Microsoft PowerPoint - Helen Zamboni

5/26/2017

LegalImplicationsof

Electronicvs.Paper

Charts

HelenA.Zamboni,Esq.

hzamboni@underbergkessler.com

(585)258‐2844

Underberg&KesslerLLP

5/26/2017

NewYorkHealthInformation

ManagementAssociation

Papervs.ElectronicRecords

Aredigitalrecords

better

thanpaperrecords?

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

Papervs.ElectronicRecords

Advantagesofelectronicrecords

• Easiertoread

• Subspecialtynotesaregroupedtogether

• Improvedconfidentiality

• Electronicpromptshelpassurethatmedicationsand

carearetimely

• Canbeaccessedfrommorethanonelocation

• Entirerecordisavailableallthetime

• Includesdecisionsupporttools

5/26/2017

NewYorkHealthInformation

ManagementAssociation

Papervs.ElectronicRecords

Disadvantagesofelectronicrecords

• Notasmuchdetailrecorded

• Whenthereisnothingnew,thereisnothingrecorded

• Entriescanlookrepetitive

• Digitalentriesdonottriggermemoryofeventsaswellas

personalhandwriting

• Notallmodulesarereviewedbyoraccessibletoallstaff

• Automationbiascancausedependenceonpromptsand

alerts

• Alertfatiguecancauseuserstoignorepromptsandalerts

• Informationoverload

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

Papervs.ElectronicRecords

Butaretheapplicablelawsdifferentfor

digitalrecords

andpaperrecords?

5/26/2017

NewYorkHealthInformation

ManagementAssociation

GoodDocumentationMatters

• Goodcommunication

• Clinicallyrelevantinformationiseff ectivelytransferred

betweenshiftsandstaff

• Goodpatientcare

• Gooddocumentationfocusestheentireteamon

clinicallyrelevantchanges

• Morelikelythatapatient’sconditionwillbeproperly

diagnosedandtreated

• Goodreimbursements

• Accuratedocumentationsupportsproper

reimbursement

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

GoodDocumentationMatters

• Gooddefenseofcare

• Providerscandefendthemselvesifcareisproperly

documented

• Goodriskmanagement

• Accurateandtimelyrecordsreduceriskoffraudulentbilling

• Poor/falsedocumentationriskscivilandcriminal

liability

• Canresultinfines,lossofemployment,lossoflicense,

prison

• Corporatecompliance,professionalconduct

• Accurateandcomprehensivedocumentationhonors

conceptsonwhichbestpracticeisbasedanddemonstrates

thebasisforprofessionalandclinicaldecisions

5/26/2017

NewYorkHealthInformation

ManagementAssociation

GoodDocumentationMatters

• Agoodcharthelpstodefendprovider

• 35‐40%ofmedicalcasesbecomeindefensiblebecause

ofproblemswithdocumentation

• Ifitisnotcharted,lawyerswillarguethatrequired

caredidnothappen

• Documentationisscrutinizedbythefamilyandthe

family’slawyer

• Jurywillassumethatsloppydocumentationmeans

sloppycare

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

GoodDocumentationMatters

• FACTFormula

• Factual

• Accurate

• Clinicallyrelevantandcomplete

• Timely

5/26/2017

NewYorkHealthInformation

ManagementAssociation

FACTFormula

• Factual

• Objective,notsubjective

• Whatusersees,hears,smells,notwhatusersupposes,

assumes,guesses,believesorfeels

• E.g.write“woundis4cm x2.5cm,withredandbrown

edgesandwithoutanyodor”

• Donotwrite“woundisugly”

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

FACTFormula

• Accurate

• Usershoulddocumentown observations

• Usershouldnotcopysomeoneelse’snotes

• Usershouldtakecaretoaccuratelydescribe“left ” or

“right”sidedcomplaints

• Usershoulduseonlyapprovedabbreviations

• UsershouldNOTusetextingabbreviations

5/26/2017

NewYorkHealthInformation

ManagementAssociation

FACTFormula

• Clinicallyrelevantandcomplete

• Usetermsthathaveclinicalsignificance

• E.g.“moderateamount”ofbleeding,not“alot”

• Usetermsthatothermedicalpersonnelwilleasily

understand

• Completeallrelatedportionsoftherecord

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

FACTFormula

• Clinicallyrelevantandcomplete

• Documentallphonecalls,meetings,conversations

• Towhomdidusertalk?

• Diduserleaveamessageorspeakpersonallytothat

person?

• Ifinformationrelayedatameeting,whoelsewasthere?

• Whatspecificallydidusertalkabout?

• Whatdiduserlearnduringtheinteractionwithothers?

• Diduserwriteormodifyordersasaresult?

5/26/2017

NewYorkHealthInformation

ManagementAssociation

FACTFormula

• Timely

• Notesshouldbemadecontemporaneously (ASAP)

• Thelongerthewaitafterencounter,thelessdetailed,

thelesscompleteandthelessaccuratethenoteswillbe

• Ifenteringalatenote,makesurerecordisclearabout

thetimeanddate oftheearlierevent

• Electronicchartslogtimeofentryforaudittrails

• Trynottowaituntil theendofashifttodocument

• Somedocumentationisbetterthannone

• “Thepalestinkisstrongerthanthestrongestmemory”

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

So…

Aretheseconceptsanydifferentwhen

appliedtoelectronicvs.papercharts?

