1. Compliance with Medical Student documentation in the EMR: controversies and practical educational strategies David Power, M.B., M.P.H. University of Minnesota Medical School Aaron Michelfelder, M.D. Loyola University Chicago Stritch School of Medicine Scott Fields, M.D., MHA Oregon Health and Science University

2. Objectives By the end of this presentation, participants will: –Be familiar with (Centers for Medicaid Medicare Services) CMS guidelines for teaching physicians –Cite recommendations from AAMC Compliance Officer’s Forum (COF) in regards to student documentation in the EMR –Learn of JCAHO recommendation on student prescribing

3. By the end of this presentation, participants will: –Recognize the practice guidelines from Alliance for Clinical Education (ACE) and AAFP on students and EMR –Hear 3 institutions’ policies and practices on medical student EMR documentation –Identify controversies around student use of EMR –Discuss practical educational strategies to optimize student use of EMR Objectives [continued]

5. CMS Guidelines summary Students may document services in the medical record Fact Sheet: Guidelines for Teaching Physicians, Interns, and Residents. Dec 2011. Medicare Learning Network, Center for Medicare and Medicaid Services. Department of Health and Human Services http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNProducts/downloads//gdelinesteachgresfctsht.pdf

6. CMS Guidelines summary Physicians may only bill Medicare for the services they have personally performed If students performed the service, physician billing for it constitutes fraud Documentation needs to reflect that physician provided service

7. “Any contribution of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident in a service that meets teaching physician billing requirements –(other than the review of systems [ROS] and/or past, family, and/ or social history [PFSH], which are taken as part of an E/M service and are not separately billable)”

8. CMS Guidelines summary To Bill : Teaching physicians –May refer to the student documentation of the ROS and /or PFSH (Not physical examination) (Not medical decision making) –Must verify and re-document HPI,PE, and A/P

9. Compliance Advisory: Electronic Health Records in Academic Health Centers Topic 1: Medical Student Documentation June 11, 2011 https://www.aamc.org/download/253812/data/appropriatedocumentationinanehr.pdf AAMC Compliance Officer’s Forum (COF)

10. Recommendations: The only parts of a medical student’s note that should become a permanent part of the medical record are ROS and PFSH AAMC COF Advisory

11. If scribing is allowed (which is an institutional decision), the compliance officer should contact the Medicare contractor to determine whether it has a definition of a “scribe.” Scribing by a medical student is a distinct activity from allowing a medical student to write a note as part of his/her educational experience. If possible, the EHR should allow clear identification regarding whether a note is scribed or whether it has been written by a medical student as part of his/her educational experience. If this is not possible, then medical students themselves should be required to clearly indicate when they are acting as scribes rather as students. AAMC COF Advisory

12. After review of medical student documentation (other than review of systems and past, family, social history) by the resident and/or teaching physician is complete, permanently block ability to copy the note. Positive identification of services that have been repeated by the teaching physician and re- documented (No drop down box attestation of medical student note) AAMC COF Advisory

13. If possible, design a distinct security class for medical student. (block copy and paste except for ROS, PFSH) AAMC COF Advisory

14. Summary: –Only Med Student documentation of ROS and PFSH should become a part of the actual patient chart –Scribing needs to be clearly designated as such in the chart –No Copy and Paste (Except for ROS, PFSH) –EHR system should automatically recognize med student documentation to apply limits AAMC COF Advisory

15. Joint Commission (JCAHO) and Medical Student Order Entry Query to the Joint Commission –Medical Student CAN enter orders –Must be co-signed by licensed practitioner –Must have safeguards to prevent acting on orders prior to co-signing

16. Medical Student Documentation in Electronic Health Records: A Collaborative Statement From the Alliance for Clinical Education, Teaching and Learning in Medicine: An International Journal, 24:3, 257-266, 8/12/12 http//dx.doi.org/10.1080/10401334.2012.692284 ACE Statement on Electronic Health Records

17. Students must document in the patient’s chart, and their notes should be reviewed for content and format Students must have the opportunity to practice order entry in an EMR-in actual or simulated patient cases-prior to graduation ACE Guidelines

18. Students should be exposed to the utilization of the decision aides that typically accompany EMRs Schools must develop a set of medical student competencies related to charting in the EMR and state how they would evaluate it. This should include specific competencies to be documented at each stage, and by time of graduation ACE Guidelines

