EMR Management Procedure
Contents
1. 3 Change the password completely when prompted by the system or if security has been compromised 4 Lock the computer workstation when stepping away from your device every time This can be done by using Ctrl Alt Delete and then selecting Lock this Computer 5 Do not share password with others 6 Do not write down the password 7 Do not allow others to log in as you 8 Do not allow other people to watch you key your password in Page 2 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 9 Do not save your password in your internet browser Passwords are set to expire every 90 days in the EMR If you forgot your password you may use the link Forgot My Password on the login screen to reset it and obtain a temporary password If you have been locked out due to many unsuccessful attempts you will need to contact the IT help desk 517 780 3367 to obtain a reset Physical Controls Users are responsible for maintaining the physical security of their workstation that is used to access the EMR and protected health information This includes immediately locking the device when not in use closing doors when away from the office where the device is located placing devices out of site when traveling e g truck of car password2. information Terminated Access It is expected that users complete a discharge summary immediately when it is known that their organization program will no longer serve the case a discharge summary will close out the access level The IT team may request a discharge summary from the provider to properly close from the case LifeWays reserves the right to conduct an administrative closure of agencies or users to remove access to a case record when there is a period of inactivity The purpose is to minimize case access to only users that are authorized for service delivery and are activity serving the case Once the case is closed the provider and assigned staff will have limited view only access to the case through LEO for a period of 90 days The 90 day window after case closure is intended to provide the Page 3 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 user with limited access to the case in order to complete final claims submission and clinical documentation activities After the 90 day period the system will automatically restrict access to the record and the user is forbidden from accessing the consumer s electronic medical record INTEGRITY AND COMPLETENESS OF INFORMATION EMR Standards Professionals accessing the EMR shall c
3. 37 MC Medication consents are present and include consumer and medical staff signature for all current medications Review the most recent Medication Review to determine the medications that are active then review the Signed Medication Consents in the Medical Chart to determine if there s a signed consent for each active medication 38 MC AIMS worksheet is completed quarterly for psychotropic medications Review CMH Medications to determine if Psychotropic medications have been prescribed and evaluate if AIMS testing has been completed every three months since the effective date of the prescription 39 MC Allergies adverse reactions have been completed in last 12 months Adverse reaction allergies have been recorded within the last 12 months If no allergies this is accurately recorded as NKDA No Know Drug Allergies as the Drug Allergen 40 MC Dispense notes are present for injectable medications If consumer is prescribed an Injectable Medication dispense notes are present to record the dispensing at the frequency noted within the prescription 41 MC Lab results are scanned or electronically transmitted results are reviewed by ordering physician If consumer has a Lab Order in LEO there is a corresponding Lab Result that has been reviewed by the ordering physician 42 MC CMH medications are present and current and align with the most recent medication review note Review last medication review and c
4. No G Does a lack of the enhancement inhibit quality service delivery to the consumer Yes No H Does the opportunity impact Mark all that apply Quality Productivity Safety Customer Satisfaction I Rating 1 Rate the severity S of the problem The seriousness of the problem or condition non conformance as it relates to the consumers and or the internal external customers 5 Very High Safety issue which poses potential harm to consumer and or internal external customers 4 High Ethical or quality issues that impacts service to internal external customer s 3 Moderate Probably has a noticeable effect on internal external customer s satisfaction 2 Low Slight chance of the internal external customer s noticing the effect 1 Minor Unlikely internal external customer s noticing the effect 2 Rate the occurrence O of the problem the number of times the problem or condition non conformance occurs during the defined process cycle within the scope of the element 5 Very High 80 or more of the time 4 High 60 79 3 Moderate 40 59 2 Low 20 39 1 Minor 0 19 3 Determine the number N of consumers and or customers affected The number of consumers and or internal external customers affected by the problem or condition non conformance during a defined period of time within the scope of the element 5 Very High 80 or more of consumers 4 High 60 79 3 M
