AHIMA to ONC: Better clinical documentation needed to ensure EHRs' efficacy

"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,
By Mike Miliard
10:24 AM

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.

[See also: Brainstorming About the Future of Clinical Documentation.]

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:

  • Advance information management and governance in healthcare, ensuring that 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.

Health information management 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," said AHIMA CEO Lynne Thomas Gordon in a statement.

AHIMA's full testimony before the HIT Policy Committee's Meaningful Use Workgroup and Certification and Adoption Workgroup can be found here (PDF).

[See also: AHIMA calls for improved health IT governance]