AHIMA News

Documentation Quality Discussed at AHIMA Conference

By Heather Hogstrom

AHIMA recently held its 88th Annual Convention and Exhibit in Baltimore, where integrity in EHRs was one of the themes. A session on compliance risks in the EHR by Sandy Giangreco, RHIT, CCS, PCS, CPC, CPC-H, CPC-I, COBGC, and Kim Garner Huey, MJ, CCS-P, CHC, CPC, PCS, CPCO, emphasized balancing medical necessity and meaningful use. They noted that bringing forward medical history in the EHR is an important aspect of meaningful use, but that doesn’t mean you can count that comprehensive history toward the level of service for every encounter. Misuse of the copy-and-paste function can lead to overcoding. Giangreco and Huey advised that you should only document what you did today, since you already got paid for work that is copied and pasted. They mentioned a need for copy-and-paste standards, including one that would address the ability to check how much of a document is plagiarized, suggesting the medical record contain a certain percentage of original information in order to be billable.

Cloned notes and template exams without patient-specific information don’t support medical necessity, they said. Auditors are checking the documentation for red flags such as medically implausible documentation, contradicting information, grammatical errors, and authentication (ie, signatures and dates). Lack of training may be contributing to these compliance issues. According to the speakers, physicians use copy and paste to save time because they haven’t been properly taught how to use the EMR.

Darice Grzybowski, MA, RHIA, FAHIMA, and Sandy Routhier, RHIA, CCS, CDIP, also discussed EHR documentation quality, citing a survey in which 60% of HIM respondents believed the EHR is worsening the quality of documentation. In “EHR Lessons Learned From the Wizard of Oz for HIM Professionals,” Grzybowski and Routhier used examples from the Wizard of Oz to discuss EHRs and compared “sick” records to flying monkeys, listing problems such as cut and paste, out-of-sequence and duplicative documentation, decreasing case mix, inadequate choices in templates, carryover of historical conditions and medications, conflicting documentation, poor grammar, and the inability to tell the patient’s story. HIM is getting less involved in EHR implementation, according to the speakers, who challenged attendees to step up in their role of legal custodians of the record, adding that HIM can help advance the solution. Much like Dorothy in Oz, HIM has had the answer all along, and the time to act is now for interoperability and integrity, they said. Tips for success include not isolating yourself or the HIM department; preventing, not just managing, problems; reporting EHR issues such as a quality indicator; and using automation to your advantage.

— Heather Hogstrom is an editorial assistant at For The Record.