Ella Plainfeather Phyllis Curley Rebecca Jackson Jacqueline M. Jones EHR Best Practices Fort Defiance Indian Hospital

EHR Impact on HIM By Ella Plainfeather, RHIA, HIM Director

 Paperless lab reports began in June 2004 after providers were trained to look up lab results.  We are continuing with filing hard copies into the charts such as outside consults, pathology reports, etc.  Improvement: ▪ Cumulative reports received from Laboratory Department decreased. ▪ Staffing is unaffected.  Future functions/plans: Vista Imaging Scanning process. In the planning phase; including procedure and policy being devised, training and site visits are being conducted. Equipment is being researched, and creating a list of forms to be scanned. Laboratory Report Filing:

Release of Information  There are no major changes except printing off the EHR.  The ROI package is still being used, it is entered manually, and it does not cross over from EHR into the ROI package. The requests are filed into the charts.  Opportunities for improvement: ▪ It is time consuming to print notes, you have to click on each visit page and print instead of selecting dates like laboratory reports. ▪ There is no tracking mechanism in place for release of information. ▪ The POVs are not included on the notes, it is in a different section. EHR does not print health summary, have to go back into the RPMS.  Future functions/plans: ▪ Recommendations for improvement submitted to the EHR Implementation Team and the IHS EHR.

 In the clinics using EHR, the decentralized coders analyze the EHR visit notes.  Inpatient: ▪ Vital signs are entered into the EHR by the nurses. ▪ History and Physical (H&Ps) are entered into EHR by the providers.  Improvement: ▪ Real time analyzing. ▪ Legibility. ▪ Staffing is unaffected. Outpatient and Inpatient Analysis:

Outpatient and Inpatient Analysis: (con’t)  Opportunities for improvement: ▪ Printing hard copies until we are fully EHR. ▪ When inpatient coders complete their coding, the coders mark the coding queue as complete. ▪ Final diagnoses are out of sequence when it gets to the Billing section. When diagnoses are entered into the EHR, it creates a visit on the RPMS side. Inpatient coders are manually modifying the diagnoses on the RPMS side when they get a notice – re-sequencing. ▪ RN’s showing up as the attending physician on the A-sheet, the coders are manually changing the names during their coding processes until a template is developed in the system.

Outpatient and Inpatient Analysis: (con’t)  Future functions/plans: ▪ A Database was devised by the local CAC to track deficiencies identified by coders and/or analyzers. ▪ Queries for note clarifications are either ed to the providers, or the notifications are processed in the EHR to alert providers. ▪ Recommendations for enhancements submitted to the EHR Implementation Team and IHS EHR.

Legal Issues:  Provider signature: a document is incomplete until the provider signs off on the document in EHR, the incomplete note is returned to the provider by notification.  Addendums: Erroneous notes are processed only by H.I.M director and the CAC. They are retracted, never deleted and are always discoverable. They are visible only to the Chief of M.I.S. or the CAC depending on the business rules.  Notes: Can be reassigned to the correct date of service if necessary & again are only done by H.I.M. director or CAC. They will still reflect the date they were written. However, one must be cautious as the use of patient data objects will pull information from the date of service they were originally connected with.

 Access to EHR: All personnel needing access go through the Privacy Act/HIPAA training, computer security awareness training, and complete the computer access form. Chart reviewers are trained on EHR, they cannot print, and they are given view option only.  Sensitive Patient Tracking in the PIMS application: keeps track of who accessed a patient chart. The Quality Management Director and H.I.M. Director are the only ones that have the option and who perform audits. Legal Issues: (con’t)

 Future functions/plans: ▪ There are ongoing challenges with the implementation of EHR and we are making recommendations to the EHR Implementation Team and the IHS EHR. ▪ We are drafting procedure and policies as we progress. Legal Issues: (con’t)

 Received the Text Integrated utility Management (TIUM) menu.  This system will allow you to be the “Chief M.I.S.” user class.  You will be able to track the following: ▪ Retracted notes (not deletion) ▪ Determine how many unsigned documents exist ▪ To see how many unsigned documents for specific providers ▪ To track whether a chart is complete or not Responsibilities as a HIM Director/Supervisor:

 Menu Options consist of: ▪ IPD = Individual Patient Document ▪ LAD = List of Active Document Titles ▪ MPD = Multiple Patient Documents ▪ PDM = Print Documents Menu ▪ SIG = Awaiting Signature Listing ▪ SSD = Search for Selected Documents ▪ STR = Statistical Report ▪ UPL = TIU Upload Menu ▪ VUA = View a User’s Alerts Responsibilities as a H.I.M. Director/Supervisor: (con’t)

 Site visits to facilities that are using EHR.  Reassure employees.  Hands-on training.  Communication and education. Methods to engage staff in making the changes:

EHR Impact on Coding By Phyllis Curley CCS-P, PCC Supervisor

 11 decentralized coders in the outpatient clinics, ED and Dental clinics are non-E.H.R.  2 Float coders  1 Non-E.H.R coder centralized in Medical Records  1 Non-E.H.R ASC coder centralized in Medical Records Outpatient Coding Setup

 The CACs conducted noon and evening training sessions for clinic staff as each clinic rolled out with E.H.R.  Train-the-trainer  One-on-one: assessment and analyzing  Competency assessment Training Coders on EHR

