Author Archives: Joey

EHR and the Hidden Agenda

So you’re thinking: “Another article about Document Integrity and the Electronic Health Record (EHR). Haven’t we had enough?” Granted, there’s a lot out there: Opinions, Vendors and Insurance “drivers”, Physicians, and Hospitals. Caught in between the cross-fire? Patients! So how does this translate into meaningful take-aways for you, for iData… really for all of us? Let’s get into the facts.  Below are excerpts from an article by Hermann W. Børg, M.D., in the Journal of American Physicians and Surgeons, Summer 2017, which scream against the outlandish propagation of EHR systems and related requirements. As Dr. Børg concludes,

“Well-designed research studies refute the enthusiastic expectations about EHR. Such studies provide very valuable evidence in discussion of its future directions. However, the research studies per se will not rectify the accelerating EHR debacle. Powerful EHR proponents will not be persuaded by scientific data. They have an agenda, and the EHR serves it well. “

Click here to Read More

Document Integrity – Racing the Tour de Fact

Document Integrity – Racing the Tour de Fact

If you’re like most people, we just keep moving with the inertial forces thrust upon us.  Indeed, we’re creatures of habit.  After all, most of us resist, if not fight change, because its hard: Change of schedule, locations, food, routines, people, jobs, friends, status, and so forth.

But deep down, we know that change is often necessary to move the pedals of our life’s “bicycle”. One pedal is depressed called “knowledge”. The other pedal depressed is called “action”.  Both are necessary and both must be depressed in sync to make our so-called bike roll down the road.

And so it is with Medical Document Integrity.  Knowledge that things can be better, problems can be avoided, quality can be enhanced, patient care can be  improved, liability can be reduced, and an accurate patient story can be told – that Knowledge isn’t enough. We also need Action. Let us no longer perpetuate the habits that replicate substandard results in our industry.

iData is focused on gaps caused by changes (and the related bad habits) related to the Medical Record, which often occur whenever a facility moves to an new EMR system. iData wants to come alongside your existing solution and fill those gaps with Action and nurture positive change!

Our method is pretty simple. It includes:

  • Use documentation audits as needed to identify the problems.
  • We provide specific feedback so specific solutions can be implemented.
  • We show our clients how traditional transcription reporting avoids these oversights.
  • We guide Physicians on the same – paying special attention to avoiding EMR shortcuts.
  • We show Doctors where and how transcription safeguards this entire process.

Contact us now for more information and be sure to check out our latest White Paper entitled, “The Emerging Role of Medical Transcription in the Electronic Health Record” authored by Darice Grzybowski (H.I.Mentors, LLC) – a nationally renowned author and speaker in the field of medical health documentation, processes, and systems.

And don’t forget to check out our latest blog: Documentation Integrity and Healthier Patients

 

Do You Have A Medical Transcription Backup Vendor?

Why is it that we often fail to have Plan B’s in life? Backup plans, third string players, an emergency battery or generator, a standby flash light, hidden emergency money, backup for your family photos, an extra key to your front door, or a backup parachute? Yet, just when we need them, we don’t often have them.

 



Do You Have A Medical Transcription Backup Vendor?
It’s The Intelligently Veiled Value Proposition!



Medical Transcription is no different. You’re a hospital or an MT service with many important clients that depend on your uninterruptible service pipeline. Patients, and your reputation and revenue stream depend on it. You simply can’t afford to experience service interruption from your current MT vendor and have no contingency plan in place.

This is where iData comes in. We pride ourselves with offering not only superlative front-end MT service, but we also offer a streamlined, plug-and-play backup transcription service for your hospital or document business at the flip of a switch. Power outage? Cake. Internet disruption? Easy. Did someone in the work-flow get hacked or data become irreparably compromised? You’re secure with iData’s proprietary iD3 Process!



Uninterruptible Transcription is your
Risk Management Plan. So, why wait?!



iData would love to be your backup parachute (okay, vendor)!  Let us show you our consistent and reliable approach to uninterruptible work-flow, and higher quality and TAT using iD3.  Don’t let MT supply chain interruptions strangle you or threaten your business continuity cycle. It’s time. It’s your turn to call.

Recommendations for the Safe Use of Copy and Paste

Recommendations for the Safe Use of Copy and Paste

Article published in AHDIONLINE MAY/JUNE 2017 Magazine

(Volume 13, Issue 3)

 

Lorraine Possanza, DpM, JD, MBe
and Maura Crossen-Luba, B.S., MpH, CpH

Copying and pasting information is a familiar, time saving computer function. However, errors in copy and paste can occur quickly and may not be readily recognizable. When a copy and paste error occurs in the context of patient care, the consequences can be devastating—patients may need to undergo additional or repeated procedures or may receive the wrong medications or treatments. The risks associated with using copy and paste in health care include the following (Partnership):

  • An overabundance of information (i.e., “note bloat”), which makes relevant information unclear or hidden
  • Propagation of internal inconsistencies and errors
  • Delay in diagnoses
  • Inaccuracy in billing
  • Documentation in the wrong patient chart

READ MORE

Document “Integridation” – Would you give your patients a rotten loaf of bread?

Would you give your patients a rotten loaf of bread?