19. AAFP AAFP encourages teaching hospitals and clinical clerkship sites to allow medical student access to patient electronic medical records. AAFP recognizes the independence of each teaching site to develop policies regarding student access to electronic medical records with the goals to protect patients, recognize different EMR capacities, comply with federal and payor regulations, reduce administrative burden and to ensure appropriate reimbursement. Such policies might include, but are not limited to: –Read-only access; –Special designations of medical student documentation in the EMR; –Medical student documentation outside the EMR; –Co-signature requirements; –Guidelines for acceptable parts of documentation by medical students and supervising physicians; and –Development of EMR safeguards and/or templates to ensure institutional policies are met. (2012 COD)

20. Student EMR Use Year 1, 2, 3 and 4. –(Training begins in week 1) At OHSU Students have‘medical assistant’-level access –Update History (PMH, Surgical History, Family History, social history) –Review and reconcile medications –Pend orders –Write notes for co-signature Many OR hospitals on the same EMR (EPIC) –Hospital systems have differing student EHR use policy Students have remote access –Simulated-EMR modules are feasible with remote capability Simulated EMR use with OSCEs and PBL/TBL cases Oregon Health & Science University

21. Students are integrated and engaged in health care team, and are expected to fully engage in EPIC in both the inpatient and outpatient settings. Students, in both the ambulatory and inpatient settings, may: –Write progress notes; pend orders, enter information into all components of the patient database, including past medical, family, social history (PFSH) and the review of systems (ROS); access and view all data; use a student in-basket for purposes of receiving feedback about their documentation; initiate the discharge summary. The expectations for residents/attending involved in teaching students: –Supervising physician is expected to review the student notes and orders; provide the student with feedback –Supervising physician must approve and sign orders that are pended by a medical student –Supervising physician will write their own primary note, but may refer to a student’s note –Students are not to be used as scribes Students do not have the ability to do the following in EPIC: –May not cut, paste, or duplicate another person’s note in the medical record –Are discouraged from using pre-established completed note templates –May not sign orders http://www.ohsu.edu/xd/education/schools/school-of-medicine/academic-programs/md-program/upload/School-of-Medicine-Handbook.pdf http://www.ohsu.edu/xd/education/schools/school-of-medicine/academic-programs/md-program/upload/School-of-Medicine-Handbook.pdf (page 45, pdf p51/114) OHSU Policy and Procedure

22. Mixed interpretation depending on department / system affiliation and whether location is attached to a hospital or not –eg. Required EMR training Scribing by a clerkship medical student in clinic is acceptable (FM and EM clerkship and others) University of Minnesota

23. A “medical scribe” is defined as an individual who is present during a physician’s performance of clinical services and documents on behalf of the physician everything said during the course of the service. A scribe does not document his or her own findings or plan. In order for a student to both have direct patient care experience as well as the ability to document in the EMR and receive feedback on their documentation, it may be an option for a student to serve in the role of a medical scribe. DRAFT University of Minnesota Medical School policy statement: Guidelines for Medical Student Documentation in EMR, 2013

24. Student has unique login Student documents the note as if they are transcribing for the physician –“I did” not “we did” etc. –“This note is scribed by Medical Student, MS4 on behalf of Attending Physician, MD” –Attending reviews and edits the note: –“I confirm that I personally performed the entire clinical encounter documented in this note.” Clerkship scribing

25. If student works with licensed resident in a non-hospital linked clinic, above is OK Compliance Officer LOVES exam-room precepting (TIPP) – increased observation Billing by time does not require documentation Other caveats:

26. How Student Documentation Helped Us Students Have Full Access to Charts Student Work Clearly Identified Write Notes, Enter and Pend Orders, Update Meds Problem List Attending Only How We Got Here Loyola University Chicago

27. At your institution? Questions / Comments? Controversies?

28. Is there information here that will help you? Next steps? –Make sure you are in compliance –Meet with your compliance officer! –Agitate for medical student education exception –STFM position statement Practical Educational Strategies

29. David Power, M.B., M.P.H. power007@umn.edu Aaron Michelfelder, M.D., amichel@lumc.edu Scott Fields, M.D.,M.H.A. safields@ohsu.edu Thank you!