ACOE_Self-Study

privileges. Privileging of residents is based on a recommendation by the director of residency programs and approval of the Chief Medical Officer.

8.2.4 The patient record must allow for efficient review of the patient’s condition and any pertinent previous care provided at the program’s clinical facility . In preparation to meet the continuing requirements of health care reform, the UEC invested in a new electronic health record system which includes scheduling, registration, e-prescribing, patient accounts, billing, patient portal and optical inventory management in June 2015. NextGen, a leader in the health information technology industry, provided our center with an integrated solution to securely document and access information as well as streamline our clinical and operational functions. The system was critical to the ICD-10 transition in October 2015, the implementation of e-prescribing in March 2016, and it is compatible with Meaningful Use Objectives, Physician Quality Reporting Initiatives as well as the Merit-based Incentive Payment System (MIPS). Current patient records (and past records of active patients) are stored in an electronic format. The UEC Policy and Procedure Manual M-2 ( Appendix VIII-6 ) addresses specifically what information should be contained in the medical record. Patient records allow for efficient review of patient conditions and any pertinent previous care provided at the UEC. Access to records is restricted to the practitioner or student who sees the patient. An audit trail can be obtained of who viewed a patient record. The confidentiality of patient information is of paramount concern. Students, faculty and staff are reminded annually on a formal basis about confidentiality of clinical records. The UEC has a Privacy Officer for issues related to confidentiality, a Compliance Officer for issues related to “business integrity” and an Information Security Officer for issues related to the physical, technical and administrative safeguards of information. All employees and students are required to take an annual on-line course on HIPAA and Business Integrity and successfully pass a quiz associated with the course. Access to records by accreditation site teams must adhere to HIPAA regulations ( UEC Policy and Procedure Manual H-4 and 5; Appendix VIII-6 ). 8.2.5 The clinic must conduct a continuous quality assessment, improvement and compliance program that provides for remediation when deficiencies are identified. Quality Assessment and Improvement The UEC’s Quality Assessment and Improvement Plan can be found in Appendix 5 of the Policy and Procedure Manual ( Appendix VIII-6 ) . It is the University Eye Center’s policy to review charts of patients seen within the UEC’s in -house clinics. The quality and appropriateness of care rendered by faculty to patients are retrospectively reviewed by the Quality Assessment and Improvement Committee (QA). This team meets weekly. Generally, a minimum of 10 records are reviewed for each faculty member per year. For FY 2017-2018, over 640 charts have been reviewed. QA activity for this period can be found in Appendix VIII-9 .

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