Category Archives: Uncategorized

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.

Pausing for Dollars

Before you earnestly launch into your “To Do” list you created at the end of 2016, do yourself a favor and PAUSE!

 Surely you’ve created a list (at least in your mind) that more-or-less hits the mark on critical near-term goals, but have you considered that we – the human types – are creatures of habit and often govern our actions based on past experience? We are so engrossed in the weeds, the details, the urgent, that we fail to step back and reconsider the view from afar.  You see, the beginning of a New Year should compel all of us to ask, “What can I do better?”, “What should I do more of?”, and “What should I do less of?” In other words: What should change!

 It is with this posture that I ask you to reexamine your core business relationships with transcription or coding partners (and notice I said partners, not “vendors”).

Definition of Partner (according to Meriam-Webster): noun  part·ner \ˈpärt-nər also ˈpärd-\. Archaic. 1. one that shares. 2a. one associated with another especially in an action. b. either of two persons who dance together. c. one of two or more persons who play together in a game against an opposing side. d. person with whom one shares an intimate relationship.

 Simply put, partners are people that share, do things together, dance and play together. 

 At iData Medical, we are not your stereotypical medical documentation company, and we certainly do not view ourselves as “vendors”; rather we are partners.  Truth is, that many medical documentation companies do a good job.  But what sets us apart? What do we do that’s better? What differentiates us from the rest.  It’s simple: Our people. Companies like ours have software, processes, policies, etc.  But our biggest and most valuable assets are our human assets – our work force. Talented people are our differentiator!

 This forms that basis for our iD3 philosophy.  We have reduced our entire business DNA to three distinct concepts:

Client ID – We will get the right people in place to serve you.

Every organization is different. In one hospital or medical practice, the IT department may be really involved in projects, and in others not so much. The CFO may be hands-on in a hospital system, or the Health Information Managers might be left to make the tough choices. We work to understand your organizational DNA, and we set in place a plan for long-term success.  Our list of gratified clients isn’t only long, but most partnered with us for almost a decade.

Workforce ID – Because great results starts with a great talent.

Based on your identified needs in the Client iD process, we select the workforce that can deliver. We are superlatively selective in our hiring practices: We hand-select professionals from our team of fully-vetted high-gear human assets. We have learned that intelligent and satisfied professionals provide exceptional, consistent, and reliable work.  Exceptional technologies and processes abound. It is our human, intelligent assets that are our differentiator.  Front loading the right team skill level to successfully service your account, and we ensure that ongoing training and support aligns with your ongoing goals. In the end, we prefer (and value the wisdom of) paying now, not later. 

Secure ID – Your standards are our first priority.

 A globally-recognized Information Security Standard like ISO 27001 is not a one-size fits all in a privacy-starved market place. Your IT department or other constituents sometimes have security protocols and requirements that are unique. Your organization also quite likely has different ways of using technology and software. We assess those use cases and your unique requirements, and set a security program in place to give you peace of mind, ensure strict and audit-certified HIPPA compliance, and keep everyone happy.

And to top things off, we very often can do all of this at a decisively competitive price. 

So, how about we talk and see how iData can partner with you? In 2017, do things differently and Leverage the Power of iD3!

Importance of Transcription in the EHR

This article is written specifically for iData Medical by Darice Grzybowski, MA, RHIA, FAHIMA, President and Founder, H.I.Mentors, LLC and is a certified AHIMA Approved ICD-10-CM and ICD-10-PCS Trainer and Ambassador.

BACKGROUND

The electronic health record (EHR) is still in very much of an infancy state when it comes to accurately being used to tell the story of the patient.  There is much fragmentation in the method of recording information into the record vs. how it is displayed and organized for the end-user (reader) of such information.  Often lost in translation is the continuity from one note to the following report, from one order to the results, and between one caregiver and the next.

Much of this was due to the very confusing requirements of the Meaningful Use standards that tried to force practitioners into too heavy use of structured discrete data within template, while EHR vendors simultaneously were limiting physician flexibility due to restrictive designs in format. Adding to this decline of dictation use was the provider organization’s push to eliminate costs associated with the practice of dictation and transcription to justify the expensive purchase of an EHR. The EHR vendors were also supporting this push toward use of templates to build a return on investment case, but with no one considering the impact that the loss of dictation would have on the integrity of the medical record itself.

IMPACT OF TEMPLATE OVER-USE IN THE EHR

When clinicians are forced, or choose to use templated 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.

Rushing the act of documentation, or performing template fill-ins may allow the doctor to see more patients, but can result in several problematic and risk prone situations that can result in harm to the patient as well as create legal risk for the organization.   For example:

  1. Copy and paste can create fraudulent billing as coders may accidentally code a situation more than once or bill for something that was documented more than once, but truly only completed once
  2. Automatic filling of templates from previous information from another record or practitioner speeds up documentation, but fails to update current information such as the status of medications, conditions, allergies or other items that change frequently. When relying on old data, a safety risk is present for patients.
  3. Incorrectly populated drop down menus that come from limited diagnostic problems lists can omit critical detail necessary for care of the patient, communication to other providers, and denials for medical necessity.

It is no wonder why physicians are demanding the use of dictation and transcription once again, and why the CMS has come out with statements supporting the use of dictation once again within the EHR and many hospitals are returning to fully transcribed core documents such as history and physicals, operative reports, consultation reports, and discharge summaries.

