WoundExpert Flash #22

{Straight talk for clients}

Are you wondering if there’s any easier way to identify the contributing authors in the Progress Note? Let us tell you about new changes in WoundExpert that will help you see easily who documented which sections of the medical record.

Dear WoundExpert,

My physicians regularly ask how they can identify the contributing authors of content within the Progress Note narrative, such as the Wound Assessment details. Outside of viewing the current and previous versions of these specific documents, is there an easier way for them to identify who documented this information?

The Solution

The heart of this question comes down to authorship integrity, which is a crucial part of data integrity overall. Both must be maintained within the legal medical record to ensure safe, high quality, and coordinated patient care, while deterring fraud and abuse.

According to the American Health Information Management Association’s (AHIMA) article Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013 update):

Authorship attributes the origin or creation of a particular unit of information to a specific individual or entity acting at a particular time. When there are multiple authors or contributors to a document, all signatures should be retained so that each individual’s contribution is unambiguously identified.

To put it simply, authorship integrity means you can easily see who documented which sections of the medical record and each contributor’s signatures.

Net Health is enhancing the medical record by delivering additional transparency into contributing author(s) and content, which will support the integrity of your legal medical records.

The first change you’ll see will include an update to the Progress Note to allow you to see the author(s) for each contributing document. For example, in the objective section of the Progress Note, you’ll be able to see, at a glance, who documented the wound measurements versus the wound description within the Wound Assessment document, along with the date and time the information was entered.

The second change will occur later this year. Instead of flipping between current and previous versions to manually notice the changes, you’ll be able to compare document revisions in the same window to easily identify what’s different and who made the change. The screenshot below gives one option for how the proposed changes would appear. The text highlighted in red represents what was initially documented and the text highlighted in green shows what is saved in the current version of the document.

Other options to see this information in a clear and concise way are being considered. We know there is a fine line between helpful and distracting. We’re working to maintain your uninterrupted focus on the overall medical record while ensuring you can easily see the information you need, when you need it.

What now?

• If you’re excited about these changes and are interested in providing feedback along the way, consider joining our Net Health Insiders program. Insiders are customers ready to provide thoughtful feedback on new feature designs and functionality enhancements. Click here to learn more.
• Keep your eye out in the coming months for more information via email and directly within WoundExpert letting you know when these new features are here.
• Check out the full article from AHIMA about EHR documentation best practices, including authorship integrity: Integrity of the Healthcare Record: Best Practices for EHR Documentation.

This month’s contributor was Sheila Cougras, Director of Compliance.

Connections Corner

Check out the most recent Connections forms enhancements!

Over the past few months, several of our vendor partners have enhanced their forms to make submitting DME orders even easier. Specifically, Wound Product Supplier (WPS) vendors American Wound Care, Byram Healthcare, Cardinal Health/Edgepark Medical, Community Medical, McKesson Patient Care Solutions, and Sound Health have all made significant updates to their order forms recently. Be sure to check out forms from each of these vendors to see what’s new!

We’ve also recently added two new vendors to the Wound Product Supplier (WPS) module. Apollo Medical Supply is now available to serve facilities in the state of Florida, and Medi Mart is available to serve facilities in the state of New Jersey. If your facility is located in either Florida or New Jersey, don’t miss out on these new WPS forms.

Brought to you by Michael Ashbaugh, Account Manager.

Did you know?

CMS announced changes last November within the Final Rule that impact those reporting on Promoting Interoperability for 2019.  We are aware there are changes coming, however ONC (Office of the National Coordinator for Health Information technology) has not released the technical specifications for what changes we will need to make within WoundExpert.  We are continuing to monitor this and as soon as ONC has released the final changes we will begin the work on those changes and update the PI grid within WoundExpert, so that you are remaining compliant for your 90-day reporting period.  Currently the changes we are aware of are:

• Removal of measures from your PI Grid
  • Patient Education
  • Secure Messaging
  • View, Download, and Transmit
  • Patient Generated Health Data
• Renaming measures within the PI Grid
  • Released in August 2019
• Updating the calculation for the measure Support Electronic Referral Loops by Receiving and Incorporating

     Brought to you by Brittany Hartz, Product Analyst