technologies exchanging information or the pipeline between these systems are unsecured.

“In terms of what I think some of those challenges are, it’s no big secret; we’re working on interoperability,” Lucia Savage, the new Chief Privacy Officer for the Office of the National Coordinator for Health Information Technology, recently told

“Of course there are the topics that have been well-discussed in the press, like data lock and all that stuff that have to with people’s proprietary systems,” she continued. “But what’s really more essential in the privacy and security realm is making sure people understand how are current legal and regulatory environment actually help support interoperability — right now, at this very moment in time.”

New models for care delivery (e.g., accountable care organizations) emphasize the need for interoperable EHR and health IT systems, added Savage. Interoperability, however, is limited to certain geographies and contexts. In short, there is tremendous room for improvement.

“For example, insurance companies contract with large systems to the ACOs. For that to succeed, just like the Medicare ACOs, data has to flow between the two parties,” Savage explained. “That data is flowing right now in some ways, and in some ways it could flow better and could make better use of the delivery system was built with the meaningful use incentive.”

According to the ONC’s Chief Privacy Officer, a lack of health information exchange (HIE) as a result of limited interoperability comes as a surprise to patients who “thought their doctors were doing this already.” And what is essential is that the healthcare organizations and providers, both private and public, make use of new forms of exchanging information while adhering to the privacy and security rules laid out by HIPAA.

“The HIPAA environment we have is perfectly designed for that. It’s media-neutral, meaning 20 years ago when faxes were new, that’s how the information started to move. Now the information is moving through other media but the rule hasn’t changed. We’re going to capitalize on that,” she maintained.

The next step involves the building of trust among providers and patients, which will come with time and use:

When we introduce a pretty significant technological innovation it takes optimally to breed trust. If through interoperability it facilitates physicians engaging their patients through electronic health record systems and the portal, and giving patients access, giving dialogue with patients about their data that they collect and share about themselves, then patients confidence in the system will grow because they’re using it too.

For the ONC, the path forward requires the federal agency to gather information and listen carefully to the insights of subject-matter experts so that the “potential benefits and the possible risks” of a fully interoperable, HIE-enabled healthcare environment are understood and incorporated into emerging and evolving regulation and oversight.

“Most of the people in the know understand well how HIPAA works for these big data analytics, but there’s new sources of data, whether its wearables or patient generated data or the way people want to take a healthcare transactional data and add data from public records systems to it for analytics purposes,” Savage said.

Not only is interoperability a challenge from the technology side of healthcare, but it also presents new challenges to health IT security and privacy.

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