Elimination of Individual Mandate One of the differences between the GCHJ and the ACA is that the individual mandate, the IRS penalty assessed on those who do not purchase health insurance, is not only eliminated but is repealed retroactively to Many experts believe that the elimination of the mandate with nothing to encourage health individuals to purchase health insurance could lead to higher insurance premiums because insurance companies would view the pools as limited to high-risk customers. The Commonwealth Fund reported that between 15 and 18 million people could become uninsured as soon as This is not necessarily due to the inability to afford insurance, but because healthy people will no longer be required to pay for healthcare and may choose not to spend money on those premiums.
Copying clinical documentation can be a time-saver for busy clinicians. It also can pose a risk to document integrity. For organizations that allow use of the copy functionality in their EHR systems, part of keeping compliant with organizational, state, and federal requirements is auditing the practice for proper use.
Ensuring Documentation Integrity Copying forward clinical documentation is the process of copying existing text in the record and pasting it in a new destination.
Clinicians may use it to save time when updating notes on an existing patient. It is also known as copy and paste, cloning, and carry forward, among other terms. Carrying existing information forward may be appropriate when the copied information is: Based on external and independently verifiable sources, such as basic demographic information that is stable over time Clearly and easily distinguished from original information, such as automatic summaries that populate data fields that are clearly identified as nonoriginal and cannot be mistaken for original information Not actually rendered as part of the record until after a re-authentication process and also auditable for identifying actual origination Thoughtfully and appropriately managing copy functionality requires that organizations have sound documentation integrity policies.
This is especially important given that EHR implementations change operational processes and documentation and workflow practices within the organization.
The use of copy functionality without the ability to review, test, audit, and approve presents significant medical and legal risks see sidebar. With appropriate checks and balances in place, however, prudent use of the functionality can be systematically evaluated so that documentation integrity is ensured.
Even organizations that have barred the use of copy and paste through policy will still require auditing if the copy function is available in its EHR system and cannot be turned off. HIM professionals can take a leadership role in addressing copy forward processes by listening, conversing, and collaborating with other stakeholders within the organization.
Determining System Audit Capability Ensuring that copied documentation follows all appropriate organizational, state, and federal requirements requires system tracking audit trailsobserving organizational use, and testing system capabilities. How an organization approaches this task depends in part on the record system it uses.
Some early electronic documentation systems have allowed functionality that would not be considered acceptable today—for example, cloning encounters or copying content without attribution to the original source. More recent EHRs address this loophole.
In all cases, however, organizations must confirm how the functionality works in their particular systems. If organizational policy bars a given use of copy and paste but the system supports that action, the organization must decide how this behavior will be monitored and measured.
Some systems will be capable of tracking and detecting the action and can report retrospectively on who used the functionality, as well as how and when they employed it. Organizations should not assume that even certified products provide the ability to audit copy functionalities. The certification criteria from the Certification Commission for Healthcare Information Technology do not require that copy functionalities of any type be auditable events.
Developing an Audit Plan Organizations can develop an audit plan by first determining how providers plan to use the copy functionality. If the intention is to allow the copy of documents from one system to another e.
The organization should test each of the proposed uses. Testing may require thorough investigation to systematically identify what can be audited and what cannot. An interdisciplinary approach including HIM professionals, IT staff, and perhaps system vendors is recommended.
See sidebar for sample testing activities. HIM professionals are a key participant in the development of copy audits, in part because of their knowledge of essential state, federal, organization-specific, and Joint Commission documentation requirements.
To that end, they can ensure that all of these standards are identified, reviewed, and met in conjunction with the proper implementation of the copy functionality. Failure to consider these key documentation requirements can result in inaccurate or erroneous information within the health record, even potentially a deficiency from an accreditation body.
Timely reporting is also a key part of the process to ensure that the audit results are reported to the appropriate organizational committee, and it should be a part of the ongoing review process. Violations of the copy policy should be identified, validated, and rectified through factual documentation.
Such action should take place in an appropriate timeframe. Copy Risks Using the copy functionality in an EHR system poses risk to documentation integrity, including: Following are three copy functionalities recommended for testing.As part of its goal to support a culture of patient safety and quality improvement in the Nation's health care system, the Agency for Healthcare Research and Quality (AHRQ) sponsored the development of patient safety culture assessment tools for hospitals, nursing homes, ambulatory outpatient medical offices, community pharmacies, and ambulatory surgery centers.
Welcome to CPARS. CPARS hosts a suite of web-enabled applications that are used to document contractor and grantee performance information that is required by Federal Regulations.
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Lincoln-Douglas Debate – November/December. Resolved: In a democracy, the public’s right to know ought to be valued above the right to privacy of candidates for public office.
Health Care Facts: health care reform is a good first step towards fixing our health care system. The health care facts show ObamaCare, while an effective program in many respects, isn't enough The World’s Greatest Healthcare Plan Vs.
The American Health Care Act; The cost of health care is not regulated by the government. The American Health Care System: Principles for Successful Reform.
Robert Graboyes. The government must not protect insiders from competitors, and all producers must be free to innovate, experiment, and take prudent risks. Domestic insurers should be able to cover visits to overseas facilities.
American hospitals should be free to adopt.