5/26/2017

NewYorkHealthInformation

ManagementAssociation

CriminalandCivilPenalties

• Criminalliabilityforfalserecords

• PenalLawSection175.05

• ClassAmisdemeanor

• Violatorcanbesentencedtojail

• Termsofprobationcanlimitpractice

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

CriminalandCivilPenalties

• Apersonisguiltyoffalsifyingabusinessrecordin

theseconddegreewiththeintenttodefraudif:

• Makesorcausesafalseentryinabusinessrecord

• Fa ilstomakeatrueentryinabusinessrecordin

violationofdutytodoso

• Preventsatrueentry

• Causestheomissionofatrueentry

• Alters,erases,obliterates,removesordestroysatrue

entryinabusinessrecord

5/26/2017

NewYorkHealthInformation

ManagementAssociation

CriminalandCivilPenalties

• ViolationofPublicHealthLaw

• Anyonewhoviolates,disobeysordisregardsany term

orprovisionofthePublicHealthLawshallbeliableto

theStateofNewYorkforcivilpenaltyupto$2,000per

violation

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

CriminalandCivilPenalties

• Revocationoflicenseforunprofessionalconduct

mayoccurfor:

• Fa iluretomaintainaccuraterecordsreflecting

evaluationandtreatmentofthepatient

• Fa iluretocomplywithfederal,state,orlocallaw,rules

orregulationsgov erningyourpractice

• Filingoffalsereport

• Fa iluretofileorimpedingorobstructingfilingof

reportrequiredbylaw

5/26/2017

NewYorkHealthInformation

ManagementAssociation

CriminalandCivilPenalties

• Revocationoflicenseforunprofessionalconduct

mayalsooccurfor:

• Disclosureofpersonalidentifyingfacts,dataor

informationobtainedinprofessionalcapacitywithout

thepatient’sconsent

• Delegationofprofessionalresponsibilities toaperson

notlicensedorqualifiedbytraining,licenseor

experiencetoperformthem

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

Papervs.ElectronicRecords(Again)

• HIPAAappliestoanyhealthcareprovider“who

transmitsanyhealthinformationinelectronic

form”

• HIPAAhasenforcement“teeth”thatcanbevery

costly,hencetheimpressionthatlegalissuesare

different

• Realityisthatchangesinbusinessprocess

causedbyuseofelectronicrecordsmayresultin

increased

legalrisks

5/26/2017

NewYorkHealthInformation

ManagementAssociation

BusinessProcessChanges

• EHR systemsdesignedtocapturedatafrom

manyencountersoverlongtimeperiods

• Designedtotrackandreportoutcomesandtrends

• Drivenbychangesinnationalhealthcarepolicy

intendedtoreducecostsandimprovequality

• Checkboxesfor“withindefinedlimits”:arelimitswell

documentedandknownbystaff?

• Haslossofextensivenarrativeresultedindecreasein

qualityofcare?

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

BusinessProcessChanges

• EHR systemsenablereal‐timecharting

• Anyoneincareteamcanseepatient’scurrentstatus

andtakeappropriateaction

• Trade‐offbetweengivingcareanddocumentation(like

distracteddriving)

• Locationofchartingchangedfromofficetoexamroom

• Potentialincreasedriskofunauthorizeddisclosureof

PHI(ininstitutionalsetting,wherevisitorstopatientor

roommatemaybepresent)

5/26/2017

NewYorkHealthInformation

ManagementAssociation

BusinessProcessChanges

• EHR systemsaccessibleviamobiledevices

• Supportiveofreal‐timecharting

• Screensizemaydiscouragedetailedchartingand

increaseriskoferrorinentryselections

• Potentiallossormisplacementofdevicecarries

enormousriskofunauthorizeddisclosureofPHI

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

BusinessProcessChanges

• Increaseduseofscribes

• Demonstratesrecognitionofpotentiallegalrisk

• Allowsmedicalprofessionaltopayattentiontopatient

withoutdistractionfromneedtochart

• Enhancespatient/professionalconnection

5/26/2017

NewYorkHealthInformation

ManagementAssociation

BusinessProcessChanges

• Conclusions

• Applicablelawsnotreallydifferent,but…

• Consequencesoffailuretocomplyhigherthanbefore

EHR systems

• Focusofmanagersshouldbelessontraininginuseof

EHR systemsandmoreonchangesinbusinessprocess

thatincreaselegalrisk

5/26/2017

NewYorkHealthInformation

ManagementAssociation

5/26/2017

Questions?

Thankyou!

5/26/2017

NewYorkHealthInformation

ManagementAssociation

LegalImplicationsof

Electronicvs.Paper

Charts

HelenA.Zamboni,Esq.

hzamboni@underbergkessler.com

(585)258‐2844

Underberg&KesslerLLP

5/26/2017

NewYorkHealthInformation

ManagementAssociation