CHA News Article

CMS Addresses Role of EHR Navigators During Hospital Survey Process

The Centers for Medicare & Medicaid Services (CMS) has issued the attached Survey and Certification memo addressing the issue of Electronic Health Record (EHR) navigators during the survey process for hospitals and critical access hospitals (CAHs). CMS explains that state survey agency (SA) surveyors may request that experienced hospital/CAH EHR users with appropriate system permissions be assigned as “navigators” to assist surveyors with medical record information retrieval for survey tasks requiring detailed medical record review. Hospitals/CAHs are expected to provide the necessary assistance to enable surveyors to review EHRs. Providing such assistance, according to the memo, is analogous to the traditional expectation for paper-based records that hospitals and CAHs retrieve.

Key points of the memorandum include:

  • At a minimum, an EHR navigator would assist a surveyor in retrieving records that the surveyor has identified.
  • Navigators should have sufficient system access to EHRs and any paper records.
  • It is not expected or advisable to ask that all requested records be printed for the surveyor to review.
  • Surveyors may permit a navigator to shadow them throughout the survey, as long as navigators do not intervene when surveyors are observing how hospital staff use the EHR.
  • Declining to make a navigator available to the surveyor when requested may be grounds for terminating the Medicare provider agreement.
  • If the hospital or CAH instead offers to furnish direct surveyor access to the EHR system, the SA must determine whether it is willing and able to continue the survey with the surveyor directly accessing the EHR system.

Additional details can be found in the attached memorandum.