INSURANCE INSIGHTS Health Information Technology Toward Safer, More Efficient Use INFORMATION TECHNOLOGY (IT) SYSTEMS are changing the practice of medicine. Well-designed and carefully implemented electronic documentation formats can significantly enhance clinical care by increasing consistency and legibility, while facilitating provider access to vital patient data at the point of care. However, IT systems that fail to reflect actual workflow patterns and provider needs ultimately may hinder effectiveness, continuity and coordination of care. As pressure grows to automate the documentation process, providers must ensure that their IT policies and practices accord with regulatory requirements and risk management objectives. This article is intended to help physicians and other health care professionals comply with federal mandates for demonstrated use of IT, boost patient safety and practice efficiency, minimize unauthorized access to protected health information and other individually identifiable data, and establish and maintain appropriate boundaries for patient relationships in the age of electronic communication. Achieving ‘Meaningful Use’ Under the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, physicians and other providers are entitled to Medicare and Medicaid incentive payments when they demonstrate “meaningful use” of electronic health care records (EHRs).1 By utilizing a combination of IT tools in concert with EHRs—such as computerized patient registries, e-prescribing software programs and mobile technology devices— health care providers are better equipped to achieve and demonstrate meaningful use of IT, which involves the following functions, among others: Œ Capturing patient medication regimens, as well as problem and allergy lists. Œ Querying patient records for specific conditions or procedures. Œ Incorporating clinical decision-support software, which reflects evidencebased pathways and practices. Œ Utilizing e-prescribing tools in conjunction with local pharmacies. Œ Sharing data with ancillary service providers (e.g., radiology and laboratory). Œ Adhering to proactive patient population management principles, in order to increase both effectiveness and efficiency of care. Œ Monitoring baseline metrics to reduce disparities in care for common medical conditions (e.g., hypertension, asthma, COPD). Œ Retrieving data elements in standard code terminologies, such as CPT categories and ICD-9 codes (which are scheduled to be replaced by ICD- 10 codes as of October 1, 2015). Œ Producing an annual quality report that tracks at least three quality measures, such as adherence to clinical guidelines, patient outcomes and care coordination.2 Expanding the Role of Medical Assistants An important component of health IT is computerized provider order entry (CPOE) for medication, laboratory and radiology orders. Under Medicare and Medicaid guidelines, medical assistants are eligible to enter data into a CPOE system only if they are certified by an external organization, such as American Medical Technologists (www.americanmedtech.org). Risk management solutions from CNA Healthcare Depending upon circumstances, practices may wish to consider encouraging medical assistants to obtain certification, in order to improve productivity and demonstrate a commitment to meaningful use of information technology. Among other functions, certified assistants can: Œ Complete data entry and other timeconsuming EHR input requirements, such as diagnostic histories, medication profiles, laboratory test findings and consultation results. (Note that medical assistants must receive ongoing reinforcement that accuracy counts more than speed, as inputting errors can seriously jeopardize patient safety.) Œ Act as scribes during patient encounters, capturing patient data while freeing up time for medical practitioners to interact with patients. Œ Explain to patients about medical practice portals or interactive websites, thus encouraging them to become more informed and active partners in their treatment. Œ Collaborate on EHR design to ensure that access points correspond to existing workflow processes, including registration, history, patient encounters, coding, billing and collection. For medical practices contemplating expansion of medical assistant duties, the Medical Society of Metropolitan Portland offers a course for assistants on changes in Medicare and Medicaid regulations. Securing Data Under HIPAA and Medicare/Medicaid guidelines, unauthorized disclosure of protected health information and other breaches of data security can result in substantial penalties. To prevent violations of privacy regulations, practices should 1. For more about meaningful use regulations, visit www.healthit.gov/policy-researchers-implementers/ meaningful-use-regulations. The HITECH Act Enforcement Interim Final Rule can be accessed at www.hhs. gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.html. 2. For more information on clinical quality measures, visit www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms/ClinicalQualityMeasures.html. For additional information on CNA risk management solutions, please contact us at (800) 341-3684. 26 Medicine in Oregon www.theOMA.org
OMA Winter 2015 Magazine
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