 Coders run the EHRD report on a daily basis to capture all the E.H.R visits pending for audit in each clinic  These reports are available via the E.H.R coding Queue in RPMS *see following slide  Coding Queue reports sorting options Coders Responsibilities

Coding Queue

 Coders audit each patient’s visit utilizing the PEHR coding tool *see following slide  The coder analyzes data under each of the following tabs: completion of notes, orders signed and completed, medications dispensed, labs accessioned and resulted, wellness tab, cover sheet and POV tab Analysis of the EHR visit

PEHR Coding Tool

Chart Audit Status  After analyzing the data in E.H.R. the coders audit the visit in RPMS for accuracy  The coders mark the chart audit status REVIEWED AND COMPLETE after appending, merging and validating an accurate and complete visit utilizing the Coding Queue  The coders mark the chart audit status INCOMPLETE if any clarification or additional documentation is needed for specific code assignment or the visit documentation is incomplete.  A deficiency reason is entered in the chart audit status of the Coding Queue *see following slide

Chart Audit Status and deficiency reason

 The notification tab in the E.H.R is used to query the physicians and notify the physicians of any ICD-9 coding changes  The notification tab is also used to notify the providers of an incomplete coding and missing Evaluation and Management Code Coding Query

 Fort Defiance Business Office is also tracking E.H.R. deficiencies via the Coding and Billing Tracking database. The most common deficiencies to date are the following: ▪ Providers selecting.9999 code ▪ Missing Note ▪ E&M not coded ▪ Incomplete Coding ▪ *see CBT database CBT Database

 The EHRD Audit report is run daily by each coder decentralized in the clinic to capture pending E.H.R. visits  The PCC Supervisor runs the EHRD Audit report for all clinics every Monday and distributes among the coders.  The TXER report is run every Monday by the PCC supervisor and distributes among all coders to correct Reports

EHR Impact on Billing By Rebecca Jackson, Special Projects Coordinator

 Centralized  6 Billing Technicians  2 File Clerks Billing Staff Set-Up

 CAC conducted training  Interaction training: Supervisor training staff on all new developments with EHR  Mapping of PCC forms and EHR  Payer based training Training for Billing Staff

 Review EHR and hardcopy charts to ensure all potential billing is submitted to optimize revenue  Training on how to locate provider’s data entry (notes, quick orders, POV, etc.)  Cross reference between EHR and RPMS for completeness of documentation  Analyze each component of EHR tabs – notes, labs, medication, radiology, wellness, POV Services Billing Processes

 Internal Billing Office Query sheets, Patient Registration, Medical Records, Coding/Data Entry, Billing and Collections  EHR Coding/Billing Track Database (CBT)  Weekly CAC meeting  EHR Implementation Team meeting Reports/Tracking

EHR Impact on IT By Jacqueline M. Jones Information Technology Specialist

 For the provider  For other users  Notifications  Business rules  Clinic Rollouts  Electronic Health Record The Electronic Health Record Configurations

 ORES key: Is given to those who are authorized to write orders in the patient chart. Users can verify with their electronic signature. Given to licensed Physicians.  User class (add to PROVIDER Class)  Pharmacy setup (assign DEA# so that the provider can write medical orders)  Electronic signature  BGO keys ▪ Problem list edit ▪ VCPT Edit ▪ VPOV Edit Provider setup

 ORELSE keys: Is given to those who are authorized to release telephone and verbal orders, by policy for Providers. Generally, RNs and Pharmacists  OREMAS keys: Is given to those who can transcribe orders off of a chart. Assigned to Medical Clerks, Nurse Assistant, and Medical Technologist.  User class (RN, LPN, NA, Medical Clerk, Pharmacist, Provider, etc.)  Electronic signature  BGO keys ▪ Problem list edit ▪ VCPT Edit ▪ VPOV Edit Other users setup

User Classes

Notifications for HIM  There are many notifications that can be sent in the EHR. Users can schedule a notification to themselves or to others.  Users will receive notifications for unsigned documents, unsigned orders, missing POV.

Notification Menu

Business Rules  A completed (Class) Clinical Document can be viewed by a User  An unsigned (Class) Clinical Document can be edited by a provider who is also the expected signer of the note  An unsigned (Class) Clinical Document can be deleted by Chief, M.I.S.

Clinic Rollouts Sep 04  Podiatry  Optometry Nov 04  Well Child  Ob/Gyn  Rehab Feb 05  ACC  Ortho Mar 05 Speech Therapy May 05  Peds  Inpatient Nurses enter Vitals  MSU, ICU and Ob Ward entering Wellness Tab and pre-immunization screen notes Inpatient Ward Computer On Wheels  Outpatient (4)  Inpatient (2)

EHR Implementation Discussions  EHR Implementation Team  CACs  Coordinate templates (provider notes) with the coders  Equipment assessment  Medical Orders  Laboratory Orders  X-Ray Orders  Communicate new services  Review clinic setup (clinic code, location, create visit)  Setup users (keys, user class, e-sig, etc.)  Training users (clinical staff, coders, billing, ancillary services)  Conduct patient walk-thru with staff Working Projects  Inpatient Wards  Reminders  MARs  BCMA  Vista Imaging  Policies

Key  Communication  Involve Billing, Coding, IT, Nursing, Pharmacy, Lab, X-Ray, and Medical Staff  Training (CACs and Users)  Weekly meetings

Questions