Even with the most effective EHR, practices and HCOs need to use the EHR tool in an effective manner and upgrade the tool appropriately. In many cases, practices and HCOs are not using EHRs or maintaining patient information in a manner that will stand up to scrutiny and discovery in the event of a medical professional liability event.
Clinical Content – Clinical content refers to the various forms, checklists and other documentation tools in the EHR. In most cases, physicians are using clinical content that came with the EHR and was a reason that the product was purchased. In most cases, the clinical content was developed by the EHR vendor based on experience with similar practices. However, the clinical content should be vetted by the physicians before they start to rely on the EHR to adequately and accurately describe patient care.
EXAMPLE:
A primary care doctor was distributing exam notes that contained inappropriate findings for patients. The doctor was using a vendor provided template of findings that included review of systems that were not included in the specialist’s services.
Due to the lack of appropriate clinical content, physicians were using ad hoc notes to document patient care. Many of the items in the ad hoc note could be directly entered into the EHR. However, the EHR could not use the ad hoc notes to determine standards of care or drug allergy issues.
DISCOVERY ISSUES:
Was information on the patient condition entered, stored or presented in a non-standard manner since the clinical content was not adequate for the physician’s services?
How were the clinical setups, checklists and documents validated for clinical relevancy and appropriateness?
What is the practice’s strategy for maintaining the relevancy and use of appropriate clinical content?
What was the procedure for reviewing the patient exam information and any reports produced from that information for accuracy?
Who verified the clinical content?
What standard was used to verify clinical content?
RISK REDUCTION STRATEGIES:
EHR clinical content should be tested before use by physicians to assure that the EHR can correctly document the various aspects of patient care and services.
The quality assurance procedures of the practice should provide continuing information on the relevancy of the clinical content. The practice should have a process to address any deficiencies.
Training programs for physicians and staff should address proper use of the clinical content with the EHR.
Cloning – EHRs include a number of features to speed recording of notes. “Cloning notes” can be accomplished by accepting a disease or provider specific template of information which is then edited for the specific patient. Cloned notes can also be based on previous patient visits which have been copied to document the current visit. Cloned notes pose a number of problems for the discovery process.
EXAMPLE:
A physician using cloned notes didn’t realize that the template included a wide array of information that was not visible on the current EHR screen. Exam notes were released that documented inappropriate observations.
An EHR allowed the nurse to cite forward information from a previous visit for the patient. However, the physician assumed that the displayed findings were current information from the patient and based clinical decisions on the cited information.
Most EHRs do not differentiate between information that has been cloned and information that has been entered as a result of the visit. Thereby, the physician cannot discern information that should be confirmed.
DISCOVERY ISSUES:
Did the physician or staff use cloned notes or templates to start care for a patient?
Did the physician or staff cite forward any component of a previous patient note as a basis for the relevant patient notes?
Does the EHR product require confirmation of cloned patient note components, or are the cloned note components automatically included in the current patient note?
Are there any inappropriate observations in the exam information that may have been the result of cloning? Inappropriate observations due to cloning may open questions about all components of the note.
Are there any extraneous observations that would not be logically included in the patient note based on the patient chief complaint and history of present illness? Extraneous findings may indicate cloned information that was automatically added to the patient note.
Were the physicians and staff aware of the nature of the cloning process and the information that was added to the patient record?
What were the standards under which cloning was used?
What quality assurance procedures monitor the efficacy of patient notes with cloned components?
RISK REDUCTION STRATEGIES:
Physicians should verify the basis for cloning before the EHR is activated and on a periodic basis thereafter. Verification will insure that the notes represent the clinical standards, and the resulting documentation reflects the standard of care.
Training programs for doctors and all clinical staff should cover the use of the EHR, and the representations of care produced by the EHR. The training program should cover how the EHR reflects the standard of care.
Use of cloned notes should be support by CME and EHR training that verifies the clinical treatment and documentation standards with appropriate clinical care.
.A continuing quality assurance program should verify the appropriateness of patient notes on a daily basis.
Inconsistent or Non-Standard Use – One of the key benefits of EHRs is information access for reporting and to trigger patient service and care standards. However, EHRs depend on certain information being entered to trigger the care standard or activity. For example, if one were to put the distribution of a medication sample in an ad hoc note instead of the medications list, the drug utilization review would not consider the drug sample. Inconsistent EHR use can undermine the reliability of the patient information as well as practice wide use of the EHR.
