AHIMA IDs clinical documentation challenges in EHRs

Three clinical documentation and record management challenges in electronic health record systems were identified by the American Health Information Management Association at the Office of the National Coordinator for Health IT's HIT Policy Committee meeting this week.

The problems--which include an inability to meet business requirements for a provider's record of care for a patient; subpar management, preservation and disclosure of health records; and a lack of focus on data quality, information integrity and solid documentation practices--were outlined by AHIMA Foundation Director of Research Michelle Dougherty, who could not understate the importance of remedying the situation quickly.

"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," Dougherty said in her testimony at the meeting. "It's crucial to address data quality and record integrity now before health information exchanges become widespread."

Dougherty listed four recommendations for healthcare leaders to prioritize for such a push, including:

  • Advancing information management and information governance in healthcare
  • Implementing health IT standards for records management and evidentiary support
  • Working with the U.S. Department of Health & Human Services toward the establishment of contemporary requirements for medical records
  • Utilizing the knowledge of health information management professionals for the support of EHR deployment

"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 said in a statement.

Added Dougherty, "EHRs offer so much potential, but standards of practice haven't been adopted across all systems.  This can lead to clinicians checking off services they haven't performed or material being incorrectly copied and pasted."

Copying and pasting of EHR information is common among physicians, according to a study published last month in the journal Critical Care Medicine. According to the researchers, the notes of more than four-fifths (82 percent) of the residents and three-fourths (74 percent) of the attendings who participated in the research contained at least 20 percent of copied information.

To learn more:
- here's AHIMA's testimony (.pdf)
- read the accompanying announcement (.pdf)