To err is human, but to really foul things up, you need a computer. So stated the introductory slide for the convention session “To Err is Human…To Correct Takes an HIM Professional” presented by Mary Jedlicka, RHIT, and Nick Judd, MBA, RHIA, from the Cleveland Clinic Health System.
This quote, from Paul Ehrlich, American biologist and environmentalist at Stanford University, captured the tone of the three sessions in the EHR Management Track, which took place on Monday from 1 p.m. to 5:30 p.m. All three presentations focused on data quality and how EHR functionality presents the opportunity for quality data capture but also challenges—such as temptation for shortcuts and distinct errors and omissions not encountered in the paper record.
Data Quality and Copy and Paste
In the first session, “Chief Complaint, Copy and Paste,” Michelle Mitcheff, RHIA, CDIP, CCS, from Indiana University Health System-Southern Indiana Physicians, explored this common documentation shortcut used by providers. Truly unique to the electronic environment, the practice of “copy forward,” which includes “copy and paste,” is the “process of using previously documented text from notes, reports, or other electronic sources to document a current patient encounter.”
Mitcheff used AHIMA’s Data Quality Management Model to identify the areas related to copy and paste: accuracy, consistency, and timeliness.
Examples of how patient care is compromised when cut and paste functionality is misused were presented:
- A 77-year-old patient who was to receive antithrombolitic treatment had their note copied and pasted over and over, but treatment was never given. Patient was readmitted two days post d/c with pulmonary embolism.
- Pressure ulcer with abscess note copied and pasted. “Patient needs drainage, may need OR” was continuously copied and pasted even after OR treatment, which almost caused an antibiotic therapy medication error.
The responses to “cut and paste” from the payer, provider, vendor, and patient view were discussed. A number of recommendations were offered by Mitcheff to control the practice of “cut and paste” in the EHR, including:
- Re-engineer templates to avoid unnecessary duplication of artifacts
- Minimize inserting patient data available elsewhere into the narrative record
- Develop medical history and examination data objects that can be reviewed, amended, and reused
- Enhance the problem list function as a better alternative to copying text lists
- Caution clinical departments against excessive use of copy and paste to boost productivity
- Teach practitioners and students that careless copying creates untrustworthy records
- Adopt a policy stating that unethical copying is unacceptable
Mitcheff highly recommends that “HIM professionals attend the EHR vendor training sessions for providers to observe what they are teaching physicians about documentation and the copy and paste functionality of their EHR system.” It is important to ensure that the vendors and providers understand the laws and the risks regarding the practice of cut and paste.
Data Quality and Correction Tracking System
Jedlicka and Judd from the Cleveland Clinic Health System followed with their presentation “To Err is Human…To Correct Takes an HIM Professional.” This presentation addressed the question of how to efficiently process corrections of electronic data.
HIM professionals all learned the right ways to make corrections in paper records in HIM 101—“Line through and initial.”
However, as organizations move toward robust EHR endeavors, the need and process to make corrections is much more complex. The initial incremental steps and eventual progression and evolution toward the development of a “home-grown” corrections request database were described. The HDS-EMR-CTS (Health Data Services-Electronic Medical Records-Corrections Tracking System) is an efficient point of contact system used to manage corrections in Cleveland Clinic’s complex multi-facility organization.
Correction Tracking System Flow
Errors in the EHR occur for many reasons: organizational (culture, policies, procedures and regulations), environmental (equipment, staffing, resources, and constraints) and human factors (technical and functional skills, communication, and problem-solving skills).
At Cleveland Clinic, the HIM department receives correction requests through the CTS. Each request is reviewed to determine whether the correction is to be made by the requestor, internally through the sending source, or reported to the EHR vendor to make the fix. The resolution of all requests is communicated back to the person who requested the correction. This results in a complete process in which communication is key.
Measuring Patient Identity Integrity
In the third presentation of the EHR Management Track, “Measuring Patient Identity Integrity: Foundational to Healthcare Analytic Success,” Barbara Demster, MS, RHIA, Stacie Durkin, MBA, RN-C, RHIA, and Lorraine Fernandes, RHIA, defined “patient identity integrity” as “the accuracy, quality, and completeness of data attached to or associated with an individual patient.”
This includes the accuracy and quality of data as it relates to the individual as well as the “correctness of the linking or matching of all existing records for that individual within and across information systems.”
All three presentations stressed a common message—the importance of education and communication in all efforts to improve data quality. HIM professionals should “encourage and educate peers and others,” should “educate your providers (they want to know!)” and should understand that “training is essential—guides are helpful, but face-to-face is critical.”
Follow the news and get insights from AHIMA’s 85th annual Convention and Exhibit being held October 26-30 in Atlanta, GA. For a complete list of event coverage on the Journal of AHIMA website, click here.