5. protecting the device for user authentication and being aware of the immediate surroundings and risks Minimum Necessary Rule Users are created with very specific access to areas in the EMR based on their position and function It is expected that the user access only the minimum information that is necessary to complete their job function The actions carried out by users in the EMR are logged and recorded This includes all attempts to read write and delete data LifeWays reserves the right to review the audit trails to determine if the access level is necessary and appropriate Audit trail reports are available to LifeWays System Administrators on the IT team The agency retains the right to terminate any user access at any time ACCESS TO CASE RECORDS Users are granted access to case records in LEO based on their affiliation with a service location LifeWays or the designated Provider Administrator is responsible for assigning the user to a location and grating functional access Location assignments must be done with great care and caution Users shall not be assigned to locations in which they are not employed Once assigned to a specific location by LifeWays or the Provider Administrator the user will have access to the consumer records that are also assigned to that location Case records within the assigned location must be accessed on a need to know basis Simply having access to the file does not grant the user rights to review protected health
6. If child CAFAS PECFAS assessment has occurred in last three months If the consumer is age 7 17 a CAFAS score is present If consumer is age 4 6 a PECFAS score is present Score should be recently entered in the last 3 months 9 AS DD proxy measures have been completed in last 12 months If consumer has a DD disability designation there is a DD proxy measure entered in the last 12 months 10 AS Assessment has occurred in last 12 months An intake or update assessment was completed within the last 12 months for open case 11 AS Health conditions are complete A selection is present for every health condition listed in the health amp other conditions page 12 AS If consumer is authorized for a BTP there is a BTP scanned into LEO If consumer is authorized for H0032 BT there is a scanned BTP in the scanned document file 13 AS Psychiatric inpatient stays are managed through continued stay reviews and hospital discharge planning If psychiatric inpatient authorization is present there is a continued stay review and hospital discharge from 14 CR Chart Notes are used appropriately for miscellaneous documents or chart warnings If a chart note is present in the record it is for miscellaneous purposes and not billable documentation or information that is applicably stored elsewhere LifeWays EMR Standards Rev 10 15 14 1 LEO Quality and Integrity Standards for Electronic Medical Records Item Cate
7. LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 7 01 03 ELECTRONIC MEDICAL RECORD EMR MANAGEMENT PURPOSE The purpose of this operating procedure is to establish a management process for the electronic medical record that defines access and permissions system integrity and record completeness standards training and technical assistance efforts system change control process and communication plans Management of the EMR requires decision making planning and quality improvement throughout its life cycle The EMR is a mission critical function that supports the provision of care across the entire provider network system As a result procedures must be in place to support the integrity and accuracy of the information and components in order to achieve the highest effectiveness from the product It is also imperative that users of the product follow strict access confidentiality and security practices to provide for acceptable use and security of the protected health information maintained by the system SYSTEM COMPATIBILITY The LEO system is hosted developed and maintained by PCE Systems The LEO applicable is available in three environments 1 production 2 training and 3 development The production environment is the live setting that use
8. OVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 Treatment Plan amp Crisis Plan Treatment Plan Addendum Treatment Plan Formal Review The following is a list of the optional electronic forms that are available within LEO to providers programs of LifeWays It is understood that programs may utilize this form or their own forms until a standard consent is created for the entire CMH network At that time the LEO consents will become mandatory Consent to Exchange Release Information Consent to Participate in Services Scanned Documents If a particular electronic form does not exist in the system the user may scan in their version of the form to complete the electronic record It is expected that scanned documents are consistently uploaded using the appropriate category type to enhance the organization of these images Each scanned document page shall include the consumer s name and case number Additionally the date of the scanned document shall match the date of the scanned image for historical archiving Timeliness of Signed Documents Users shall recognize the importance of completing clinical documentation soon after the contact with the consumer Unsigned documents negatively impact billing encounter reporting timeliness reporting and other areas of perform
