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Must know Secrets For Easier EHR Documentation

  1. Must Know Secrets for Easier EHR Documentation Presentation #CureMDWebinar
  2. Presenter Key Technical Services Account Manager, CureMD Joe Martin
  3. 03 Let Me Introduce You to…
  4. An unhappy EHR user 04 My EHR has slowed me down I am seeing less and less patients My Practice took a revenue hit since I went electronic and there is no recovery in sight ICD-10 is coming. If my EHR is the only savior I have; I should Kiss my Practice Good Bye + + + ICD 10 Coming
  5. 05 Do you have the right system? Wrong System Generic No One-On-One Training In-Built Provider Notes Built for Billing Purposes mostly No Efficiency Reporting Built for a non-familiar Platform Support is negligible Specialty Based Proper Training and Implementation Customized Provider Notes Built for Patient Care Practice Productivity Insights Built for a Platform you’re familiar with Support is available when needed Right System
  6. Polling Question Q1. Which category do you fall in? a. Right system b. Wrong system
  7. 06 If you have the right system and are still spending more than 10-15 minutes on a simple patient visit. You need an EHR Documentation Fix!
  8. Why Bother? 07
  9. Physician documentation is Important! Inform subsequent care Inform current care (“writing-as-thinking”) Legal purposes Gets You Paid !- ICD-10 Medical NecessityICD 10 Coming 08
  10. PROBLEM ? 09
  11. Our World Pre-EHRs 10 “If it’s not documented, it didn’t happen?”
  12. The Paper Work Burden 11 Care setting Ratio of patient care to paper Every hour of patient care requires Emergency department care Surgery and inpatient acute care Skilled nursing care Home health care 1.0 1.0 1.0 0.6 1.0 0.5 1.0 0.8 1 Hour of paperwork 36 Minutes of paperwork 30 Minutes of paperwork 48 Minutes of paperwork What does it Mean?
  13. Here comes the New World 12 “If it’s documented, was it done?”
  14. The Murky World of Audits 13 OIG will be reviewing multiple E/M services for the same provider and beneficiaries to identify electronic health record documentation practices associated with potentially improper payments The results of a recent CMS study suggest the OIG will find plenty of E/M documentation problems among EHR users Highest failure rate Each physician pays back $ 150,000 lowest failure rate= Each physician pays back $50,000
  15. 14 7 Commandments for creating the Perfect Provider Note Save Time while Staying clear of Compliance Landmines
  16. 15 Commandment Number 1 The‘Dead Doc’rule If something happens to you, can someone else know what you did by looking at your notes?
  17. 16 Commandment Number 2 Do not Compromise On Documentation Integrity Every exam component. .Every time you copy  forward Family/Social  History . . .Every HPI and  ROS item you document means YOU PERFORMED THEM ON THAT VISIT . . .  If you document something you did not do . . .  YOU ARE PUTTING YOURSELF AND THE  INSTITUTION AT GREAT RISK!
  18. 17 The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck and leg pain. Our ED Physician came in and did his exam from the doorway holding his Tablet PC, marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupil and ocular movements, euro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. The same physician had the same general exam pattern for most of his patients and the same comprehensive documentation of his exams. “ ”
  19. 18 Commandment Number 3 Which EHR Entry Modality to use? No Hard and Fast Rule
  20. Documentation Methods Compared 19 Description Structured templates are partially filled-in notes created in advance for the most common cases seen by a clinic, department, and/or doctor. Such templates allow clinicians to create a note that not only serves as the medical record, but also stores the data as structured vocabulary, which can drive clinical decision-support functions (such as alerts and/or treatment suggestions based on established care guidelines). Advantages Structured templates ease note-taking by presenting a draft to the clinician, who then modifies portions of the note to reflect the current patient’s condition. Depending on the values and content of data fields, additional forms may pop up (as determined by care guidelines of the health center) to ensure a thorough exam. For example, a symptom of chest pain could prompt questions about exertion, family history of heart disease, and history of smoking. Standardized templates allow for uniformity in data capture and in the standards of care provided. Over time, templates improve Disadvantages Physicians often complain that notes from structured templates are difficult to read as a narrative of the patient’s condition, as they appear more as lists than as prose. A “chart by exception” approach, where all findings are prepopulated as negative unless the provider explicitly checks and documents a positive finding, brings its own problem of seeming to provide data the clinician may not have actually captured. Considerable preparation is required to develop structured templates that present enough structured vocabulary to cover the types of patients and conditions seen in the practice, but not so much that clinicians are hobbled, or that the data cannot be classified. Structured Method Structured Templates Structured Templates
