Duplicate Medical Records; The Unintended Consequence of Implementing EMRs
The Velocity Interoperability Blog and Velocity Interoperability Podcast are sponsored by Velocity Health Informatics. Velocity provides both data quality and data integration as a service offerings to ensure that healthcare providers access the correct patient record with the right data for each patient they serve. See the introductory blog post. Visit Velocity on the Web and follow them on Twitter, LinkedIN and Facebook!
TODAYS GUEST Leigh Williams, Administrator, Business Systems for UVA Health System.
Leigh joined us to discuss the problem of duplicate medical records; how and why they are created, the problems that they create and how to fix them. Specifically, we discuss the following with Leigh:
- (3:13) A recent guest told me that providers’ EHRs typically contain 8-12% duplicates, is that consistent with what you’ve seen at UVA and your former employer, University of Mississippi?
- (6:25) What causes duplicate medical records?
- (8:35) What kinds of problems are created downstream by duplicates in your EHR?
- (10:19) What’s a medical record department to do? How should they react to the current challenges with duplicate and erroneous medical records
- (13:07) Very soon, you will be attending and speaking at the Revenue Cycle Solutions Summit in Boston. What can you tell us about the event and about your presentation?
- (15:50) I am excited to share the news that you have a book coming out very soon. Will you please tell us about the book? What’s the title and what will we learn when we read it?
- (18:03) How will the folks in Medical Records be impacted by MACRA and MIPS?
About Leigh Williams
Leigh Williams is an innovative revenue cycle leader specializing in transforming health information management to improve care communications, gain accuracy in health data capture, and in successfully operationalizing a response to governmental mandates for improved quality in healthcare systems. As director of revenue cycle at the University of Mississippi Medical Center (UMMC), Leigh heads the hospital and professional fee coding, electronic health records, and clinical documentation improvement departments. She has served as the institute’s executive director for ICD-10 implementation since 2013 and currently oversees the clinical documentation excellence program for 6 hospitals and more than 100 clinics. Leigh lectures across the nation on how to engage physicians in change initiatives, EHR work flow optimization, revenue cycle process improvement, and on current issues in health information management (HIM) and teaches a master’s course on Healthcare Reimbursement Methodologies and Financial Management in the health informatics program at UMMC.
Previous Interviews with Leigh:
The Velocity Interoperability Blog and Velocity Interoperability Podcast are sponsored by Velocity Health Informatics. Velocity provides both data quality and data integration as a service offerings to ensure that healthcare providers access the correct patient record with the right data for each patient they serve. Visit Velocity on the Web and follow them on Twitter, LinkedIN and Facebook!
Joe Lavelle 00:54 Welcome to the Velocity Interoperability Podcast brought to us by the guru’s at Velocity, I’m your host Joe Lavelle. I’m really looking forward to another thought-provoking discussion where we further investigate data quality, interoperability, and medical record remediation.
We’re going to get right to it today. We are joined by Leigh Williams, the Administrator of Business Systems for UVA Health System. Leigh, welcome to the Velocity Interoperability Podcast.
Leigh Williams 01:17 Thank you Joe, I’m glad to be here.
Joe Lavelle 01:20 Well, thanks so much for making the time. Before we start the discussion, could you take a few seconds and tell the audience about you and your background?
Leigh Williams 01:26 Sure, I am currently in the IT department at the University of Virginia Health System. My background is actually in revenue cycle. The last decade I’ve been sort of straddling the line between revenue cycle and information technology because as we all know, nothing is getting done in healthcare systems these days without a strong IT foundation.
I’ve been at academic medical centers. I was at the University of Mississippi before coming here and my focus had been on the med cycles, the point between the clinical worlds and the revenue cycle world. And I was part of the large EHR implementation and that’s how I really got into why technology is so important for the hospital operations specifically within the documentation captures with the physicians and then moving in to the billing section, coding and HIM documentation.
My experience has been in both physician practice, working with the faculty practice groups and with the academic medical center hospital side.
Joe Lavelle 02:21 Outstanding, could you take a couple of minutes and give our audience a ten thousand foot overview of what UVA Health Systems is all about?
Leigh Williams 02:29 Sure, we are located in Central Virginia, which is a lovely area of our country. We have a 570 bed, acute care hospital in Charlottesville, Virginia. We are academic medical center so we have over 100 physician specialties that we support and a large ambulatory practice with over 100 clinic locations throughout central Virginia.
We do a strong pediatric program here. We’ve got oncology services and all of the specialty services that you would expect with academic medical center and our goal is to be the safest place to give and receive care. We are highly focused on quality and are really looking to make sure that we’re providing excellent service for all of our constituents in Virginia.