9. alue and feasibility Recommend solution Define impact and expected outcomes Define measure for success Schedule according to priority list 5 Implementation amp Training Deployed to Production system Communicated through News Bulletin Training materials published on website 4 Prototype Testing amp Pilot Development system test Input from primary users Subsequent revisions Electronic Medical Record Management System Change Control Process Flowchart August 1 2013 LifeWays System Enhancement No Refer to Help Desk Close Yes Approve Enhancement No Yes 6 Sustainment Re evaluate change Seek input from primary users Subsequent revisions 3 Design amp Planning Define change Define purpose Develop screen layout Develop process diagram Develop instructional manual and business rules Develop screencasting video or training LEO System Change Request Form LifeWays LEO System Change Request Form 1 Requested By Email Date of Request Identify Need amp Initiate System Concept Development A Describe the problem B Describe the recommended solution or concept C Define the scope or boundaries of the concept D Describe the impact expected outcomes and how success will be measured E Does this enhancement fit into the LifeWays mission and values Yes No F Does this enhancement fit into the LifeWays strategic plan Yes
10. ance As a result LifeWays has adopted a timeliness standard for clinical forms in LEO to be completed within 3 business days from the date of service Therefore clinical documents must be fully executed completed and signed within 3 business days of the date of service The first exception to this rule are crisis interventions which must be completed within 24 hours from the time of disposition The second exception to this rule are progress monitoring notes for specialized outpatient services specifically RN RD BT and OT services which must be completed within 5 business days from the date of service Document Deletion The agency maintains a position that the documentation in the EMR system must be of high integrity Therefore documents entered in the LEO system are considered part of a permanent record and shall not be deleted The only exception to this standard is documentation that is done in error e g wrong chart duplication If a document has been entered in error the user shall report this to their Supervisor for deletion If the Supervisor does not have permissions to delete that specific type of document the request for deletion shall be reported to the LifeWays IT Help Desk by the user s supervisor with a written request to delete using the Help Desk module to enter a ticket which signifies the supervisor s approval of the document deletion A LifeWays System Administrator IT Staff retains all rights to deletin
11. be evaluated through an annual survey process Requests for training can be made through the IT help desk at any time The IT team will coordinate a training to occur with the subject matter experts LifeWays may request a corrective action plan if after adequate training and technical assistance has been provided to the user non compliance with EMR standards and expectations remains The Quality Improvement amp Technology Division shall engage the Contract Management Team in any corrective action processes related to the EMR standards and expectations Resources The agency shall supply various learning materials such as written instructions how to guides FAQs tutorials or other forms of educational content that can be made readily accessible and utilized by the end user when technical assistance or troubleshooting is needed Help Desk If the user is unable to self resolve the issue the user shall contact the LEO Help Desk by calling 517 780 3367 internal x2367 or submitting a ticket through the Help Desk module within LEO The LEO Help Desk is intended to provide technical assistance and troubleshooting of system errors for traditional business operations that currently exist within the EMR The agency shall maintain high standards for timeliness of response and resolution and maintain open communication with the user regarding attempts made to resolve the help desk ticket The LEO Help Desk is not designed to field system enhancements or sugges
