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.
While the government is starting to think about Stage 3, it hasn't yet begun Stage 2 of Meaningful Use, which starts next year. And although Stage 3 will not go into effect until 2016, the government has already released preliminary recommendations for its requirements. The HITECH portion of the American Recovery and Reinvestment Act (ARRA) of 2009 specifically mandates that incentives should be given to Medicare and Medicaid providers not for EHR adoption, but for "meaningful use" of EHRs.
In July of 2010 and August 2012, HHS released that program's final rule defining Stage 1 and Stage 2 Meaningful Use. The government states it is "strongly signaling" that that the bar for what constitutes Meaningful Use would be raised in subsequent stages in order to improve advanced care processes and health outcomes.
While EHR use is increasing dramatically, there are many flaws that must be overcome, especially, day-to-day sloppiness in use of records. Doctors and other providers are "cutting and pasting" information haphazardly to improve EHR efficiency, but their quick actions are likely to be detrimental to overall recordkeeping and patient care in the long run.
In addition, physicians are using dictation tools that are eliminating the traditional "editing" process of their work, which results in errors, Dougherty says.
Dougherty wasn't alone in her concerns about the EHRs among those who testified before the HIT committee. "All too often a patient's medical information is inconsistently stored—many times in multiple locations, within disparate systems that are not interoperable," Rosemary Kennedy, PhD, MBA, RN, FAAN, VP for health information technology, the National Quality Forum, told the committee.
Some day-to-day miscues are troubling. But large and significant alleged abuses related to EHRs are even more so. Dougherty referred to a report by Center for Public Integrity that found "thousands of doctors and other medical professionals have steadily billed higher rates" for treating older patients on Medicare in the past decade.
Those medical billing abuses were linked to improper use of EHR, Dougherty says. At least $11 billion or more were added to physicians' fees, according to the Center for Public Integrity.
"The Obama administration is forging ahead with a multi-billion dollar plan to shift from paper to electronic medical records, despite continuing concerns the program may be prompting some doctors and hospitals to improperly bill higher fees to Medicare," the center concluded.
The HIT committee's hearings are part of the government's effort to evaluate EHR issues, Dougherty says.
Dougherty told the Committee in a statement that there is inadequate attention being paid to the integrity of clinical documentation in EHR that could compromise the usefulness of records for patient care and quality reporting as well as business, compliance and legal issues.
"EHRs offer so much potential, but standards of practice haven't been adopted across all systems," Dougherty said in her statement. "Sometimes when a full medical record is needed, EHRs produce information that is redundant, difficult to read and not comprehensive."
Often, the problems have nothing to do with the evolving technology, but simply the process used by physicians and other healthcare providers in their utilization of EHRs. For instance, documentation produced by cutting and pasting information from previous patient visits "continues to be a significant problem" that creates "unnecessary redundancy and at times inaccurate information," Dougherty says.
"This can lead to clinicians checking off services they haven't performed or material being incorrectly copied and pasted," she told the committee. "If clinical documentation was wrong when it was used for billing or legal purposes, it was wrong when it was used by another clinician, researcher, public health authority or quality reporting agency."
Dougherty calls the improperly copied information as "cloned" material. That could include social, medical and family histories; visit/clinic notes, inpatient progress notes, consults, vital signs and reviews of physical exams. "We may need records [from] two years ago, but we need to know these records actually [reflect] what happened then and haven't been modified over time because of system updates," she told me.
Ivy Baer, senior director, regulatory and policy group at the Association of American Medical Colleges also expressed concerns about how the written record is being used in EMRs in testimony before the HIT committee. The AAMC represents all 141 accredited US and 17 accredited Canadian medical schools as well as 400 major teaching hospitals and health systems.
"Unlike a note written on paper, a note written in an EHR can be generated by using information that already has been recorded elsewhere," Baer told the committee. "The result can be a note that appears to be new and contemporaneous but actually is a combination of pre-existing material. Incorporating information that is not original to the author onto a note has the potential to jeopardize patient care and expose providers and/or institutions to liability."
Software advances and dictation tools also can lead to problems, Dougherty says.
Some software enables doctors, with a single mouse click, to check a box indicating that all body systems were examined and found to be normal, even if that isn't the case, she says. And the dictation tools force physicians into the role of an editor—a self-editor.
Transcribed reports are often the most frequently used and exchanged medical record documentation, according to Dougherty. AHIMA members report that errors in all voice recognition dictated reports include incorrect diagnoses, age and other demographic information or facility name, she says.
"We're hearing that this dictation is forcing physicians into an editor role and is resulting in many errors," Dougherty says. "In the old method, they used to hire transcriptionists, dictate it and then provide the review. What is lost now is any type of editor."
The comments illustrate that as the government moves through its stages of Meaningful Use, the picture of EHRs is still blurry and must be resolved to ensure proper patient care and monetary rewards that are tied to quality.
"The importance of accurate information and documentation in EHR systems cannot be overstated," Dougherty stated.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
