System ‐ Based Project 2012 ‐ 2013: Impact Issues Vertical Team: Jared Roberts, Blake Porter, Nicki Nguyen, Haller Smith Faculty Mentor: Joseph Biggio
Electronic Medical Record: best thing since sliced bread? • The advent of the EMR has changed the way that the healthcare system functions: Unprecedented sharing of • information between providers. Rapidly accessible • Facilitates inter ‐ specialty • cooperation • Despite the many benefits of EMR, it is not without its problems.
Problem: Appropriate documentation of patient counseling. Liability created by lack of • documentation of of ominous symptoms and potential risks. Discuss with risk management • what expectations for documentations are and whether our current documentation practices meet their standards. For example, is “PreE precautions” • adequate or should we be writing “Patient counseled to return to the MEU with headache, visual disturbance, or RUQ pain.”
Problem: Appropriate documentation of patient counseling. Action Plan: Penny Monroe in Risk Mgmt • More documentation is better than less if • is both appropriate and accurate. In conjunction with faculty advisors, • develop standardized macros for common counseling and make them available to all residents in the chart “Powernote, OB” Use macro’s as: • #1 Educational tool to teach incoming PGY1’s • about r/b/i/a to procedures and precautions for pregnant and post ‐ op patients. #2 Standardized form of documentation that • provided accurate medical information and protects our physicians from liability
What’s Next?... • Superfluous / “Clone” Documentation
United States of America vs William King Dr. King (GYN physician) developed an office visit template that • included all required elements for a comprehensive level 5 visit after attending a coding in ‐ service. Dr. King completed the form on all patients and billed level 5 visits. • Problem: • Dr. King checked off elements of the exam that he did not perform. • Patients testified that they did not receive the exams noted. • Result: • Dr. King incarcerated • $800,851 in False Claims. • *Slide taken from Dr. Brian Bates, Corporate Compliance Officer presentation on Resident Compliance on Health Stream
Problem: Clone Documentation. • The convenient copy/paste and copy forward functions of Impact give opportunity for clone documentation. Auto ‐ populate functions can cause errors in documentation • Advertently or inadvertently, documenting portions of the review of • systems and physical exam that were not actually performed. • This can lead to serious repercussions for both the physician and the hospital due to billing fraud. • Auto ‐ populate and copy ‐ forward functions can lead to notes that are cluttered Incorrect, outdated, or useless information, making it difficult to • identify the issues that are actually relevant to the current care of a particular patient. • Ex: the “49 ‐ page” post ‐ op note
Clone Documentation: possible solutions?
Clone Documentation: Ways to Improve and Monitor Resolution Action Plan: • Meeting with Dr. Stephen • Discuss clone Stair and Brian Bates documentation with risk mgmt and corporate • Effects on reimbursement could be drastic in future compliance officers • DHHS’ OIG set to review • Effects on reimbursement series of notes to look for • Invite risk management cloning and corporate compliance • Implications in fraudulent coding to lecture our department and billing practices on ways to improve. • Happy to assist OBGYN dept • Determine whether with continued compliance “Copy to new Note” can • “Copy to new Note” is system be revoked?... wide; not user specific
Clone Documentation: Ways to Improve and Monitor Action Plan: Resolution: • Consider creation of • To be determined… department ‐ wide committee to review documentation and violations. • Charge Attendings and Fellows to monitor for clone • To be determined… documentation.
Acknowledgements • Faculty Mentor: Dr. Joseph Biggio • Corporate Compliance Officer: Brian Bates
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