EHRs were a hot topic at the 88th annual American Health Information Management Association’s (AHIMA) conference held October 16-19 in Baltimore, MD. Various sessions addressed ways in which health information management professionals working in physician practices and hospitals can help mitigate risk, engage patients, and develop best practices.
Copy and paste/cloned documentation—and its effect on data integrity and clinical care—were mentioned frequently.
Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, independent coding and reimbursement consultant, said auditors increasingly review multiple records for the same patient over time—making it easy to spot documentation that’s repeatedly cloned. This also makes it easy for auditors to question whether appropriate codes were assigned.
Physicians should preface historical information copied from one note to another with a sentence such as, ‘I copied this for historical and continuity of care purposes to show the patient’s trajectory,’ said Sandy Giangreco, RHIT, CCS, CCS-P, RCC, CPC, COC, CPC-I, COBGC, coding compliance audit senior manager at CHAN Healthcare. This helps coders identify what information is relevant for coding-purposes, and it indicates to auditors that a physician reviewed the copied information and is including it for a specific purpose.
Christine Lee, MHA, RHIA, CCS, CPC, manager at Provider Practice Audit Services, reiterated the importance of capturing ICD-10 specificity and risk-adjustment. She said copy-and-paste functionality, smart text, and poor typing all potentially jeopardize data integrity and could even affect performance under MACRA. She said providers need to read their documentation before finalizing it. Does the documentation make sense, and does it tell the patient’s story completely and accurately?
Also, beware of templates, said Giangreco. They may help save physicians time, but are they personalized for each complaint and/or diagnosis?
EHRs and Patient Engagement
Patient portals were the focus of a presentation given by Michelle Basco, RHIA, training consultant at Children’s Health System of Texas. Basco talked about the importance of patient engagement at every level of an organization or physician practice. Providers need to identify what information patients want or request most frequently, and then use that as a ‘selling point’ for the portal. Portal sign-ups and education should ideally be embedded into the registration process, she added.
Unanswered Questions Remain
As providers continue to venture into the world of EHRs, they’ll need to address a variety of questions internally and from patients.
ONC Chief Medical Information Officer Andrew Gettinger, MD, touched on the importance of harvesting digital dividends from the EHR. How are providers using the technology and other data-driven solutions to solve problems? And how can these ‘lessons learned’ be shared to develop best practices?
Gettinger said the use of EHRs continues to raise questions for which there are no clear answers, such as:
- How can providers and vendors address data segmentation for privacy purposes? And what role do patients play? Patients don’t always understand how restrictions on data sharing can potentially affect clinical care, he said.
- Will providers ultimately integrate patient-generated data into the EHR? If so, how can this data be authenticated? And how will providers handle a potential tsunami of information?
- How are providers handling record retention? This is somewhat uncharted territory in the age of EHRs during which providers frequently switch vendors and/or upgrade to new systems, said Gettinger.
The ONC is working to provide additional resources for providers. Gettinger mentioned the recent ONC publication of a new guide titled EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print to help providers select and negotiate the acquisition of an EHR system.
Other speakers touched on these unanswered questions as well.
During a panel discussion about future healthcare trends, Susan Turney, MD, MS, FACMPE, FACP, CEO of Marshfield Clinic Health System said physicians need more information at the point of care. How can this information be integrated into the EHR and presented in a way that is useful for the provider?
Physicians need access to a 360-degree view of each patient, said co-panelist Robin Wiener, president and founding partner at Get Real Health. This requires building application programming interfaces (API) between medical devices/fitness wearables and the EHR. It also requires patient consent to share this information.
Co-panelist Jennifer Covich Bordenick, CEO of eHealth Initiative, reminded attendees than an EHR implementation is not a one-and-done event. How can providers change their mindset so that innovation remains at the forefront?
“It’s just about just getting your EHR in place. It’s about linking with other partners,” she added.
Watch for more posts in our series of updates from AHIMA.