It’s Not About The Box Improving Care at Group Health with People, Process and Technology

July 31, 2007

Copy-Pasting in the EMR gaining more attention

Filed under: Quality / Affordability — admin @ 5:39 am

As I mentioned previously, we are completing an internal audit of EpicCare Documentation.

One of the issues being raised not just at Group Health but across the industry is authorship integrity. For the past several years, warning flags have been waving around the use of templated text in medical record documentation.

This has been a bit of a difficult conversation involving clinicians and non-clinicians alike in discussions of “what’s right” when it comes to duplicating parts of text to support accurate documentation. My opinion is that the technology has probably moved a bit faster in this domain than has the industry’s ability to understand how to use it most effectively.

The outcome of these discussions has to be that we know how to use the technology in the most beneficial way for our patients. I wanted to share the following document that demonstrates that we are not alone in having this concern:

Anti-Fraud Measures coming to EMR Systems

In addition, there is a requirement on copying notes (also known as cloning or cutting and pasting). When physicians copy an existing note about a patient and paste it into another chart entry as a shortcut with updating required, they must retain the date, time and user stamp of the original author, the requirement states. If it’s copied from another patient, the original patient ID should not be kept. The draft rationale: “Copying and pasting all or a portion of a previous note is a provider efficiency tool. This process can be abused by appearing to attribute observations made by a previous provider to the current provider. If the intent is simply to provide common terminology or phraseology for reuse, templates or defaults may be used for this purpose.”

The requirements are just in draft mode. They are designed not to go to users of EMR’s, but EMR vendors, through the Certification Commission for Health Information Technology. This is what we want, because we’ll get the functionality automatically.

I happen to be sitting on CCHIT as of July, 2007, as a representative of Group Health Cooperative, and will keep my eye out for this.

July 30, 2007

Workplans for Informatics Physicians, Quarter 3

Filed under: Informatics Team — admin @ 6:00 am
Quality & Informatics Physician Workplan Wiki - Ted Eytan Workplanthird Quarter 2007

Q3 2007 Workplan, Ted Eytan, MD

Quality & Informatics Physician Workplan Wiki - Tom Schaaf Workplanthird Quarter 2007

Q3 2007 Workplan, Tom Schaaf, MD

Quality & Informatics Physician Workplan Wiki - David Kauff Workplanthird Quarter 2007

Q3 2007 Workplan, David Kauff, MD

Quality & Informatics Physician Workplan Wiki - Ruth Krauss Workplanthird Quarter 2007-2

Q3 2007 Workplan, Ruth Krauss, MD

Quality & Informatics Physician Workplan Wiki - John Kaschko Workplanthird Quarter 2007

Q3 2007 Workplan, John Kaschko, MD

Attached are the 90-day workplans for the 5 physicians on the Informatics Team for Group Health Cooperative. We are using a process based on LEAN, where we specify what we’re doing for our members (of GHC and GHP) in 90 increments. We also key off of the work of the Q3 CIS Workplan. The workplan is what Group Health has decided are the priorities are for the quarter, so our job is to help that work happen.

This process been a bit of a breakthrough for us, in that we first work to understand what Group Health needs through the CIS Workplan, and then we define how we are going to help that work. In the past, we might have driven the work based on what we thought was important as physicians.

LEAN has been influential in creating discipline around “prioritize once, implement quickly.” The other influence it has had is in making the work we do more visible. We support all workplans being accessible by any Group Health member who wants to know how we are serving them.

See what you think. Comments are welcome, as well as questions if you don’t know what something is. Our goal is to add value to our members’ care experience.

Documentation & Coding QIST 2 – Northshore Edition

Filed under: Coding,QISTs — admin @ 4:30 am
Nsh 7-27-07 Coding Final Newsletter

Newsletter, Northshore Documentation and Coding QIST 2

The second documentation and coding QIST wrapped up on Friday, led by Kim Nichols, Wende Keyes, and John Kaschko, MD.

There are some big helps, like the chronic disease coding aid, and several little goodies, including auto-filling of blood pressure for cholesterol orders sent to the lab and last menstrual period for pap smears.

