SALT LAKE CITY -- Accuracy in medical records hinges upon understanding who entered what data, and when. Updating patient data occurs routinely, as clinicians struggle to get it right, and now federal policymakers are considering best practices for creating what they call “EHR addendums” to electronic health records.
New incentive programs tied to quality of care (such as ACOs) as well as the ICD-10 implementation will require physicians and nurses to add more specific documentation to patient records for compliance and reimbursement purposes. All of it is done with the understanding that more -- and more accurate -- data will lead to better quality of care in the U.S. health system, according to attendees of the AHIMA 2011 conference.
The drive for accuracy will also lead to more additions, corrections, and deletions of data in the patient record, said Lou Ann Wiedemann, AHIMA director of professional practice resources, in a presentation at the American Health Information Managers Association 83rd Convention and Exhibit.
Federal authorities are now looking at how best to manage edits in electronic records. EHRs must enable edits in a HIPAA compliant fashion -- meaning only authorized users have access to electronic personal health information as needed in the course of care -- to earn ONC certification. EHR certification criteria also require the ability to generate audit logs. The ONC Privacy & Security Tiger Team , a work team that helps create recommendations for health IT policy, is currently developing best-practice advice on editing EHRs, for which it has assigned the umbrella term "EHR addendums."
In paper medical records workflows, many hospitals had policies for additions or deletions to patient data that were followed to various degrees, employing things like white-out, colored text, underlined and strikethrough text. Sometimes, papers just disappeared from records as practitioners made changes, which often removed evidence of why a particular course of treatment was followed (i.e. decision-making might have been different before a practitioner corrected a problem in the chart). With EHR systems networking together to form health information exchanges (HIEs), that process just got a whole lot more complicated, especially considering EHR systems are not standardized and will display edits in different ways, if at all.
Hospitals whose HIM managers and IT staffs aren't developing policies for EHR addendums, Wiedemann told SearchHealthIT.com, "are jeopardizing the integrity of their health information. If you have an allergy to penicillin [mistakenly reported in the EHR] and it goes to the HIE, and you’re really allergic to darvocet and the HIE releases it to five other physicians, that incorrect information really jeopardizes the patient's care."
Train staff to be HIPAA compliant when making corrections
Non-HIPAA compliant practices might be occurring in a hospital's paper records workflow -- such as late entry of information weeks after patient care takes place, or clinicians ripping pages out of a chart and replacing them with corrected pages after they signed off on it -- unbeknownst to medical records staff. When a new EHR implementation exposes such problems, Wiedemann said, it's incumbent upon HIM managers to educate physicians and nurses about why they are wrong and show them how to do it in a more compliant way.
In the paper world, [addendums] happened all the time but we didn't know all of the time.
Lou Ann Wiedemann, director of professional practice resources, AHIMA
With their knowledge of the technology on the hospital network, IT staffers can help HIM managers set up policies and procedures for editing patient records. They know -- or can help figure out -- application feature sets to enable EHR addendums.
Since EHR systems are not standardized across the industry, they display text in different ways. New information might be shown in all caps, or in different colors or fonts, Wiedemann said. Some systems also have "draft modes," or features that suppress printing of certain information, which also can help prevent practitioners from using errant information. How your hospital handles such situations is left to you -- but establishing policies to prevent practitioners from altering the records after they've signed off on a chart is key to HIPAA compliance.
In addition, keep track of guidance in regards to best practices for EHR addendums, through associations like AHIMA as well as from the ONC. Wiedemann said that currently, ONC's advice is in draft form; she expects the privacy and security work team to issue updated guidance early next year. The point of the guidance will be to offer advice on standardized medical records editing across health care, so that each hospital doesn't have to develop its own program in an ad hoc manner.
"In the paper world, [addendums] happened all the time but we didn't know all of the time -- which is why it's become such a big issue," Wiedemann told SearchHealthIT.com. "I think that as hospitals implement EHRs now, it's a little more prominent." Based on anecdotal evidence, she guessed that maybe half of hospitals are working on formal EHR addendum policies in an ad hoc fashion -- but they all need to be working on them, or risk compliance problems.
Let us know what you think about the story; email Don Fluckinger, Features Writer.
This was first published in October 2011