Joe Lavelle 03:12 I love it, perfect. Leigh, let’s start with this. A recent guest told me that provider’s EHRs typically contain 8 to 12% duplicate in terms of medical records. Is that consistent with what you’re seeing at UVA and what you saw at University of Mississippi?
Leigh Williams 03:28 Sure, I can talk about both of those places and 8 to 12 is, I think to me, it sounds like a scary number because that is a lot of duplicates. If you think in one of 10 patients that comes in to your facility has a potential to be a duplicate with someone else that presents a lot of risk.
I’ve seen rates anywhere from— so after we put in programs at both facilities to really be dealing with the duplicates on the regular basis, they got down fairly low to less than 2% at each of those. But for example at Mississippi, when we first went from paper records about 5 years ago to up on to a full EHR solution for our health system, our first duplicate medical record rate after we did that combination of the consolidation of the master patient index was more in a 20 to 25% range.
I was horrified by that because it meant that about 25% of our patient population had the potential to be coming in and being identified at somebody else when they presented at our facility. We worked really hard to get that down and it took a tremendous amount of work.
We did a risk stratification to the data by saying, “Okay the patients were actually scheduled to be in our facility and are identified as a potential duplicate.” We need to address those first and then we looked at patients who we’re recurring patients.
Some of our service line asked us to deal with those, oncology and the dialysis unit. They said, “Please make sure none of our patients have this issue.” We went and note it down that way and I think the story is very similar here at Virginia. We’re going from paper to an electronic system.
It suddenly helps you to see all of those potential duplicates and through— for both facilities, it was really a ton of work. We have a lot of good HIM professionals reviewing charts and seeing if you do have a duplicate or not. They can be kind of difficult to find out sometimes.
In both cases, the work went back decades to be able to resolve duplicates that existed for a long time. So 8 to 12% is probably high for those facilities that are staying on top of it but not unrealistic in the scope of the world. I actually did take a minute to look up to see what AHIMA, they are the American Health Information Management Association, to see what their most recent publications about duplicates rates are and they just put out something last month.
The data shows that facilities are anywhere from 1 to 10-12%. In less than 9% of them were at the rate that you’re setting 8 to 12%. but the number that stood out to me was in 45% of facilities that they did not know. That’s I think pretty concerning because of if you don’t know that’s we were in Mississippi when we have that 25% rate.
I think the ones that aren’t even looking at it have the potential to have a very high number. The numbers that are coming in from facilities where they’re saying they’re keeping it low, like less than 1%, those are the ones that are staying on top of it, that have a plan around duplicates and are doing that work daily.
Joe Lavelle 06:26 Leigh what is it the causes duplicate medical records?
Leigh Williams 06:28 This was actually very interesting for me to learn as a I took on that responsibility at Mississippi. All those various ways that they occur and one thing that stood out was that the majority were coming from emergency services areas and the registrars who were not at all trying to make errors but often where in stressful situations where someone needs to be seen urgently, that’s why they’re at the ED.
If they were faced with 10 options on finding Tom Smith in the system, would choose to enter something as a new record rather than choosing one of the options where they weren’t confident. So sometimes it’s just not being able to identify quickly from the options that you have which one of this is a match.
Other times it was that the patient would provide information that the system couldn’t recognize was a match. Maybe they were giving a new telephone number or new address or they have gotten married and have a new last name. Any of that demographic information, when it changes, if it’s not a match, you’re system may not recognize but that where it’s coming.
Then we did have to read through a lot that were false positives. You have to look at those as well. A lot of father-son pairings of names where people were named Francis Thomas and the son was Francis Thomas and you have the same gender and you have the same race and you have the same address so it makes that easy for the system to think that they are the same person when they’re really not.
Some of our more tricky situations where when you have very close matches but need to make sure that they weren’t the same person. So (duplicates are caused by) a variety of different things and I think that as our electronic heath record tools become more sophisticated and our users become more sophisticated, both the patients and the people that are in the hospital systems will get better at being very accurate with that data, it can avoid some of the duplicates. But it’s just like taken out a username and password at the website that you’ve been in before and you don’t recognize or you already opened this one and you create something new, you’ve just made it duplicate and you didn’t even realize it.
So (duplicates are created) lots of different of ways and data integrity and using the tools in the EHR is the best way to be able to identify and start to put some QA in place that will prevent them going forward.
Joe Lavelle 08:36 Leigh, what kinds of problems are created downstream when you have duplicates in your EHR?