EXAMPLE:
Some physicians were documenting information in a patient note, while other physicians were documenting that same information in a patient message.
Patient information that was used to select patients for clinical based reports and to trigger health maintenance items was not correctly entered by several physicians in a practice.
In order to customize use of the EHR for various physicians, a wide array of different terms and scales were used to document the same information. For example, some physicians were using a severity scale of 1 to 10, while other physicians were scales of 1 to 7 and 1 to 3. Reporting for clinical issues based on different scales was ineffective.
DISCOVERY ISSUES:
Did the ad hoc notes in the EHR include information that should have been entered in a specific area of the EHR? Did the failure to enter information in the specific area contribute to the incident?
Did the information that was not entered in the clinical content area of the chart fail to update the patient status that was relevant to the incident?
Did the alternative use of the EHR result in the patient being excluded for EHR features that affected patient care?
Did the alternative use of the EHR result in the patient being included in a report or indicate an inappropriate health maintenance item?
RISK REDUCTION STRATEGIES:
The practice should maintain and establish standards of use that are the basis for physician and staff training as well as quality assurance measures.
Periodic quality assurance evaluations should be undertaken to verify proscribed use.
Physicians and staff should be trained on the correct use of the EHR. Such training should cover the dependencies of the EHR and patient information accuracy on specified use of the EHR.
Non-standard or inconsistent use of the EHR should be evaluated when discovered. Appropriate amendments and updates should be considered and the documentation issue should be discussed with the source of the inconsistency.
Clinical Life Cycle – Patient service activities require management of the clinical lifecycle of each patient service item. For example, messages containing patient questions may be handled by several doctors, but the final disposition of the issue and notification to the patient should complete the message.
EXAMPLE:
Due to a training issue, doctors were not properly completing their messages which were cluttering up their EHR workflow screens. To work around the problem, staff members were assigned responsibility for printing the messages and the doctors would record their findings on the printed message. The printed message was scanned into the EHR, and the electronic message was never completed or attached to the scanned documentation.
An EHR only offers two order statuses (open and closed.) The practice left open orders for care that had be superseded, became obsolete or were rejected by the patient. The patient summary screens and order management screens became cluttered and misleading.
A review of patient exam notes in an EHR uncovered thousands of unsigned exam notes going back to the initial start of EHR use. The unsigned notes opened the practice to the efficacy of the EHR based patient notes and even issues with supporting documentation of insurance claims.
Presentation of outstanding patient orders highlighted the failure to maintain order status (open, scheduled, results received, results reviewed, or complete) and patient reminder status. Medical staff ignored all patient orders since so many order statuses were incorrect. The failure to maintain information on outstanding orders and notifying patients about treatment orders (a Meaningful Use Menu Item) may become a standard of care.
DISCOVERY ISSUES:
Does the EHR fully support the clinical life cycle of the various clinical items such as orders, treatment requests and patient questions?
Did the failure to maintain proper order status affect patient care and the incident?
Are patient orders properly entered and managed in the EHR?
Were patient messages relevant to the incident properly handled and prioritized?
Were patient messages and orders related to the incident properly managed at the patient level and within the management tools of the EHR?
Were patient messages and orders related to the incident obscured or distorted in any way by the EHR system?
Were patient messages and orders related to the incident obscured or distorted in any way by the practice’s use of the EHR system?
RISK REDUCTION STRATEGIES:
Verify that the workflow procedures and use of the EHR adequately manage the clinical lifecycle of relevant activities including, but not limited to notes, messages, treatment plans, orders, and surgery scheduling.
Establish a quality assurance program to identify overdue or incomplete activities and address the overdue items.
Maintain a program to assure adequate maintenance of the clinical life cycle for all relevant patient events and activities.
Include the clinical life cycle as part of the training program for all physicians and staff.
CONCLUSION
Even if the practice utilizes the EHR transition and use risk reduction strategies documented in Parts 1 and 2 of this series, the greatest EHR challenges remain the day to day use of the EHR by physicians and staff. With the best of intentions, the use of the EHR without proper training and validation will present a number of challenges to any healthcare organization facing discovery triggered by a medical professional liability event.
In order to use the EHR effectively and properly document the due diligence of the providers, practices and healthcare organizations need to establish a standard of EHR use, and train doctors and staff on those standards as well as monitor day to day use of the EHR. Otherwise, you may be facing a vulnerable set of patient information in the examination of EHR use and management as part of a medical professional liability driven discovery process.
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