Increasingly complex documentation requirements are making it very difficult for ambulatory surgery centers to achieve compliance. With the move from ICD-9 to ICD-10, the task will become even more difficult as greater specificity will be required. Facilities that are unable to demonstrate the appropriate documentation upon request will run the risk of non-compliance, which can result in fines and a failed audit. Fortunately, EMRs (also known as electronic health records, or EHRs) have gotten much more sophisticated over the years. Deploying an ASC-focused EMR system can help centers simplify processes, improve documentation and achieve compliance. Taking the time upfront and doing due-diligence will ensure audit success. For ASCs contemplating the move to an EMR in an effort to achieve compliance, consider the following:
1. Get it right on paper first. To ensure a successful transition to an EMR system, processes must first work smoothly on paper. While everything may look right initially, oftentimes it isn't until you start using a new process that you realize there are errors. Errors take longer to fix once a process is up and running on an EMR system than they do on paper. Furthermore, vendors typically charge for EMR change orders. Doing things on paper first and perfecting each process along the way will save you time and money.
Most vendors offer blank templates, which are a good starting point; however, they should serve only as a starting point. It is in your best interest to look at the templates to see what is right for your facility in terms of flow, your specialty and adhering to standards set up at the state and federal levels; templates should be adjusted based on your facility's needs. Enlist the help of your staff, the folks who will actually be using the system, to ensure all they need is included within the templates. Use each template on paper for about a week to determine if there are any bugs that need to be fixed. If the template works well, launch it and move on to the next template.
2. Make it user-friendly. The success rate of an EMR system is directly related to how user-friendly the system is. If it is not easy to use, nurses, surgeons and anesthesiologists won't use it. Deploying a system that requires users to navigate from page to page will result in non-compliance.
To ensure a user-friendly process and staff compliance, everything a user needs should be in one place without requiring them to navigate anywhere but within their tab. Information should be organized based on job description. Under each tab, provide subspecialty tabs; these should include all the documents the person needs to do his or her job. For example, the "surgeon" tab should contain subspecialty tabs for consent, orders, H&P, post-op notes, discharge instructions, etc.
3. Populate information. When setting up templates, look at the information and determine in advance what is needed for each person to do their job. In instances when information is required by more than one person, there will be areas of redundancy. Rather than requiring staff to navigate to various tabs to review or input information, set your system up so that information auto populates to each person's tab as necessary.
For example, pre-admission data should be included in the pre-admission nurse's tab, within the surgeon's tab, the post-op nurse's tab and maybe even the billing person's tab, depending on the level of information that is gathered. Nurses and surgeons can quickly view any allergies or special needs without having to navigate back through a separate pre-admission area. Meanwhile, billing can quickly review patient demographics and even policy numbers if gathered during the pre-admission process within their own tab.
4. Consider regulations. Ensure requirements for all regulations — state, federal and accreditation — remain current. Information entered along the way should populate into these fields as necessary. For example, some states require surgery centers to track anesthesia orders (i.e. drops per minute dispensed within an IV). To be compliant, a box may need to be added to the anesthesiologist's page to ensure this information is not overlooked. The system should allow you to quickly pull reports in the case of an audit. With documentation complete and current, compliance easily can be achieved.
The state of Connecticut and CMS recently visited the Middlesex Center for Advanced Orthopedics. We had no deficiencies at all based on our new improved EMR system. The auditors were impressed at how we set up our SourceMedical system and the dynamics of how people used it. With some careful planning and attention to detail, other facilities can achieve this same success.
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