HIM`s Role in Facilitating Chart Correction in the EMR

Report
HIM’s Role in Facilitating
Chart Correction in the EMR
Terry Lary, CMT
Operations Manager, Lebanon
Cheryl Rowe, Operations Manager
Community Group Practices
Beverly April, RHIT, BS
Senior Clinical System Analyst
Patricia Sorento, M.Ed., RHIA
HIM Consultant
Dartmouth-Hitchcock is…
New Hampshire’s only academic medical center
• An integrated academic healthcare delivery system
Directly serving the health care needs of more than 1.5
million patients in northern New England.
~ 8,700 total employees
• 977 physicians, residents employed
• 1,386 direct-care RNs employed
Dartmouth-Hitchcock is…
Dartmouth-Hitchcock Medical Center
• 396 bed tertiary/quaternary medical center
• Lebanon, NH
Multi-specialty Community Group Practices
• Manchester, Concord, Nashua, Keene, NH and
Bennington, VT
Regional Clinics
• Throughout New Hampshire and Vermont
Dartmouth-Hitchcock
• Our Mission:
We advance health through research, education, clinical
practice and community partnerships, providing each
person the best care, in the right place, at the right time,
every time.
• Our Vision:
Achieve the healthiest population possible, leading the
transformation of health care in our region and setting
the standard for our nation.
Our HIM Departments
• Lebanon/Manchester/Nashua
– Traditional HIM Services
• Release of Information
• Chart Completion
• Chart Correction
• Record Management
• Privacy
• Transcription
• Forms
– Expanded HIM Services in the EMR
• D-Hconnect
• myD-H patient portal
• Scanning for non-DH or legacy systems
• Total Number of HIM Employees: 85
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Our Medical/Health Record at D-H
DHMC Professional Staff By-Laws/Rules &
Regulations define the record as follows:
“The ‘medical record’/’health record’ is a legal business record
of the Hospital and the Clinic. As such, medical records
must be created and maintained in a manner that is in
compliance with:
•
•
•
•
•
applicable law
regulations
accreditation
standards
professional practice standards
• Primary purpose of the Health Record:
Documenting the care of the patient
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Our Medical/Health Record at D-H
Access to Clinical Information
• Multiple MRN’s linked by one Enterprise number
– Unique MRN’s at various locations
• Legacy EMR System (CIS)
• Historical paper records
– Scanned into EMR
– Stored Records
Access to EMR
–
–
–
–
D-H Clinical Staff
Patient Access through myD-H
Referring Provider through D-Hconnect
Multiple Outreach Providers
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Uses of the Medical/Health Record
Health Records are being used daily for a multitude of
purposes including:
• Communication among the healthcare team caring
for the patient
• Evaluation of the adequacy & appropriateness of the
care
• Providing data for billing & strategic planning
• Protecting the legal interests of the patient, facility
and the clinical provider
• Providing clinical data for research & education
• Release of Information to patients and 3rd parties
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HIM Role in Facilitating Chart
Correction in the EMR
Environment
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Our Goal: Protecting the Integrity of
the EMR
• Erroneous or inaccurate clinical
documentation should be corrected as soon as
the error is discovered.
• Audit Trail of the Correction
• Errors have implications for:
– Patient safety
– Reimbursement
– Release of information
– Patient confidentiality
– Risk management
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Customary HIM Corrections
• Duplicate Number – Two or more unique MRN’s for
One patient
• Patient Overlay – One MRN contains patient data on
two separate patients
– Two patients confused as one
– Misfiled documentation
• Patient Demographic Updates
– Name changes
– Address
• Professional Billing Charges
– Dates of Service
– Correct provider
– Correct Service
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HIM’s Approach to Errors
• Analysis of Error
– Type of Error
•
•
•
•
•
Clinical Content Error
Demographic Data
Filing
User Error
System Error
– Environment
• Inpatient or Ambulatory
• Affected Modules
– Orders; Ambulatory; Inpatient; Lab; Flow sheets;
Operating System; Pharmacy; Billing;
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Approach cont…
– How was the error generated
• Ancillary System Feed
• Author/User Error
• Third-party System (ie scanning)
• Who should be involved in correcting the
error
– Established an enterprise wide multidisciplinary
committee comprised of regional representatives
from:
• Revenue Management Department
• Health Information Management
• Each Ancillary Team: Lab; RIS; Cardiovascular
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Approach cont…
•
Clinical Applications Team Leadership
(providers)
•
Technical expertise for each module
– Created a Chart Correction Reference
Tool
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HIM’s Facilitation Role
• HIM is notified of an error
– User Help Desk, user reported, or found during a
workflow such as Analysis or Coding
• Performs an analysis on the error
– how it should be corrected
– Who needs to be involve
• Contact Appropriate Staff:
– Provider and informs them of the error
• Walk through Correction Process
• Remote to Provider’s device to offer Assistance
• Monitor until Completed
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Facilitation cont…
• Ancillary System
– Notify Contact Person for System
• Lab, Imaging, Pharmacy
• Verify EMR is Updated
• Determine “Upstream” and
“Downstream” Events
– Was the patient given incorrect
information at the time of the visit (AVS)
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Facilitation cont…
– Registration needs updating
• Patient Requested Changes
– Amendment
– Correction
• Audit Trail
– Revisions identified in Document
– Flagged as “Addendum”
– Flagged as “Deleted”
– Audit Trail of Changes in Source System
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