Overlays: Eradicating One of Healthcare’s Greatest Patient Safety Issues – Part Two of Two
By Beth Haenke Just, MBA, RHIA, FAHIMA, Founder, CEO &
Karen Proffitt, MHIIM, RHIA, CHP, Vice President of Industry Relations/CPO, Just Associates, Inc.
In the first installment of this two-part series, we discussed the costs and causes of overlays. In part two, we deliver actionable information on preventing overlays, including overlay corrections plans and best practices.
Preventing overlays is a challenging undertaking, particularly when EHR adoption and provider mergers and acquisitions have resulted in combining multiple MPIs, thus pushing erroneous information out into multiple systems. We’ve found that the best approach is to implement a comprehensive Overlay Correction Plan to guide the identification and repair process.
Overlay Correction Plans are complex, often including as many as 65 check points, but well worth the time and resources that go into their development. Repairs can also take months, especially if the impacted patients have lengthy inpatient stays. Numerous clinical orders, notes and other documentation often must be moved to the correct record or to a new record. Thus, a key component to a successful data quality management plan is to implement a process to proactively and rapidly identify possible overlays, as the sooner an overlay is found, the easier it is to correct it. (See part one of this series).
Once an overlay is identified, the first step is to assess the required time and available resources to correct it. This should include a downstream system assessment to determine how many are impacted by overlays and how long it will take to fix the issues.
As for resources, industry best practice dictates that HIM data integrity staff “own” the overlay correction process and that they be the main facilitators to ensure all steps are taken to resolve the issue. However, HIM typically cannot perform all the required steps on its own. It is usually necessary to collaborate with teams from other areas, such as IT, nurses and other clinicians, physicians, pharmacy, billing, etc., to correct existing overlays across all impacted information systems.
Further, certain departments like release of information (ROI) require special consideration due to the nature of their work. Because a HIPAA violation is likely if patient data is co-mingled and released to a requester who had authorization to receive only one patient record, the ROI team should be alerted immediately so they can exercise extreme caution when carrying out a request that may involve overlaid records. This process can sometimes be automated, as some EHR systems enable a warning flag to be placed on affected records to alert ROI staff and other providers when accessing certain portions of the record.
Overlay Correction as Risk Mitigation
Eradicating overlays from the EMPI is an important aspect of overall patient safety and care quality improvement initiatives, as well as HIPAA compliance. When overlays are eliminated, one potential source of a data breach is gone as well; specifically, the release of incorrect patient data within a patient portal by uploading the wrong person’s information. Fewer overlays also means a lower risk of adverse patient events caused by patient misidentification—something that 86 percent of healthcare executives surveyed by the Ponemon Institute said they encountered. Those adverse events could be anything from mistreatment based on incorrect patient information like blood type and/or allergies to performing the wrong care intervention.
Overlay Correction Plans should also include the notification of patient billing, which enables a “bill hold” flag to be placed on impacted accounts so inappropriate billing or release of records to payers can be avoided. The department responsible for patient portal management should also be notified so access can be deactivated for patients involved in the overlay, then reactivated when the issue is resolved.
The Overlay Correction Plan should guide the HIM data integrity staff on flagging charts that are in process for correction, as well as how best to reconcile patient data, e.g. problem list, past history, current medications, allergies, etc. Attending and emergency department physicians, physician assistants, nurses or residents may need to clarify what medical information belongs to each patient to ensure their complete medical record information is restored. Once the clinical/ EHR records have been corrected, there should be additional key steps in the Overlay Correction Plan to cover re-analyzing the chart for deficiencies, coding and other areas of concern.
Prevention Best Practices
While the Overlay Correction Plan will guide the resolution of existing overlays, preventing the creation of new ones requires establishing best practice-based registration processes and controls. Stepping up staff training on policies and procedures governing the creation of or updates to patient records, particularly when the patient is still in- house, can go a long way toward keeping errors to a minimum.
Seek to implement tight controls for any updates to key demographic information (name, date of birth, etc.), e.g. requiring legal proof supporting the change request. AHIMA recommends requiring a photo ID such as a driver’s license, passport or state-issued identification card at check-in, though it may not be a viable option for certain populations such as children and immigrants. As such, supplement ID requirements by asking patients to verbally state their name, birth date and address at registration. Also, add photo identification to the EHR, which lets staff determine quickly if the person they are speaking to belongs to the record they are viewing. Finally, compare patient signatures on consent forms, develop guidelines around the enrollment for patient portals and limit change authority to HIM data integrity or patient access management team members.
Leveraging the functionality that comes standard in many EHR systems is also a smart option. For example, Epic and others allow for routine monitoring and research of possible overlays via a standard report. If no report is available, utilize an ADT audit report that reveals all key demographic changes for a day. These types of reports can be cumbersome to work with because they provide all data changes, including when a value is changed from a default data element to real data. However, the time required to monitor the report, especially if done routinely, can be well worth it.
Evaluate incoming interface matching logic and ensure the adequate patient matching algorithm logic is in place. Auto-linked patient records should be routinely audited to uncover overlays and the inadequate logic that created them so it can be corrected. Without this process, overlays will not only exist in the EHR, they will infect multiple systems throughout the health system and its information-sharing partners.
Given the previous discussion around technology’s role in creating overlays, it is important to use it prudently. Avoid auto-linking any same system duplicates, as that primary system feeds many downstream systems which may not get corrected if the auto-link doesn’t generate a merge message or the downstream system cannot process the merge message.
Be wary of relying on third-party data for matching two records, particularly because a significant percentage of possible duplicates that the third-party systems may validate as true are often determined to be non-duplicates when a quality assurance process is utilized. Technology, after all, is not infallible; there is no magic button.
Finally, it is often beneficial to consider engaging a third party with specific MPI and data integrity expertise to augment internal resources. This helps to save time and free up departments that would otherwise be bogged down with identifying and resolving existing overlays, determining their root cause and crafting strong policies and procedures to prevent new overlays from being created.