Errors in the Record

Scott Mace, for HealthLeaders Media , December 13, 2013
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All these changes reflect a groundswell in modern U.S. healthcare toward much more transparency in everything providers do, Middleton says. "There's no point in resisting it. We need to be transparent in the services we deliver, in the cost of care we deliver, and the value, so that employer purchasers, patients, and everybody can make informed choices. Make sure you write your notes with the idea in mind that they will be public."

For that matter, consider that maintaining the quality of an electronic health record is an ongoing responsibility of the entire medical team, says Rachel Chebeleu, corporate director of professional fee abstraction at the 805-licensed-bed Hospital of the University of Pennsylvania in Philadelphia.

"You need people who are concurrently, proactively auditing your records for copy-and-paste issues, for copy-forward issues, and for just general compliance," Chebeleu says. Those tasks should not be relegated to billing specialists or coders but instead be assigned to staff who will audit records for their clinical quality, she adds.

"There might be some nurses who really know clinical content well, are not interested in being on the units anymore, and will just go through records and audit them, the important record-type entry stuff," Chebeleu says. The same audits can examine practice patterns, she says.

EHR audit productivity also needs to be overseen. "You don't want someone who gets so immersed in the record they are able to get through only two a day," Chebeleu says with a laugh. Penn Medicine, the system to which the Hospital of the University of Pennsylvania belongs, uses Allscripts' Sunrise Acute Care (formerly Sunrise Clinical Manager) as its EHR for inpatient computerized physician order entry and discharge summaries, and is now implementing physician notes starting with its rehabilitation facilities.

In its outpatient practices, Penn Medicine uses Epic EHR software, which in the next few years will replace Allscripts on the inpatient side, as well, Chebeleu says.

The governance challenge of achieving quality in EHRs is foremost in Chebeleu's thoughts. "Get the people who care about it" involved, she says. "Get risk management on board, your general counsel on board, your compliance department, your coders, even the quality people," she says. Find the necessary funding and tackle the problem proactively, she suggests.

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