12. f of programs or providers that are authorized to serve a LifeWays consumer is expected to document care using all appropriate modules Page 1 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 and forms that have been made available and within their scope of care This requirement is to ensure complete and accurate service documentation and facilitate effective care coordination amongst mutually serving program and providers within the LifeWays CMH system There are no exclusions to the requirement to use the LEO system unless a user can demonstrate that it creates a significant hardship and this has been reported to and approved by the Director of Quality Improvement amp Technology Services User Setup The agency is responsible for the oversight and establishment of access levels and permissions within the EMR system The LifeWays Information Systems Specialist is responsible for user setup granting permissions and ongoing monitoring to ensure security and privacy is upheld User setup shall be a centralized role within the agency that is managed by the IT team Provider Administrator LifeWays may choose to delegate the setup and management of provider staff users to a designated and trained Provider Administrator at each provider agency T
13. g documentation and will only execute this task when written confirmation from the requestor s supervisor has been received and it is determined to be done in error If there are identified patterns at the user level regarding the volume and frequency of requests to delete documents the agency reserves the right to remove the user s access to the EMR and request a training plan Page 5 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 LifeWays shall evaluate compliance with these standards through periodic desk audits The auditing results shall be used for corrective action and continuous quality improvement in an effort to support the integrity and proper utilization of the EMR TRAINING AND TECHNICAL ASSISTANCE Training The agency maintains the responsibility to provide training and education to users to support competency system integrity security and compliance with the EMR standards Training can be conducted through various methods including live instruction e learning modules written instructions with screen layouts videos with screencasting etc The trainer of the content shall be a subject matter expert LifeWays may user a peer or skilled training within a provider or program to transfer knowledge Training needs shall
14. gory Indicator Evaluation Criteria 15 CR Consent to participate is present Consents to participate for all active providers are completed electronically or scanned into the record 16 CR If consumer is enrolled in school K 12 there is consent to release information to the school present Consents to exchange release info to the child s school is completed electronically or scanned into the record and is current 17 CR If consumer reports a primary care physician consent to release information to the physician is present Consents to exchange release info to the physician is completed electronically or scanned into the record and is current 18 CR Diagnosis Axis are complete Axis 1 5 The full diagnosis table is complete including Axis I II III IV and V 19 CR Advanced Directive status is collected and scanned into the chart is active Review the most recent consent to participate If the consumer indicates that they have an active advanced directive a copy is scanned into the consumer chart 20 CR Scanned documents are appropriately categorized organized and identify the consumer s name and case number Review each scanned document that was entered during the current treatment plan and verify that the Document Type appropriately matches the content of the scanned image The date of the document should match the date within the document and not the date it was scanned There should be no du
15. his is considered a privileged function high ethical standards and security practices must be applied within this role These permissions can be removed at any time by the agency The Provider Administrator must follow the user setup manual provided by LifeWays The Provider Administrator is expected to strictly adhere to LifeWays guidelines regarding creation and management of functional access and privileges for users LifeWays shall monitor the Provider Administrators user setup audit trails and the integrity of their managed users to ensure security and privacy is upheld within user access levels LifeWays reserves the right to modify user setup at any time if it is determined to be inappropriate Non compliance with the expectations as a Provider Administrator will result in revoke privileges and possible corrective action All system users are responsible for maintaining secure practices including 1 Privacy of passwords 2 Maintaining physical control of the equipment that is used to access the EMR and 3 Following the minimum necessary rule for accessing and disclosing protected health information Secure Passwords Passwords security is critical to the protection of information in the EMR Users have a primary role to minimize the risk of improper disclosure by using the following required secure password practices 1 Keep password secure and confidential to all others 2 Create strong passwords using alpha numeric and special characters
