andrea PointClickCare

Electronic Medical Record Spotlight: PointClick Care, What Attorneys Must Know

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April 30, 2024 by Madison Bratley

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Welcome to Comperio’s Electronic Medical Record Spotlight.

Comperio’s quarterly review of EMR systems at the foundation of your cases.

Comperio Legal Services is proud to announce our entry into long-term and post-acute care (LTPAC)! In addition to our extensive acute-care electronic medical record (EMR) expertise, we now offer advisory and expert witness support for your cases involving nursing homes, long-term care, and skilled nursing facilities.

In our inaugural edition of EMR Spotlight, we focus on PointClickCare, a leading EMR software used by thousands of long-term care and skilled nursing facilities.

About PointClickCare

PointClickCare is a leading healthcare technology platform enabling meaningful collaboration and access to real‐time insights at every stage of the patient healthcare journey. More than 27,000 long‐term and post‐acute care providers, over 3,100 hospitals and health systems, 2,200 ambulatory clinics, every major U.S. health plan, and over 70 state and government agencies use PointClickCare, enabling care collaboration and value‐based care delivery for millions across North America. (source PointClickCare website)

Expert Background

Our newest EMR expert witness consultant, Andrea, has worked in post-acute care for over 27 years as a director of health information, EMR specialist, and HIPAA and corporate compliance officer. In her roles, she developed expertise in PointClickCare software customizing documentation workflows, training end users, and auditing electronic medical records. She is well known among the PointClickCare community for her 13+ years of developing best practices for PointClickCare software and readily sharing her expertise with user groups nationwide.

In this edition of EMR Spotlight, Andrea sheds light on what to look for from PointClickCare medical records to prepare you with insider knowledge to bring your cases.

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What to Look For in a PointClickCare Case

  1. Post-Care Data Alterations. The user-defined assessment (UDA) is a structured PointClickCare template tool for users to document clinical findings. “When the UDA is printed as part of a medical record production, it defaults assessment and intervention information in what appears to be chronological order without timestamps,” says Andrea. However, the system administrator producing medical records would need to activate user activity timestamps to include that information for the production request to reveal the actual chronology of documentation. Without this critical timestamp metadata, “it can appear that appropriate care was delivered” despite a sentinel event occurring.
  2. Omissions and Errors. “There is lots of room for error because not everyone knows how to use the system properly,” says Andrea. “Medication errors and omissions of care being done” from the medical record are common. Also, in the current healthcare mergers and acquisition climate, merging multiple PointClickCare systems into a unified system can lead to situations where “lots of data gets lost or scrambled that may not be presented to a legal team.”
  3. Regulatory Compliance. According to Andrea, “Federal and state regulations are always changing, so you must constantly adapt the software because PointClickCare is slow to implement changes.” CMS ensures all LTPACs meet or exceed the Medicare standards outlined in their Conditions of Participation (CoPs) and Conditions for Coverage (CfCs). Failure to meet the program requirements related to resident care and services can lead to deficiencies by state or federal regulators that may result in termination of Medicare and Medicaid participation and denial of payments.
  4. External Data Sources. Andrea points out that “a lot of PointClickCare functionality is powered by bi-directional integrations” from third-party digital health companies, such as pharmacy and medication management, ordering and resulting of lab tests, and point-of-care assessments. This means that while information coming from these integrations may be stored in the PointClickCare medical record, more “source of truth” data can exist outside the bounds of your typical legal medical record request. Inquiring about the integrations supporting PointClickCare software is critical to making sure no stone is left unturned in discovery.

What to Look For in a PointClickCare Expert

  1. Expert Resource Availability. Oftentimes, an LTPAC may only employ a single admin to configure and support their entire PointClickCare system, which means there are very few qualified options available to support a case in your local area that would not have a conflict or be willing to be retained as an expert. Speaking of highly competent PointClickCare system administrators, “there just aren’t a lot of us out there” notes Andrea.
  2. Depth of System Experience. Andrea emphasizes this area as critical for attorneys retaining experts. PointClickCare does not provide certification for their client system administrators, therefore there is no minimum level of training or competence to independently validate their true knowledge or expertise. Since the system is very compartmentalized, “one person is not going to know all aspects of PointClickCare—it’s literally ‘learn as you go’” says Andrea. Finding someone with robust knowledge of the entire system requires experience across clinical, financial, compliance, and technical facets.
  3. Operations Knowledge. Understanding how clinical and business operations work in the LTPAC space is key for not only building out the right documentation and supportive EHR tools but also lends to identifying bad user behaviors within the system. Many aspects of care are required to be documented on a schedule and it is easy for a user to see missed patient evaluations, care plan assessments, or education and ‘backdate’ entries. “These timestamps don’t flow into the dated progress note that a lawyer may receive” whereas the users can clearly see the late entries in their forms.

Let Andrea Help You Navigate Your PointClickCare Case

Your success is our priority. Contact Comperio today to schedule a free consultation with Andrea to evaluate your PointClickCare case and provide the expert insight support you need to obtain justice.

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