Please refer to the article “Transcription and EHR’s: Benefits of a Blended Approach” by Jay Cannon and Susan Lucci to understand many of the industry issues that support a return to dictation and transcription as a core strategy for the EHR. http://bok.ahima.org/doc?oid=97974#.WIlUUIcryuU  [i]

Although this article was penned in 2010, very little has changed and it is still relevant today to the need in the physician community for the documentation of clear, concise, complete, chronologic and compliant documentation in the medical record.

USE OF DICTATION AND TRANSCRIPTION

Caring for patients is a very human business. It consists of the simple actions of

  1. assessing a patient
  2. creating differential diagnoses as to the cause of a symptom/condition
  3. ordering diagnostic testing
  4. creating a treatment plan based on results of testing (which may include procedural-surgical components as well as therapeutic/pharmaceutical modalities)
  5. monitoring the patient over time to validate the diagnoses
  6. and then eventually repeating the evaluation, diagnostic, and therapeutic cycle

To describe these stages effectively, the SOAP process was put into place (Subjective, Objective, Assessment and Plan) as a guideline for clinicians to document their care. These principles are still taught in medical schools today as a proper form of documentation that follows language in a spoken format to describe each of these components.   The problem is that EHR’s tend to require discrete templated documentation that consists of fields of drop down choices that do not appear in very SOAP oriented format and certainly don’t convey that phased process when reading the output of the documentation.

It is ONLY in use of dictation and transcription that one can truly read a formatted note within the EHR to help support SOAP charting, and to create the true infrastructure of the medical record content that supports telling the story of the patient during each episode of care.

Disclaimer: This blog represents the opinion of the author and is not to be considered legal advice. Grzybowski is the author of the award-winning book “Strategies for Electronic Document and Health Record Management” (AHIMA, 2014) You can read more about her at http://www.himentors.com/about-himentors/

[i] Cannon, Jay; Lucci, Susan. “Transcription and EHRs: Benefits of a Blended Approach” Journal of AHIMA 81, no.2 (February 2010): 36-40.

 

The ICD-10 coding vacation is over!

Ever been on vacation?  We all have.  The lead up, ripe with excitement and anticipation. The unknowns. The spontaneous confidence that something big is going to happen.  The day finally arrives. Perhaps a plane trip. Activity-filled excursions. The suntan. Mimosas or a Dark-and-Stormy, garnished with some island music.  Good food, a good book, and lots of rest!  But then, before it even starts, you are back home in the grind. The party is over.

And so is the ICD-10 implementation that kicked off October 2015.  Debate about its effectiveness, ability to help control costs, and whether there will be enough qualified coders to do the work was in hyper warp mode.  But finally, right or wrong, the standard was codified and required.

As we approach the 1-year anniversary of ICD-10 in the United States (no one is breaking out the Champagne), there will be another (almost) 6,000 codes released (as if the original amount wasn’t enough!). Along the way, experts in the coding world have been busy auditing and assessing program efficacy, as well as the accuracy and specificity of coders and health-care systems nation-wide.

What have they learned?

According to study conducted by ICD10 Monitor, the overall average accuracy during the 1st quarter 2016 for inpatient, ambulatory, and emergency coding types has dipped to as low as 80%, far lower than the 95% industry standard inherited from the days of ICD-9.  Digging deeper, the study revealed that for some coding categories, the accuracy approached a dismal 50%.  While audits indicate an uptick in accuracy during 2016YTD, the industry effort continue to fall short of the mark and has reduced productivity by as much as 15% (Source: Becker’s ASC Review).  Of course this is clearly on the lower end of the scale when compared to pre-October 2015 estimates (10 to 50 percent productivity impact), it is still a downward trend that has substantial monetized effects.

So, what to do? 

Perform you own internal audits. Do them more often.  Conduct them with greater rigor.  Ask yourself these questions:

  1. Does my facility use EMR? Do we dictate?
  2. How is my hospital, clinic, or practice entering the codes? By hand? Drop down lists? Are the lists complete and accurate, or do they enable the coder to derive errors through repetition?
  3. What are the coder knowledge gaps? What is the mixture of highly trained-and-certified in-house coders versus outsourced coders?
  4. Now that ICD-10 is well underway, what are you doing to maintain a robust continuous training program, especially as codes are added, grace periods are depleted, and accuracy thresholds are increased and expected?
  5. Is your clinical documentation complete and accurate?
  6. Are physicians providing ICD-10 quality notations or are there inherent and systemic quality gaps, requiring several iterations, thereby reducing productivity?

Some proforma and upside considerations: 

  1. While you can enter memorized ICD‐9 codes in your search, learning the recommended search strategy for your EHR may yield higher quality results.
  1. Take advantage of specific coding when you have sufficient detail or knowledge to assign a more specific code.
  1. Codes can be refined to indicate laterality, cause, type and chronicity
  1. ICD‐10 codes can now account for disease relationships indicating higher patient acuity (e.g., how many elderly diabetics do you know who actually have no complications?)

Remember that the transition flexibility with the family of code (ICD‐10 three‐character category), is slated to end September 30, 2016.

The upshot? There are a lot of internal, as well as external actions to your medical documentation systems involving accurate transcription and coding.  Doing those things isn’t enough – you must do them accurately and with minimal interference to productivity, maximizing reimbursement and quality of care.

Maybe then we can go on vacation again.  Daiquiris on the house!

For further information about how iData can assist you in the transcription and/or coding space, please contact us at 888-66-IDATA or visit us at www.idatamedical.com to learn more.