16. l use the LifeWays Provider Meeting as a mechanism to communicate critical changes to the system provide training and seek input Page 7 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 REFERENCES U S Health Insurance Portability and Accountability Act of 1996 HIPAA U S Health Information Technology for Economic and Clinical Health Act of the American Recovery and Reinvestment Act of 2009 LifeWays Operating Procedures 07 01 01 Data Validation and Management 07 01 03 Reporting Services 07 02 02 Information Access and Systems Security 07 02 06 Use and Disclosure of Protected Health Information 07 02 07 Mobile and Portable Systems and Security 07 03 02 Information Systems Service Desk Forms LEO Systems Change Request Attachments LEO Quality and Integrity Standards for Electronic Medical Records System Change Control Process Flowchart System Change Request form LEO Instructional Materials How To Guides How to Update Consumer Demographics How to Add an Admission Provider Assignment Staff Assignment and Discharge a Consumer How to Add an Initial Intake How to Add Consumer Notices How to Change a Signed Document How to Early Terminate an Authorization How to Navigate the Consumer Chart How to Add Request Autho
17. mmunication plan 4 Prototype Testing and Pilot The prototype is loaded in the Development system for user testing and training Additional modifications are requested from the developer as necessary to meet the expected outcomes Input is received from primary end users 5 Implementation and Training The tested prototype is deployed to the Production system on a scheduled date End users receive communication and instructional material from the agency for training purposes 6 Sustainment The change is re evaluated for success based on the previously defined outcome measures Input is received from primary end users to determine success COMMUNICATION The agency shall follow the change control process for system enhancements in order to effectively communicate with system users Changes are communicated primarily through the LEO News Bulletin which is published on the LifeWays website and emailed to the EMR List Serv managed in Constant Contact The Bulletin shall describe the purpose description of the change and effective date The agency shall release the Bulletin as official notice of a scheduled change Changes will usually occur on the first day of the following month Primary users shall be provided with the opportunity to test the change in the Development system and provide input before it is in the Production system Bulletins will be archived on the LifeWays website for future reference and instruction The agency wil
18. oderate 40 59 2 Low 20 39 1 Minor 0 19 LEO System Change Request Form LifeWays LEO System Change Request Form 2 Priority Ranking Score PRS S x O x N Design amp Planning Description of design and planned change Purpose of the change Attachments Screen layout Process diagram Instruction manual with business rules Screencasting video Prototype Testing amp Pilot Development System Effective Date Summary of input from testing and subsequent modifications Implementation amp Training Production System Effective Date Included in News Bulletin Training materials posted on website Sustainment Planned Evaluation Date Measures used to determine success Results of evaluation References LifeWays Operating Procedure 07 01 03 Electronic Medical Record Management
19. onsistently follow the standards established by the agency to achieve and maintain a high level of integrity and completeness of information within the EMR The agency has established a detailed set of Quality and Integrity Standards for Electronic Medical Records Attachment 1 Conformance to these standards is expected by all users Use of Electronic Forms LifeWays has created electronic forms within the EMR for primary chart documents These forms must be completed electronically within LEO and are no longer offered on paper It is expected that users fully utilize the electronic forms as appropriate to their scope and practice A scanned document of a paper form is unacceptable if an electronic form has been made available The following is a list of the standardized clinical forms that are required for providers and programs of LifeWays Access Screening Crisis Intervention Clubhouse Progress Note Weekly Death Report Discharge Summary Financial Determination Group Progress Note Incident Report Injection Dispense Note Intake Update Assessment Integrated Health Assessment Medication Delivery Progress Note Medication Review Pre Planning Progress Note Psychiatric Evaluation Residential Quality of Life Assessment for services providing in a residential setting Supported Employment Progress Note Page 4 of 9 LifeWays Operating Procedures SECTION G
20. plication of scanned documents Each scanned document contains the consumer s name and case number 21 CR Care coordination communication form is used and scanned into LEO in accordance with consents to release info i e beginning services medication changes hospitalizations discharges Care coordination is evident by a health care coordination form document in the record 22 CR If guardian is present there is guardianship papers are on file If a guardian is indicated in the Consumer Information there are guardianship papers scanned into the consumer chart 23 CR No documents awaiting disclosure in the Medical Record queue The requested documents have been released externally and are not pending in the Document Disclosure Queue 24 CR No unsigned documents awaiting signature All documents are fully signed and not pending a staff signature 25 CR Consumer appointments are managed through updates to the appointment status Review consumer appointments and verify that the status of any past appointments has been changed from Scheduled to Kept Cancelled or No Show 26 DQ Address is complete and accurate Complete and accurate address define by valid Street City St Zip Home Phone 27 DQ Emergency contact information is present Emergency contact is provided or Section not applicable 28 DQ Primary guardian information is present Guardian is provided or Section not applicable LifeWay