Ric Magnuson, Group Health’s Chief Financial Officer, visited on Friday, and was able to shadow a patient visit with Steve Hockeiser, MD, the Medical Center Chief. Steve showed off the EpicCare system and the use of voice recognition to document patient care.

Speaking for myself, it was really nice to see Ric as well as our Health Information Management leadership present at the event. The medical and nursing staff were also very welcoming throughout – and the results demonstrate it!

July 27, 2007

Proposed change to EpicCare: No more editing of “Display As” on Problem List

Filed under: Quality / Affordability — admin @ 3:41 pm

Proposed change – will make this field not editable, supporting accuracy

As I have posted here previously, Group Health, with full support of our medical group, is completing an internal audit of our documentation practices in EpicCare. This help is always welcomed because it allows us to find problems, which are gold, and fix them, demonstrably, for our members.

I want to share one of the results with you and a proposed fix to this, to make sure the change doesn’t cause more problems.

The fix is to disallow editing of the “Display As” field on the problem list. See the attached screen shot.

What is this editing useful for?

When we first installed Epic, we did not have the enhanced ICD-9 description dictionary. We knew that we would be sharing problem lists on line with patients and we also knew that the way ICD-9 out of the box describes things was not very friendly. To make up for this, we supported editing of this field so the problem list entries would be more relevant to practitioners and patients.

Why do we want to turn it off now?

1. We’ve discovered that changing the wording in this field changes it throughout EpicCare, on the snapshot, and more importantly, on the order entry screen.
2. If a person mistypes the “new” description or significantly changes the meaning, the next provider may be led to use an incorrect code to describe a condition.
3. There are many conditions where a change in status requires a change in code. For example, going from “Colon Cancer” (active) to “Colon Cancer” (in remission) require a change in the numeric code. Changing the words doesn’t do this.
3. Since we launched Epic, we did a massive update of ICD-9 descriptions, going from 11,000 to about 160,000. It’s much more likely that you’ll find what you’re looking for both clinically and in a way that makes sense to the patient.

If we do this, we’ll be better able to control for situations where the description of a code is misleading. The science of translating a physician’s thinking to a search engine to a numeric code is quite complex. I am sure an enterprising Ph.D. could do a dissertation on it (and a side note that 11 years ago I was doing a medical student rotation at National Library of Medicine where they thought they had figured it out. They hadn’t).

Feel free to comment if you think that there will be impacts to making this change (positive and negative). From everything I know and in reviewing our results to date, I think this makes sense as a useful change to keep our medical records accurate.

I’d like to mention that this idea didn’t come from me – it came from our partners in Health Information Management – our coding consultants pointed out the benefit that Group Health would get from this change. Many thanks for the assistance on this.

Updated 7/27/07: I/we appreciate any comments that people have about this, the decision is not committed yet.

Report: Testing of Tablet PC’s

Filed under: Informatics Team,Information continuity — admin @ 5:10 am

There has been, over the years, interest in the idea of Tablet PC’s for using Epic. From a computer industry perspective, these devices have had only modest success.

As part of thinking about Overlake and the future in general, Group Health obtained one Tablet PC device and loaded EpicCare on it as a trial. I worked with it for just a little bit before I decided that it would not meet my needs (difficult to use a stylus, handwriting recognition not useful for putting in password, etc etc), and then we lent it to Chris Cable, MD, the Chief of our Hospitalist Service. Here are his thoughts:

Well, I can tell you I don’t like the tablet PC. Too hard for input, a bit awkward to flip open and shut, and it’s heavier than the notebook. However, I’m not 100% sure people will want to carry a notebook on rounds either. It’s still awkward, nowhere to safely stash it while you examine a patient or do a procedure, security issues if it’s lost/stolen, and you still need a place to put it down to use it. One thing I can’t test is wireless, of course, so if you can log onto Citrix once all day and it stays connected that may be a benefit. If it logs you off every time the case is closed and you have to reconnect then I don’t see the difference between a notebook and a desktop in terms of access convenience.

I think it would depend on how easily the fixed computers at Overlake are accessed. If they are freely available and we can log on to one for several patients that’s probably what we’d do. If they are usually occupied and we end up waiting for a free terminal or you have to log on and off for each patient then a notebook may be preferable. It will all depend on the work site once we get there I think.

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