By Beth Haenke Just, MBA, RHIA, FAHIMA, founder and CEO, and Karen Proffitt, MHIIM, RHIA, CHP, vice president of industry relations/CPO, Just Associates, Inc.
The introduction of overlays into a medical record system can be so subtle that they often go unnoticed until one causes an adverse event, HIPAA violation or billing error—making them a primary source of patient errors, expenses and lost revenues in hospitals today.
Caused when the information of two patients is co-mingled within one medical record, the dangers of overlays have intensified with the proliferation of electronic health record (EHR) systems, which accelerate the rate at which multiple internal and external systems can be infected with dirty data. Compounding the problem is an overreliance on technology-centric solutions to resolve possible duplicates.
The American Health Information Management Association (AHIMA) puts the average duplicate rate at between 8 percent and 12 percent. A more recent survey by Black Book found an average of 18 percent. Meanwhile, an analysis of EMPI cleanup projects Just Associates completed between 2012 and 2016 showed that as many as 1.3 percent of these possible duplicates are actually potential overlaid records.
When it comes to overlays, there are three challenges facing health information management (HIM) professionals tasked with maintaining the integrity of patient records: 1) identifying and resolving existing overlaid records, 2) determining the root cause(s) and 3) implementing policies and procedures that will prevent the creation of new ones.
The birth of an overlay
The most common way an overlay is created happens at the time of registration when an incorrect patient record is selected, core demographic information is changed, and a new visit is added. Occasionally, the records of two different patients are erroneously merged during the duplicate resolution process.
Overlay creation can also be traced back to multiple departments. A study in the Journal of AHIMA involving an eight-hospital, multi-state healthcare organization found that most of the errors happened in the emergency department (ED) and, to a lesser extent, in registration, scheduling and ancillary areas such as lab and radiology.
The hospital system that was the subject of the study had been tracking and keeping detailed statistics on overlay errors for five years, beginning with the implementation of an EHR system. This provided researchers with the rare opportunity to analyze a considerable sample size of 555 errors, from which they determined an error rate of one in every 10,734 admissions. That is the equivalent to more than nine errors per month, of which 97.5 percent were caused by user oversight. The study also identified an upward trend in overlays attributed to growth of the health system and higher utilization of error identification tools that reveal more issues than manual methods.
For example, 54 percent of overlays were found by registration users while data integrity change reports that made use of EHR tools found 31 percent. Clinicians were a distant third, identifying just 6 percent of errors. Patients also found overlay errors via patient portals, which could have allowed them inappropriate access to highly-sensitive protected health information (PHI) — access that could lead to HIPAA violations.
Proactive EHR tools found most overlays within 10 days of their occurrence, and most were corrected in 30 days. This is important because the longer an overlay goes undetected, the less likely it will be found. When it is found, the older overlaid record is much more time-consuming and expensive to correct.
The high cost of overlays
To determine just how costly overlays are, it is necessary to cast a wide net, as few studies have been done to establish industry averages. Factors contributing to the full financial impact of an overlay include denied and delayed claims, lost revenues and resources required to identify and correct the error.
Time is a huge factor in the costs associated with overlay correction resources. For paper-based overlays, it can take between 60 and 100 hours, while EHR-based errors can take months depending upon system complexity. A survey by the College of Healthcare Information Management Executives (CHIME) further found that respondents typically had at least two people dedicated to “data cleansing,” including overlay correction.
Nursing is increasingly becoming as “high tech” as it is a “high touch” profession. Today’s nurses have more technology at their disposal than any nurses ever before, and as one might expect, it’s considerably improving patient care.
One area where nurses are putting technology to use is in informatics. Officially known as the study of information, in the world of health care, health informatics is the management of health information. Using electronic medical records, devices that collect health information electronically, and other electronic information standards, health informatics nurses are responsible for managing, interpreting, and communicating the data that comes in and out of health care facilities, all with one primary purpose: Improving the quality of patient care.
But how does that happen, specifically? How are nurses using informatics as a way to improve the care they — and their colleagues — provide to patients? As it turns out, there are several key ways that informatics is part of that effort.
Documentation has long been considered an important part of the nursing profession, but it’s more vital than ever to the delivery of quality care. While the theory and practice of nursing, the standards of nursing practice, legal and ethical considerations, and other points that are taught in advanced nursing programs all influence the practice of nursing, it’s information, and specifically, electronic documentation, that is having the greatest influence on modern nursing.
Modern nursing care is driven by individual patient needs and history — information that is collected and organized in electronic patient records. By documenting a patient’s condition, and sharing that information electronically, nurses are able to more effectively manage care, and by extension, improve the quality of that care.
A great deal of documentation takes place automatically thanks to connected devices, which collect specific information in real time and transmit it to patient records. By looking at the documentation of a patient’s condition over time, nurses can make better decisions about how to provide care and when changes or adjustments need to be made.
Reduced Medical Errors
Patient safety is a primary concern of any health care provider, and nurses are often on the front lines of ensuring that their patients are kept safe and preventing medication errors, misdiagnoses, falls, and other problems. Health informatics provides important data that can prevent these errors; for example, an electronic record can provide information about a possible dangerous medication interaction or allergy that might not otherwise be immediately apparent. Armed with data, nurses can make quick decisions that keep their patients safe.
In fact, in a study by the Agency for Healthcare Research and Quality (AHRQ), a majority of nurses reported that when they have access to EHRs, they have fewer problems with getting patients ready for discharge, fewer medication errors, and better quality of care. And when it comes to transfers between departments, nearly 15 percent of the nurses surveyed reported that information was more likely to be shared and less likely to “fall between the cracks” when electronic systems are used.
In the new healthcare ecosystem that is increasingly migrating to cyberspace, who can healthcare consumers rely on? Who in the healthcare service supply chain will prevail? Who will be the next Amazon or Yelp? Chances are it will be the organization that can deliver and mediate a centralized consumer experience – connecting healthcare consumers not only with care and treatment options, but also with pharmacists, labs, therapists, clinics, wellness coaches and other resources along the care chain.
More today than ever before as the care conundrum continues, fewer and fewer crave office visits, hospital stays or trying to reach physicians by phone. When we’re well, we see no reason to visit a physician. When we’re sick we increasingly wait until we’re sicker. And when we’re somewhere in between, we avoid calling because we know we’ll be put on hold. If there were a better way to consume healthcare, most of us would likely take it.
Interestingly, within this conundrum lies an opportunity for the myriad of healthcare players – from payers and providers at one end of the supply chain to wellness tacticians, retailers and mobile tool providers at the other end – to create a sustainable dialogue with healthcare consumers.