Leigh Williams 08:39 The first and obvious issue, and this is what we mostly dealt with and this is where there is an urgency comes from, is if you have a lot of risks for your patients. If a patient has— just a give a scenario that they have been previously admitted and they have a certain medication record. Then they come back to a clinic to go in and that clinic visit is put on to a new record. Then they go back into the ED and they have them an original record but you’re missing the clinic visit because you don’t even know what’s part of that record because it’s over on the duplicate, you could be missing medications the patient is on, some of the treatment history, some of their personal history.
I think number 1 is patient safety risk that needs to be avoided. Then beyond that, if you look at why would you use the patient record? And number one it’s patient care.
Also we use that patient record to be able to share information between facilities. That becomes difficult with doing some continuity of care documents, if you’re getting duplicates out of your facility, you’re not sending the right information or its clashing with some other facility’s information.
Then when you do technology implementation. So I bring up a lot of applications in my current role and when we have duplicate records, it can cause a lot of trouble with actually loading the data into the system, making sure that it’s a match back to the whatever your interfacing or integrating with and so it can really slow down those technology projects and make them difficult to know if you’ve got the right data loaded when you’re unsure of the patient population that you’re putting in it.
I think the patient risk issue, a communication issue and a technology issue all jump to mind as problems that you can have if they’re not keeping that MPI clean.
Joe Lavelle 10:20 Then what’s a medical record department to do? How should they react to these current challenges of duplicate and erroneous medical records?
Leigh Williams 10:26 I think that many of us in the HIM profession considers this to be one of the foundational issues that has to be part of your strategic plan for having technology in your system. Having a clean master patient index, a clean set of medical records is the foundation in which you build all the technology and it is the foundation in which you’re building patient safety.
Many facilities like the ones that I’ve been in, took it on as a project to just simply say, let’s get a tool or some services to help us to be able to identify what’s the existing duplicates are already within our system, working those down, getting that MPI cleaned up to where you feel like, “Okay we’ve now got rid of the past history of duplicates. And then establishing an ongoing either daily or weekly (process for eliminating duplicates) or if you need to go to something that’s a little bit longer term.” But most facilities, I think, are on top of this are more in the daily and weekly resolution of new duplicates.
You have two problems you’ve got to deal with whatever is in there already so when you go from “I don’t know how many I have” to some insight. You need to clear up whatever it is that you’re dealing with and then make sure your process, your QA process, from new data going in is as tight as possible.
1) Making sure registration has hard stops where they need to be. 2) That they’re well trained on how to search to find the right record and 3) then having a follow-up by an HIM professional who can look at a potential duplicate and work that report. Both at Virginia and Mississippi, they deal with those daily to make sure that anything new that comes in is immediately handled.
Joe Lavelle 13:02 Leigh. very soon you’ll be attending and speaking at the Revenue Cycle Solution Summit in Boston, what can you tell us about the event and about your presentations?
Leigh Williams 13:15 Yes, the Revenue Cycle Solution Summit is a HIMSS sponsored event that we do every 6 months and it’s December 5th to 7th in Boston this year.
I find it to be one of the best conferences that I’ve actually ever been to. The content is amazing and it’s really packed so I am honored to be a part of that and to be presenting. This year we’re doing on December 5th, which is Monday, a special MACRA’s Day. We’re trying to deal with healthcare legislation that is shifting payment reimbursement methodologies and amounts etc. in the next couple of years.
There’s going to be a lot of that. The final rule was out. It’s a day full of education on MACRA that’s kicked off the conference and on that one, I’m going to be talking specifically about how do you engage physician in revenue cycle initiatives.
It’s not their favorite thing to talk about money, sometimes you can get some pushback from physicians, where they’re really focused on patient care and they don’t necessarily want to spend time on revenue cycle or IT initiative. There are some ways that you can try to find common ground with them and some I’m going to be talking about how to get physicians to pay attention to and actively participate and move forward with revenue cycle initiatives, specifically, with the view of what’s going on with MACRA and what maybe those shared objectives that physicians would have to be able to invest some of their energy and time and to get in the organization ready for MACRA.
Then in the next 2 days, on Tuesday and Wednesday, we have full days of content and I’ll be giving another presentation that’s on the Top 10 Keys to Achieving Financial Stability in a Value-Based World. It’ll be focusing on— actually the cleaning of master patient index is part of that, making sure that your systems are communicating well and that you’re getting good clean record sets and then documentation capture and how do you help physicians to catch the right information that support ICD-10 codes and HCCs and other methodologies for reimbursement that are going into place that are either started already or going forward and what are those key pieces that you need to do to make sure that you’re able to maintain the revenue that your organization is used to without taking.