  21. Documentation Methods Compared 20 Structured templates work well for clinical scenarios with an isolated problem that fits a clear framework with a limited number of easily predictable variations. For example, a template for a patient with a chief complaint of headache can present to the provider a set of signs, symptoms, and physical exam findings that should be checked and listed as either present or absent. Similarly, structured templates work well for acute episodes of care for which there are clear clinical guidelines, for specialty care in which the range of diagnoses and conditions is limited, and for predictable well care checkups or OB cases that follow a regular schedule. Method Structured Templates Method Radio Buttons, Drop-down Lists, Check Boxes Best Suited For These data entry methods provide clinicians with a variety of ways to enter structured data. A drop-down list presents suitable alternatives to clinicians and usually offers menu options based on data entered in an earlier part of the note. Radio buttons help enter mutually exclusive data options such as gender or yes/no answers. Check boxes help in maintaining and tracking quality of care by signaling exams performed or questions asked. Each entry selected is encoded and stored as a discrete data element that can be aggregated or can drive other clinical protocols and decision support. Check boxes, drop-down menus, and radio buttons can also be embedded within sections of templates. Description These devices allow for rapid point-and-click selection of structured data elements and are especially useful when, through logic imbedded in the EHR, only the appropriate subset of available data selections is displayed. For example, only medications commonly associated with diabetes would be displayed in a drop-down list for a diabetic patient. Advantages Radio Buttons, Drop-down Lists, Check Boxes
  22. Documentation Methods Compared 21 Some providers complain of too much “clicking” and about the inconvenience of moving from keyboard to mouse to keyboard when documenting their plan of care or clinical note. As with any structured template, careful thought must be given to the appropriate level of detail for choices in lists, check boxes, etc. In addition, there has been some concern that not enough research has been done to determine the optimal spacing between items in a drop-down list to prevent accidental selection of the wrong data element.t Method Radio Buttons, Drop-down Lists, Check Boxes Method Manual Data Entry (Typing, Stylus, Free-Text Templates) Disadvantages Radio buttons and check boxes are best suited for yes/no questions such as those about smoking, drinking, or I.V. drug use. Drop-down lists are appropriate for parts of the clinical note where there are only a few possible descriptions, and for ruling out symptoms (e.g., no upper respiratory symptoms, no G.I. symptoms). Best Suited For Manual data entry is referred to as free text in EHR parlance and can be accomplished by typing on the keyboard or, in some applications, by handwriting with a stylus. Free-text templates allow providers to type in notes in any format. Description If the provider is a fast typist, text can be entered quickly and the note will be expressed in the provider’s preferredstyle of writing. Free-text templates capture notes that can be retrieved electronically and allow providers to include information that doesn’t have a predetermined place in structured vocabulary. Advantages Manual Data Entry
  23. Documentation Methods Compared 22 Free-text templates are not coded or linked, so they will not trigger prompts or additional information, and they will not show up in searches of linked terms. Method Manual Data Entry (Typing, Stylus, Free-Text Templates) Method Voice Dictation, Dictation/Transcription Disadvantages Free-text templates work well for capturing additional data or interpretations not covered by structured vocabulary, such as parts of the note where there is a significant degree of variation that does not easily lend itself to a predefined template. The History of Present Illness and the Past Medical History sections are examples. Best Suited For Traditional dictation/transcription is streamlined in many modern EHRs by having the provider dictate directly into a microphone attached to a computer. A .wav or audio file is created and embedded at the point in the chart that the dictation took place. The .wav file is then sent to a transcriptionist, typed, and uploaded back into the chart as a freetext note. Voice dictation systems translate the spoken word directly into written text within the EHR. Description Dictation offers the most rapid method for capturing a fully detailed narrative with the least effort expended. Advantages Like free text, dictated information is not structured vocabulary, although recent advances may lead to the ability to capture certain dictated phrases as encoded data. Current voice dictation systems must be “trained” to the provider’s voice, accent, common phrases, and medical specialty terminology. Advantages Like free text or manual typing, dictation works well for parts of the note where there is a significant degree of variation that does not easily lend itself to a pre-defined template. Best Suited For Voice Dictation
