There is an emerging need not just to have an oversight process for information systems, but a governance structure to ensure regulatory compliance and the quality of information, Michelle Dougherty, director of research and development at the AHIMA Foundation, tells Health Data Management. The organization is working to bring together industry stakeholders to discuss data integrity issues during its Health Information Integrity Summit, scheduled for Nov. 8-9 in Chicago.
AHIMA’s call for governance comes at a time when the Department of Health and Human Services is warning providers about “gaming” the billing process by upcoding treatment using EHR documentation. The American Hospital Association has fired back, reminding HHS that the industry has been asking for evaluation and management coding guidelines since 2003.
Many hospitals have embarked on clinical documentation improvement initiatives as technology now is available to support such efforts, Dougherty says, but no guidelines exist on what may be appropriate or inappropriate for EHR documentation from a payer’s point of view.
For instance, EHRs available today have check boxes for physicians reviewing the 14 body systems, such as heart, lungs, eyes, ears, etc. But the EHRs also may have a box that if checked will document review of all 14 systems. Doctors may check the “ALL” box thinking it helps them document more efficiently, even if they only reviewed four body systems, not knowing indiscriminate use of the box could be a compliance risk. Consequently, there is a need to standardize certain EHR functions, Dougherty says.
The need also exists to determine if certain functions should not be in an EHR, she explains. For instance, some EHRs have a “make me the author” feature that can change the authorship on documentation. Dr. A writes a progress note, but Dr. B wants to add to the note, so he copies what Dr. A wrote then adds more, but now the system identifies Dr. B as the author.
So, one of the goals of the proposed governance structure is to examine the feasibility of identifying an initial set of EHR functions that support data integrity, and could become part of Stage 3 meaningful use EHR functionality.
This story originally appeared at Health Data Management.
Joseph Goedert is news editor at Health Data Management.
