Utilization of Electronic Health Record (EHR) has opened the door for many persons/facilities/organizations to become active in customizing and/or adding items to their database wherever possible. The ability to add facility or organizational specifics has enabled uniformity and consistency with the building of templates/pick-list(s) and libraries. It can be either the time saving tool everyone loves or a problematic add-on that can have both monetarily or regulatory implications.

Sample Electronic Health Record Audit Findings

Let’s review an example found during a recent audit of an EHR. A LTPAC facility had created their own version of the Cert/Recertification required for skilled services. When creating the assessment there was an obvious oversight in the requirements of the information that was to be obtained and documented/captured in the assessment. Even though there is no specific form required for the Cert/Recertification, required elements must still be included for it to be considered a valid Cert/Recertification which may be required for payment of skilled services.

Without getting too technical, a partial listing for the Cert/Recertification example would include:

• Insured’s name
• Medicare ID number
• Signature and date of the attending physician at various intervals of the stay
• Skilled service(s) listing including details
• Estimated time skilled services to continue

Additionally, discharge plans would need to be included and because of the multiple signatures and dates required by the Physician, this form would need to be printed at each of the intervals (initial certification, 14 day, 30 day, 60 day and 90 day certifications as appropriate).

The Cert/Recertification I reviewed had several areas of concern:

• Electronic signature from physician (must ensure accepted for payment)
• Wrong dates entered by the physician with the signature
• The skilled services were not fully listed
• Pick list created put the facility at risk by only giving the choice of therapy services but not two or three which is often needed by the resident
• No discharge plans were incorporated into the Cert/Recertification

Several of these issues identified above caused the Cert/Recertification to be invalid. Because the Cert/Recertification is not appealable, the facility must forfeit payment for the services they provided. The lack of attention to detail in this one form/assessment cost the facility thousands of dollars and has put them at risk for additional negative audit findings.

Any customization can be problematic if not thoroughly planned, methodically thought-out, and meticulously reviewed. As with any project, when you are looking to customize your EHR, you should begin with a Project Plan. Review the plan with your team and consider all areas such as:

• Does it make sense to enter the item into the EHR, or does it cause more work at this time d/t hardcopy signatures that are needed
• Do the regulations allow for an electronic signature, if available, on this item
• Is the item copy written, have you received permission to enter it into your EHR
• Have you included all possible options/choices into the electronic version
• Have you tested the end-product to ensure it delivers the desired results

Electronic Health Records are most certainly making it easier for day-to-day documentation and communication but as with anything, it’s only as good as the information entered. Taking your time, careful planning and attention to the details will help you in your efforts to customize your EHR.

For help in making sure your Electronic Health Records are complete and accurate, Contact Richter Healthcare Consultants at 866.806.0799.