CEHRS PRACTICE

Qualified EHR for HITECH requirements are

1. It must be an electronic record of health information that is specific to each individual. 2. Must include patient demographic information. 3. Chronicle clinical information that would include a patients medical history as well as an ongoing list of their health problems. 4. Accommodate the addition of computerized provider order entry. 5. Must have the ability to store data and information specific to health care quality and provide functionality to retrieve this information through queries or other reporting functions.

EMR

Electronic Medical Record. One Facility.

EHR

Electronic Health Record. Hospitals / Health System.

ARRA of 2009

American Recovery and Reinvestment Act of 2009. Increased responsibilities and greater punishments for improper management of PHI.

ACA

Affordable Care Act. Requires that Medicare patients receive an annual physical of PHI.

PHI

Personal Health Information

Medical Records requires the following:

-Patient Demographic. -Medical History -Physical Exam -Clinical data and observations -Results -Physicians orders -Consultations -Discharge Summary -Patient Instructions -Acknowledgements -Authorizations -Consent Forms

Joint Commission requires

Patient Records contain a current H and P within 24 hours of admission.

CMS requires

Physician file and sign a discharge summary within 30 days of discharge.

Missing data

Puts the patients at risk and places the facility in jeopardy of losing accreditation or losing its deemed status from CMS.

Record Components

Remains basically the same in the outpatient or ambulatory setting.

Differences in the outpatient reflect the care pattern differences.

-Taking Growth of Pediatric Patients. -Documenting vaccines, immunization, and preventative care activities. -Problem List

Patient creates data

Each time they interact with the health care delivery system.

Simplest option for integrating external data into the patients EMR

Scanning the documents and uploading the images into the record.

Continuity of Care

Solution and concept that has evolved into Continuity of Care Document.

Continuity of Care Document

Allowing physicians to send EMI to other providers without loss of meaning and improvement of patient care.

CCHIT

Certification Commission for Health Information Technology. Endorsed the CCD as the preferred continuity of care format for certified EHR Products.

Continuity Care Document

Contains specific elements from the patient record that providers agree are the most relevant to continuity of patient care, including current and previous health information.

Patient Care Documentation

You should NEVER or edit Patient Care Documentation a provider enters into a patients record.

If you have a concern about a specific data entry or documentation in a patients record.

Ask the person whose signature appears on the information about the issue.

Unlawful

It is unlawful to delete information from the patient record as it is a legal record.

Incorrect Information

Must remain in the record with the correct information appearing as a correction note.

Master Patient Index

Index that requires great attention to detail to preserve accuracy and completeness of patient information.

HIPAA mandates

That covered entities limit the amount of PHI they will release.

You can release PHI without special authorization

-To support treatment. -Seek reimbursement. -Support daily business operations of the facility.

Federal, state, local laws require

Covered entities release PHI in response to subpoenas, legitimate law enforcement inquiries and in cases of suspected abuse or neglect.

STDs

Public Health Law requires the reporting of STDs.

Authorization

To release PHI is not transferrable.

You should keep a file, listing or ledger

Of the equipment software and accessories that has been purchased for the facilities use.

Document the following

-Software Title. -Version. -Publisher. -Purchase date. -Number of PCs where it is installed.

Document the number of licenses purchased for the software and collect the following information

-Type of License. -Details on the CPU, RAM, Operating System. -Documentation of the employee. -Hardware information.

Integrated EHR environment

You will find more instances of electronic capture of information and that paper records will only exist as previous records.

Providers can order medications through

The Hospital Information System and print the order out on special paper to sign and fax to the pharmacy for processing.

Fax Technology

Providers offices use fax technology to send and receive patient information.

Camera Technology

Is useful in health care for documenting physical ailments.

Surgical Information Systems include

Specialty Cameras that can take microscopic and full sixed photos to assist in documenting important findings and patient status.

Bar Code Technology

Sets the standard for patient identification, and the prevention of medical mistakes.

Many hospitals use

Computer on Wheels or Wireless on Wheels, which often include a hand held barcode scanner.

Similar use of bar code technology is

Available in the outpatient setting. Clinical staff can easily and accurately document inventory.

Facilities are legally responsible

For the providers they hire to care for patients.

Privileges

Outline the activities a provider is permitted to engage in at a facility.

Granting privileges

Follows a process known as credentialing.

You may collect data on the physician from

The National Practitioner Data Bank.

HCQIA of 1986

Established the NPDB to address bad physicians who were previously able to travel to other states after losing their license in a previous state with no follow up documentation.

Clinical Templates

Predesigned forms that capture data in a pattern that is specific to the facilities work flow and to the specific tasks within in the various work flows.

