HIM’s Role in Facilitating C hart C orrection in the EMR

1. HIM’s Role in Facilitating Chart Correction in the EMR

2. 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

3. 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

4. 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. Dartmouth-Hitchcock

5. 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

6. 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

7. 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

8. 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

9. HIM Role in Facilitating Chart Correction in the EMR Environment

10. 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

11. 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

12. 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;

13. 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

14. Approach cont… • Clinical Applications Team Leadership (providers) • Technical expertise for each module • Created a Chart Correction Reference Tool

15. 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

16. 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)

17. 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