21. r to PCP meeting If consumer has specialized residential services verify in demos and the treatment plan shell header there is a residential quality of life assessment included in the treatment plan and it was completed by the residential staff before the date of the PCP meeting 50 TP Consumer signatures are obtained digitally or scanned in as an Attachment to the Treatment plan Consumer s signature can be found within the Treatment Plan print or as a scanned document within the Attachments 51 TP Copy of treatment plan is provided to consumer Treatment plan shell header displays the date and method in which the copy of plan was provided 52 TP Notice of Hearing Rights is signed by consumer and scanned in as an Attachment to the Treatment plan including subsequent Addendums Signed paper notice is scanned is as an Attachment to the treatment plan or plan addendum 53 TP Treatment plan formal review has occurred quarterly since treatment plan effective date A formal review was completed every 3 months using the electronic form since the treatment plan effective date 54 TP Treatment plan is fully signed by provider staff Treatment plan is entered electronically not scanned and is not pending staff signature End LifeWays EMR Standards Rev 10 15 14 4 1 Initiation Define need Initiate system concept Define scope Prioritize 2 System Concept Development Assess v
22. rizations How to Update the Intake How to Update a Consumer s Diagnosis How to Add Consumer Allergies Adverse Reactions How to Add DD Proxy Measures How to Complete a Service Activity Log How to Complete a CAFAS PECFAS Assessment How to Use Discussions How to Use Electronic Labs Flow Charts Access Center Screening Process Flow Access Center Intake Process Flow Utilization Management Process Flow PSU Support Staff Process Flow Provider Clinical Process Flow Page 8 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 Provider Claims Process Flow FAQ User Manuals Login and Navigation User Manual Access Screenings Crisis Interventions Intake Assessments User Manual Treatment Plans User Manual Service Activity Logs User Manual Provider Claims User Manual Provider Management User Manual Calendar User Manual Case Load User Manual Sentinel Events User Manual Death Report User Manual Court Orders User Manual Integrated Health Assessment User Manual Consent to Exchange Information User Manual Progress Notes User Manual Medication Review Process Incident Report Manual HISTORY Effective 03 01 2014 Rev 07 01 2014 09 01 2014 10 15 2014 Page 9 of 9 LEO Quality and Integrity Standards for Electronic Medical Record
23. ross walk with the CMH prescribed medications for accuracy and completeness 43 MC No lab results awaiting review There are no lab results for the case that are Pending Review in the medical chart LifeWays EMR Standards Rev 10 15 14 3 LEO Quality and Integrity Standards for Electronic Medical Records Item Category Indicator Evaluation Criteria 44 MC Non CMH medications are present and current consumer self reports Review last medication review and cross walk with the non CMH prescribed medications for accuracy and completeness 45 MC Initial Psychiatric Evaluation is present A psychiatric evaluation is present 46 MC No verbal orders awaiting review There are no verbal orders awaiting the physician s approval for the case 47 MC Vital signs have been completed in last 12 months for consumers receiving Psychiatric services If authorization for medication review or psychiatric evaluation is present there are vital signs recorded within the last 12 months 48 PG Progress notes are present for all active providers Review authorized providers and cross reference with the progress note module A progress note should be present for all active authorized providers The progress notes should be entered electronically if a e format for the note is available otherwise a scanned progress note is accepted 49 TP Residential quality of life assessment was completed by residential staff prio