EHR Systems found in the inpatient environment generally

Do not provide the opportunity for end users to create ad hoc templates.

Outpatient Setting

There is availability of pre loaded templates.

Learning the options

Available to the end user is important.

Keep all documentation and vendor contact information

For future reference.

Clinical Templates make the documentation experience

Easier while prompting physicians to include important data items.

EMR vendors

Are increasingly developing specialty EMR systems to meet the specific needs of facilities.

Clinical Templates are also useful

In creating letters for patients who need to miss work, go on light duty, submit a school absence excuse and present proof of Physical Exam.

Joint Commission and CMS mandates

That a provider account for all the medications the patient was taking upon admission and during hospital stay as well as after the visit.

Medication Reconciliation

Is performed at the same time as the discharge orders.

Use of ePrescribing Software

Allows the providers to order a prescription for a patient and have it sent electronically to the patients pharmacy.

Maintaining up to date information

Is critical in every health care setting.

First rule of database management

Assignment of access privileges.

Role Based Controls

Manage each persons access to specific areas in the information system.

Editing databases that houses insurance company information, code sets, and other administrative information

Is important to maintaining up to date processes for the facility and remaining in compliance with the many legal and regulatory requirements for facilities.

Enter updated information

Into the appropriate database and the correct data prints from the patients record at the next scheduled visit.

As an EHR specialist

You use insurance information to generate insurance verification reports.

You enter the information

You receive from the patient to generate the patient face sheet.

ICD 9 CM

Captures diagnoses for inpatient and outpatient settings.

ICD 10 CM

Captures diagnoses for inpatient and outpatient settings.

Tabular Index

Identified diseases using a three digit system.

When you code a procedure

The code set you should use depends on your work environment.

Coding begins with

The review of documentation of patient treatment and course of care in the medical record.

Inpatient Settings

The Coding is built off the principal diagnosis or reason for admission.

Outpatient Setting

The term Principal Diagnosis is not valid.

Know the medical record

And the location of the various provider documentation sources is critical for accurate coding and appropriate reimbursement.

Encoders guide you in the assignment of codes

And in many cases eliminate the need to search through hundreds of pages to locate a code.

Most EHR and ER systems in use today

Come with an integrated encoding system.

Practice Management Software

Helps outpatient settings coordinate the business aspects of the office.

Patient Statements should include the Following;

-Patient Name -Patient Address -Facility Name, Address, fax number and website. -Patient insurance information. -Description of services rendered. -Charges per service. -Provider Name/NPI. -Charges paid by insurance. -Charges due from patient.

Some statements will

Separate the specifics like diagnosis and procedure codes.

EHR do not

Capture patient financial information.

Each Facility should have

A written financial policy in place that defines the procedures for collecting fees.

Facilities will also maintain

Records for each day patient's to track all payments.

Make certain to provide

The patient with a receipt for any payments made, and do not generate statements until payments post in the system and are applied to the account.

In the Outpatient Setting

Encounter Forms have been traditionally produced in three parts, that the providers uses to document the E&M code, as well as any prescribed medications and a diagnosis.

When a patient first enters a new Health Care System

The Facility registers the patient by obtaining information and creating an account of the patients identity and medical condition.

Complete and Accurate Documentation

Is the foundation of quality patient care and it supports appropriate reimbursement and revenue for the facility.

Hospitals and Health Care Facilities that

Treat Medicare or Medicaid patients are required to meet CoPs which were developed by CMS.

The Goal of CoPs

Focuses on setting safety and health standards.

Each care environment

Has requirements that are specific to its patient populations.

CMS requires

Facilities to maintain records for at least 5 years.

Reimbursement, Compliance, and Quality Patient Care

Depends on proper documentation.

In both inpatient and outpatient settings the adoption and use of EHR Technology

Improves the collection, organization and availability of patient data.

GIGO

Garbage In Garbage Out

Importance of Quality Documentation can be illustrated by

GIGO

In a Hospital or Inpatient Facility

The Medical Staff Executive Committee establishes documentation guidelines and codifies them or make them into rules.

Medical Staff bylaws provides

Rules the clinical staff must follow when documenting in patient records at the facility.

Only clinical staff

Can legally document patient care in the record.

HITECH Act

Requires providers to use EHR Technology in a meaningful way.

When entering data

Clinical or clerical it is important to pay attention to details.

Point of Care Charting

Reduces or Eliminates the time between the provision of care and documenting in the record.

Almost all electronic systems include a search function

Which allows you to navigate even a new system with little assistance.

The best way to locate a patient

Is to use the Patient Medical Record Number

In small to medium sized practices

You can do a search by patients last name.

Facilities with electronic records

Must also have a record retention and a record destruction policy in place.