System Based Project 2012 2013: Impact Issues Vertical Team: Jared - - PowerPoint PPT Presentation

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
• f 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

• ur 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

• n 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

Action Plan:

• Discuss clone

documentation with risk mgmt and corporate compliance officers

• Effects on reimbursement
• Invite risk management

and corporate compliance to lecture our department

• n ways to improve.
• Determine whether

“Copy to new Note” can be revoked?... Resolution

• Meeting with Dr. Stephen

Stair and Brian Bates

• Effects on reimbursement

could be drastic in future

• DHHS’ OIG set to review

series of notes to look for cloning

• Implications in fraudulent coding

and billing practices

• Happy to assist OBGYN dept

with continued compliance

• “Copy to new Note” is system

wide; not user specific

Clone Documentation: Ways to Improve and Monitor

Action Plan:

• Consider creation of

department‐wide committee to review documentation and violations.

• Charge Attendings and

Fellows to monitor for clone documentation.

Resolution:

• To be determined…
• To be determined…

Acknowledgements

• Faculty Mentor: Dr. Joseph Biggio
• Corporate Compliance Officer: Brian Bates