Updated on: September 23, 2013

More Focus Needed on Clinical Documentation to Ensure Electronic Health Record Accuracy

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Original story posted on: February 15, 2013

Washington, D.C.- – Inadequate attention to the integrity of clinical documentation in electronic health records (EHR) could compromise the usefulness of these records for patient care and quality reporting as well as business, compliance and legal uses, according to testimony given recently by the American Health Information Management Association (AHIMA) to the Office of the National Coordinator HIT Policy Committee.

Michelle Dougherty, MA, RHIA, CHP, director of research and development for the AHIMA Foundation, last Tuesday said in her testimony on the “Role of Clinical Documentation for Legal Purposes” that the more than 67,000 health information management professionals represented by AHIMA have identified these challenges with clinical documentation and record management in EHR systems:

  • Systems must meet the business requirements for a healthcare provider’s record of care for a patient, with the capability to meet today’s demands for use of information at the data and record level.
  • EHR systems must better manage, preserve and disclose health records, from creation to destruction.
  • More focus is needed on the data quality, information integrity and good documentation practices to achieve the policy goals of EHRs.

“If clinical documentation was wrong when it was used for billing or legal purposes, it was wrong when it was used by another clinician, researcher, public health authority or quality reporting agency,” said Dougherty. “It’s crucial to address data quality and record integrity now before health information exchanges (HIEs) become widespread.”

Although the envisioned changes in healthcare delivery and payment systems are not attainable without the rapid increase of health information technology, it is important to pay equal attention to the quality of the data that will be shared. EHRs have created a seismic shift in the clinician’s workflow and document process which requires establishment of best practices to ensure quality data is shared, Dougherty said.

AHIMA recommended that policymakers and leaders make the following actions priorities to address clinical documentation:

  • Advance information management and information governance in healthcare, making sure organizations are managing information as an asset and adopting proactive decision-making and oversight processes.
  • Implement health IT standards for records management and evidentiary support to make sure EHR systems can manage and preserve information throughout its lifecycle and meet the demands for valid health records.
  • Reevaluate medical record policies to make sure they strike a balance between necessary oversight while still taking advantage of the technology.
  • Utilize the health information management perspective and expertise to provide practical solutions to information integrity, management and governance advancements.

“EHRs offer so much potential, but standards of practice haven’t been adopted across all systems,” said Dougherty. “This can lead to clinicians checking off services they haven’t performed or material being incorrectly copied and pasted. In addition, sometimes when a full medical record is needed, EHRs produce information that is redundant, difficult to read, and not comprehensive.”

“HIM professionals can help ensure that electronic health records reach their full potential by assisting healthcare organizations, the government, EHR vendors and other stakeholders develop procedures to make sure the material collected is accurate and that it is clear who and when the information was entered,” AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA said.

The testimony was for the HIT Policy Committee’s Meaningful Use Workgroup and Certification and Adoption Workgroup. The information collected will inform deliberations on Stage 3 of Meaningful Use.

EDITOR’S NOTE: AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA, will report on this issue today on Talk-Ten-Tuesday, Feb. 19, 2013 at 10 AM ET.

AHIMA’s testimony can be found here.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.