AHIMA to ONC: Better clinical documentation needed to ensure EHRs’ efficacy
February 14, 2013 in Medical Technology
In testimony Wednesday before the Office of the National Coordinator HIT Policy Committee, the American Health Information Management Association made its case that suboptimal clinical documentation in electronic health records is a problem that needs addressing.
AHIMA argued that inadequate attention to the integrity of clinical documentation in EHRs could compromise the usefulness of these records for patient care and quality reporting – not to mention having an adverse impact on business, compliance and legal uses.
More than 67,000 health information management professionals represented by AHIMA identified several challenges with regard to clinical documentation and record management in EHR, according to testimony from Michelle Dougherty, director of research and development for the AHIMA Foundation.
For one thing, systems must meet the business requirements for a 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.
In addition, EHRs must better manage, preserve and disclose health records – from creation to destruction – and more focus is needed on the data quality, information integrity and good documentation practices to achieve the policy goals of EHRs, AHIMA argued.
“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.
That potential for replication of errors means that it’s “crucial to address data quality and record integrity now before health information exchanges become widespread,” she said.
Rapid increase of health IT is crucial to driving improvements in care delivery and payment reform, but it is nonetheless critical to pay equal attention to the quality of the data that will be shared throughout the healthcare system, according to AHIMA’s testimony.
As EHRs have drastically altered clinicians’ workflows and documentation processes the establishment of best practices is critical to ensure that the data is shared is of top quality, said Dougherty.
“EHRs offer so much potential, but standards of practice haven’t been adopted across all systems,” she said. “This can lead to clinicians checking off services they haven’t performed or material being incorrectly copied and pasted.”
Moreover, “sometimes when a full medical record is needed, EHRs produce information that is redundant, difficult to read and not comprehensive,” said Dougherty.
AHIMA recommended that policymakers take action to address clinical documentation. Among its suggestions: