Inadequate attention to the quality and integrity of clinical documentation could compromise electronic health records use for patient care, care coordination, quality reporting, business, compliance and legal purposes, according to the American Health Information Management Association.
That’s the message AHIMA brought to an HIT Policy Committee hearing on Feb. 13 on clinical documentation issues. Michelle Doughty, director of research and development at AHIMA, laid out three core challenges with clinical documentation and record management in EHRs:
* Meeting business requirements such as determining what constitutes the official record of care, the types of information that can be requested and disclosed, and how requirements for a medical record apply to an EHR. “It is difficult to produce a complete and comprehensive record of care from EHRs,” she noted.
* Record keeping and evidentiary requirements for EHRs are not well understood by developers and users. “EHR systems must include functionality that supports a legally-sound record producing current and historical records for evidentiary purposes.”
* Data quality and information integrity must be prioritized. “If clinical documentation was inaccurate when used for billing or legal purposes, it was wrong when it was used by another clinician, another provider at transition, a researcher, the public health authority, or quality reporting agency.”
Consequently, AHIMA offers the following recommendations:
* Advance information management and information governance in health care,
* Implement health information technology standards for records management and evidentiary support,
* Work with HHS to reevaluate regulations and policies related to medical records to establish consistent and contemporary requirements, and
* Utilize the expertise of health information management professionals to advance EHRs.
AHIMA’s complete testimony is available here.
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