Motivated by improved efficiencies and monetary incentives, healthcare is migrating to electronic health records. While this solves the issue of physicians' sloppy handwriting on paper, and creates a host of opportunities for the digitized data, it is creating a new set of challenges.
Experts are examining what doctors are entering into the EHRs, what they meant to enter, and how the information is translated. What they are finding is that plenty of mistakes are making their way into the clinical documentation process, never mind outright abuses.
"Accuracy and the quality of clinical documentation is an issue," Michelle Dougherty, MA, RHIA, CHP, director of research and development for the Chicago-based American Health Information Management Association, told me. "There's a concern about significantly compromised information captured in the EHRs. There's a lot of redundancy in the process." AHIMA represents 67,000 health information management professionals.
"As more and more organizations have only electronic medical records, how they were created and maintained is coming into question," Dougherty says. "There has to be an infrastructure that shows how the information is handled through the lifecycle of the records, that there was proper authentication, and that it was preserved without alteration." Assurances need to be built into the process to track the authenticity of authorship for any notes entered in documentation.
I spoke with Dougherty recently in the wake of her testimony this month before the HIT Policy Committee's Meaningful Use Workgroup and Certification and Adoption Workgroup, which held a hearing on Stage 3 issues in Virginia. The Health HIT Policy committee makes recommendations to the National Coordinator for Health HIT on a policy framework for the development and adoption of a nationwide health information infrastructure.