Some of the (MACRA) penalty buckets could put up to 9% of your revenue if you’re not able to meet the quality score so it’s all about getting the right document that support the quality story of your organization and avoiding those penalties.
Joe Lavelle 15:40 Leigh I’m so excited to share the news that you have a book coming up very soon. Will you please tell us about the book? What’s the title and what we will learn when we read it?
Leigh Williams 15:48 Yeah, sure. The book is called Mastering Physician Engagement – A Practical Guide to Achieving Shared Outcomes. That word practical is very important in there because it’s all about things that my co-author, Dr. John Showalter, who’s the Chief Health Information Officer at the University of Mississippi, and I did while we were learning from our physician counterparts through our EHR implementation there and then also leading the ICD-10 challenge and trying to get physicians to care about coding to the granularity and specificity of ICD-10.
(There are) lots of lessons learned about how to work with physicians and get them engage and as I was just talking about with MACRA stuff you can get some pushback from the doctors when they don’t— I mean they’re busy… we’re all busy people. In every talk, they say they’re busy.
How do you become a priority for that person to get them to change their behaviors or to do additional tasks when it wouldn’t be what they normally do in the course of their day. A lot of ideas and thoughts on how physicians learn, how medical school treats physicians, and how they actually are trained as doctors so that you can use some of that methodology in the way that you’re training them on IT initiatives or working with them, educating them on revenue cycle.
Then (the book provides) a whole bunch of information on communication styles and what works. Then return on investment, and how to communicate ROI to physicians for IT and revenue cycle or population health initiatives. Because often times, in health systems today, the governing bodies that are making a decision whether to go for an initiative or not or the key players who are going to make it successful are doctors.
(The book provides) learning how to work specifically with physicians in a new way that gets them really as your proponents that can help you push those initiatives forward, rather than in an old school way. While we treat doctors as something other and they can be a pain in that they won’t listen or they won’t meet with me. We want to get over that and make sure that we’re including them because what’s coming in health care reimbursement shifts and with population health, the physicians have got to be at a table contributing in a meaningful way. This is just some thoughts and ideas to help folks that are facing those challenges every day with seeing how do we make this happen.
Joe Lavelle 18:04 Perfect Leigh. I can’t let you go until I asked you this. How are folks in medical records going to be impacted by MACRA and MIPS?
Leigh Williams 18:11 I think that MACRA and MIPS are really continuation of all of the value-based purchasing (initiatives) that we’ve seen the shift to pay per performance and so that really is heavily impacting the HIM professionals with all of the documentation requirements.
We know, I’m an HIM professional, we all know that the words that we’re putting in the chart are the quality scores that we’re getting in the end. Being able to partner with physicians to make sure that CDI practices, if you’re doing work with physician on what language they’re putting into the chart, that’s going to be needed to address the areas of focus for MACRA and MIPS. And the quality scoring systems of PQRS is going away, it’s being replaced by MIPS.
The HIM professionals and the medical records folks need to learn about what those new rules are and we’re really good at that. We’re used that rules coming out all the time. The impact will be that they have to stay up to date on the new set of rules and understand on how they change from the past. Then be able to guide their organizations towards collecting the right information and communicating it as administrative data going out on claims forms in a way that supports, showing the quality work that we’re doing and avoiding those penalties.
They really are right at the pivot point between the clinicians and the revenue cycle and being able to aid those doctors with getting the words that support the codes that support quality so that our organizations can remain financially viable. I think that’s going to be a huge, huge component of how we succeed in the coming years.
Joe Lavelle 19:43 Leigh it was so great to have you on the show. Thanks for stopping by and sharing your great wisdom with our audience.
Leigh Williams 19:48 Thank you Joe, I appreciate it.
Joe Lavelle 19:50 Thank you so much. We’ll all be following you on Twitter @leightw to keep up with you and when your book is released. If I’m thinking right, its next month, is that right Leigh?
Leigh Williams 20:05 Yes, actually it’s coming up very soon so I think towards the end of the December but it’s already up on Amazon, which is exciting to see so it’s out there for preorder and will be available in the next 2 weeks.
Joe Lavelle 20:17 Alright, before we wrap this conversation. I want to thank the great folks of Velocity for sponsoring our show. Please go www.velocityhealthinformatics.com to find out more about the innovative ways their solving, the data quality and interoperability needs of their clients and now, on behalf of our guest, Leigh Williams, I’m Joe Lavelle and will be back soon with another informative episode of the Velocity Interoperability Podcast. See you then.