24. rs use for electronic health record documentation The training environment is a duplicate of production to use for training purposes changes within training will not harm the production system The development environment is used to create and test new system changes before they are moved to production Internet Explorer The LEO application is programmed to be compatible with Internet Explorer IE There are specific functions and forms that are not fully operable unless used in Internet Explorer Therefore the agency requires that Internet Explorer is used as the web browser to run the LEO system The most recent version of Internet Explorer should always be used as PCE Systems works diligently to maintain compatibility with the newest IE release Adobe Reader The LEO application is programmed to use Adobe Reader most recent version to be fully operational when viewing and printing PDF documents within the LEO systems Java Installation The LEO application must have the most recent JAVA update installed on your computer hardware to be compatible with viewing certain documents within LEO scanning uploading documents and capturing signatures with the compatible signature pads This software must be installed prior to installing any hardware Scanner Signature pad ACCESS AND PERMISSIONS Expected Use LifeWays staff and contracted service providers are expected to fully implement the LEO system within their workflow to document services rendered Staf
25. s Effective 8 1 2013 Purpose The following table identifies the minimal standards necessary to determine an electronic medical record as complete and accurate Reference LifeWays Operating Procedure 07 01 03 Electronic Medical Record Management Item Category Indicator Evaluation Criteria 1 AD A staff assignment exists for each provider assignment There is at least 1 staff assignment under each provider assignment 2 AD Discharge pending approval is less than 14 days since author signature or is absent Discharges present and pending UM approval are less than 14 days old 3 AD Open provider assignment has active authorization to serve the case There is a provider assignment for each authorized provider Providers without active authorizations have been closed 4 AD Primary case holder is assigned for open case Open case has active primary case holder staff assigned 5 AD Primary provider is assigned for open case Open case has active primary provider assigned 6 AS If behavior treatment plan exists BRMC case notes are present according to BTP review schedule Review the BTP for the indicated BRMC review schedule The BRMC case review notes should be completed according to the specified BRMC review schedule 7 AS BRMC Case Review form is completed prior to discharge summary If discharge needs BRMC review the BRMC case review form is less than the discharge form date 8 AS
26. s EMR Standards Rev 10 15 14 2 LEO Quality and Integrity Standards for Electronic Medical Records Item Category Indicator Evaluation Criteria 29 DQ Preferred pharmacy information is present Pharmacy is provided or Section not applicable 30 DQ Primary care physician information is present Physician is provided or Section not applicable 31 DQ Absence of critical data errors Consumer chart is free from all data quality errors 32 FI A current self pay financial determination is complete verified by LifeWays Self pay is present and includes the consumer s signature that is obtained digitally or is scanned in as an attachment to the policy Supporting financial documentation is scanned in as an attachment to the policy 33 FI Insurance policies are verified All insurance policies for the case are Verified and not in Awaiting Verification status 34 FI Medicaid deductible policy is present if the consumer is on a deductible If the consumer is on a Medicaid deductible there is a Deductible policy entered in the insurance policy area and it is not expired until the deductible no longer applies 36 IR Incident Reports are routed for signature and reviewed signed in a timely matter Search IR module for all incident reports for the consumer and verify that they have been fully reviewed by all Reviewers as indicated by a Review Date next to each reviewer The Review Date should not be null
27. tions from end users Enhancements or suggestions for system improvement and modification shall follow a separate and formal change control process SYSTEM CHANGE CONTROL PROCESS It is expected that the system will evolve and changes will be necessary as areas for improvement are identified The agency shall maintain an organized process for receiving and implementing system enhancements The following change control process will be followed for EMR system changes Page 6 of 9 LifeWays Operating Procedures SECTION GOVERNING POLICY 7 00 Information Systems IS 01 IS Infrastructure Strategy and Management SUBJECT 03 Electronic Medical Record EMR Management EFFECTIVE DATE 03 01 2014 REVIEWED REVISED 10 15 2014 Phase Description of Systems Development Life Cycle 1 Initiation Begins when a user identifies a need or an opportunity The System Change Request form is completed System analysis is conducted to validate the request 2 System Concept Development Determines feasibility Defines the scope or boundary of the concept Determines impact expected outcomes and measures for success The System Change Request form is updated 3 Design and Planning The functions and operations are described in detail including screen layouts business rules process diagrams and other documentation A prototype is created for the Development system The System Change Request form is updated to reflect the implementation and co
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