No you wouldn’t!!  Sure some of the pieces of the loaf may look fine, but mold and bacteria would probably make them sick to their stomach and give them an unplanned colon cleansing.

Nor would you give your patients inaccurate and hard-to-read medical documentation about their care that can lead to misdiagnosis, poor care, and improper billing. But that is what we in the medical industry are doing every day whenever we participate in EHR group-think and pretend that all is well since “everyone else is doing it” or “I don’t have much of a choice since this this is the system we use”.

There’s way too many rotten apples in the document integrity “barrel”. But as professionals, we must not only diagnose our patients properly, we must also diagnose our flawed systems and compel our organizations to fix them.

Several professional organizations like ACDIS, ADHI, AHIMA, and ECRI agree that an adversary to improved healthcare is the current functionality and credibility of the EHR.  Faulty EHR documentation increases the probability of undermined patient care.  ECRI has called the persistent Document Integrity degradation the #1 enemy to patient safety for 2017. We sarcastically call it Document “Integridation”.


Want to know ECRI Institute’s #1 Concern for
Healthcare Organizations in 2017? It is:

Information Management in the EHRs


Dr. Reed Gelzer, MD, MPH, of Trustworthy EHR, a nationally recognized quality and information integrity consultant specializing in the legal aspects of EMRs, offers the following observations* about Providers:

  • They use functions that result in authorship falsification
  • They disable audit functions
  • Document misattribution that have (potentially material) legal implications

“People will do things in an EMR record
that they would never do in a paper record.” * 

Dr. Reed Gelzer, MD, MPH


Whether it is lagging communication between providers and IT, mismanaged electronic document control, copy-paste errors and data-duplication, shared and compromised record authorship, or a liberal audit control authority – to name a few – the time has come to comprehensively employ policies, systems, technology, and appropriate transcription and coding functions that aspire to eliminate material EHR errors, towards improved patient care.

To read our exclusive White Paper entitled, “The Emerging Role of Medical Transcription in the Electronic Health Record”, independently authored by Darice Grzybowski of H.I.Mentors – a nationally renowned author, speaker and Thought Leader in the field of medical health documentation, processes, and systems – click HERE to get your FREE copy. You won’t want to miss Grzybowski’s 5-point Conclusion and Recommendations!

https://www.ahcmedia.com/articles/117213-data-integrity-failures-in-emrs-is-no-1-concern

Medical Document Integrity Solutions

Medical Document Integrity Solutions

iData is focused on filling the gaps related to the Medical Record, which often occur whenever a facility moves to an new EMR system. iData wants to come alongside your existing solution and fill those gaps!

Our method is pretty simple. It includes:

  • Use documentation audits as needed to identify the problems.

  • We provide specific feedback so specific solutions can be implemented.

  • We show our clients how traditional transcription reporting avoids these oversights.  

  • We guide Physicians on the same – paying special attention to avoiding EMR shortcuts. 

  • We show Doctors where and how transcription safeguards this entire process.  

Learn more about this unique analysis at our presentation at AHDI on July 14th. Or, contact us now for more information and we’ll send you an exclusive copy of a White Paper entitled, “The Emerging Role of Medical Transcription in the Electronic Health Record” authored by Darice Grzybowski (H.I.Mentors, LLC) – a nationally renowned author and speaker in the field of medical health documentation, processes, and systems.

And don’t forget to check out our latest blog: Documentation Integrity and Healthier Patients

Documentation Integrity and Healthier Patients

Documentation Integrity and Healthier Patients

Remember when the milk industry inundated us with their “Got Milk?” or “Milk Does Your Body Good” campaign? Their campaign told us that drinking milk meant healthy bodies and bones. Well… when it comes to healthier patients, it similarly holds true that “integrity does your body good”.  Better patient care is contingent on clear, accurate, and thorough documentation – or simply put: Documentation Integrity.

“When clinicians are forced, or choose to use templated EHR documentation, they fall into bad habits.  These habits include such problematic documentation short cuts such as copy and paste, auto-fill-in of existing templates from previously recorded information, over-use of drop down menus which are pre-populated with erroneous or old data, and data pulled from other sources or records that are not appropriate to be re-copied. These habits create several problematic and risk prone situations that can result in harm to the patient as well as create legal risk for the organization.” (1)


“Integrity Does Your Body Good!”


As iData Medical employs its iD3 process and continues to expand its presence in medical transcription and coding, we are proud to announce a new sponsorship and collaboration with Darice Grzybowski, a nationally renowned expert in the field of medical documentation (see her award winning book, “Strategies for Electronic Document and Health Record Management” (AHIMA, 2014). With Darice’s leadership, iData is offering a complimentary document integrity audit to help you drill down and discover how your documents stack up to industry standards and understand the level of risk, if any, your organization is assuming. Contact iData now to reserve your free document integrity audit, as availability is limited and will go fast!

For more information, click here to read the entire article entitled, “Importance of Transcription in the EHR”. And if you are really interested in this topic, iData Medical, along with Darice Grzybowski will be sponsoring a presentation and booth at the 2017 AHDI Conference in San Antonio on July 13-15. Would we love to meet with you!

(1) Grzybowski, Darice. Importance of Transcription in the EHR. Blog article found at: http://www.idatamedical.com/importance-of-transcription-in-the-ehr/, posted February 9, 2017.