  24. Polling Question Q2. Which Entry Modality do you prefer in your EHR ? a. Free text b. Drop downs c. Structured templates d. A little of everything e. Transcription services
  25. Best Practice Blended Approach 23 Does not disrupt physician workflow Facilitate better physician adoption Achieve faster Meaningful Use of the EHR Benefits
  26. 24 Commandment Number 4 EHR Documentation No No’s
  27. 25 When using EHR’s, here are the primary E/M documentation pitfalls to avoid: • Templates and billing driving care and charting • Point-and-click mentality vs. accurate and ethical documentation • Copy and paste forward • Charting for services that were not performed: use of default entries • Documentation cloning • Negatives listed vs. positives – hard to discern what is wrong with the patient • Failure to review available information • Inaccurate charting • Addendums for increased reimbursement vs. for patient care • Relative value unit (RVU) – driven care • Signing of notes without reading them • EHR revealing bad practice patterns Watch for EHR E/M Documentation No No’s
  28. 2526 Commandment Number 5 Top Compliance Rules  for an EHR
  29. 27 Each visit is unique. Cloned documentation is very obvious to auditors. Ensure each record stands alone and is unique from the previous patient or visit If you bring a note forward it MUST reflect the activity for the CURRENT VISIT with  appropriate editing Copy forward HPI, Exam, Vitals and complete Assessment Copy Paste for Multiple or Complex diagnosis. Dictate notes using software that converts it to text Use “Copy Forward” with caution Do NOT
  30. 28 Be Cautious with ROS and Exam Macros, Check‐boxes, or Free Text are safer and more individualized Read your assessment and plan and ask yourself: “Is the information contained in the history and examination relevant for the nature of the presenting problem?” If you answer yes then you have the required information for the problem presented. If the answer is no, remove unnecessary information that doesn’t have any relevance to the current problem Be careful with pre‐populated “No" or “Negative” templates
  31. 29 Never copy ANYTHING from one  patient’s record  into another patient’s note
  32. 30 Authenticate all documentation and  orders in a timely fashion 48 hours for verbal  orders 30 days for signed  documentation
  33. 31 Never copy documentation from another provider  without clearly identifying the original author Can be considered a  false claim Not always easy to do, better to avoid
  34. 32 Student or nurse may start the note Provider (resident or attending) must document HPI, Exam, Vitals   and Assessment/Plan Only Past/Family/Social History and Review  of Systems may be used from a medical  student or nurse’s note
  35. 33 Consider the medical decision making (number of diagnoses, complexity of data, and risk) to be the most critical elements in code choice. Ensure these elements are met. The Volume of Documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service
  36. 34 Commandment Number 6 Adopt an Effective Clinical Workflow
  37. 35 Work with cross-trained staff that can handle intake and documentation Document encounters as much as possible during and immediately after visits, but don't document more than necessary or spend too much clinical time on complex documentation Close all patient encounters by the end of the day – this should involve just wrapping up documentation for more complex encounters Route documents appropriately and delegate responsibility for document handling effectively Start on time
  38. 36 Commandment Number 7 Regular Audit of Provider & Staff Workflow
  39. Are your providers closing all patient encounters every day? Are your providers maximizing staff use during intake? How much time do your providers spend documenting each patient encounter? How much time do your providers spend on documentation while a patient is in the office and how much after the patient has left? Is your practice routing documents appropriately and delegating responsibility for document handling effectively? How does your practice stack up against comparable practices across the country? 37
  40. 38 For CureMD Customers
  41. 39 Free iPad app to facilitate multiple platform usage DRT Services Tweaking your Provide Notes for ICD-10 Get in touch with your Implementation or Support Manager to learn more about Audit Reports in CureMD
  42. Polling Question Q3. Which topic would you like us to cover in our next webinar ? a. Features in your EHR that faciliate ICD-10 b. Role of Clearing House in ICD-10 Transition c. Specialty Specific Documentation
  43. Session QA&
  44. Request a demo to see how CureMD can facilitate your practice for EHR documentation Get in touch with our documentation experts at 718-684-9298 For further inquiries regarding physician documentation, send us an email at the Need Help?
  45. 32 Thank you! Look out for our email, containing the webinar recording and a free eBook How to Master ICD-10 documentation in 10 days