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Unexpected Consequences: AHIMA’s 2011 LEHR Session
Sandra Nunn, MA, RHIA, CHP

Saving the best for last, AHIMA’s annual Legal EHR Summit on August 15-16, came to a close with a very lively panel discussion: “Unexpected Consequences and the Impact on Data Integrity.” The all-star session, moderated by Ross Koppel, PhD, a professor in the sociology department and the Center for Clinical Epidemiology and Biostatistics in the School of Medicine at the University of Pennsylvania, featured physicians and lawyers from prominent (Geisinger) healthcare systems. While endorsing the need for EHRs, the panel exposed the troubling unexpected negative impact on data integrity that EHRs have had through neglect for proper care in building in data-entry methods that would ensure a better, more accurate portrayal of the patient.

In addition, these professionals discussed the lack of training and pay for front-end staff such as those involved in patient registration and maintaining master patient indices. Consequently, patient demographic information is constantly compromised which, in turn, compromises patient care.

Barbara Drury, FHIMSS, president of Pricare Inc, gave the closing keynote address with a complementary topic: “Shotgun Weddings in Under-Resourced Provider Settings: Implications of the Rush to Adopt EHRs.” She discussed how the push from the government and other forces to rush small providers into EHRs is creating perilous settings for patient care since many small providers do not have the time or the money to perform the thorough research required to acquire a sound EHR. In addition, many small physicians and other types of clinicians do not have the kind of high-end staff capable of ensuring that high-integrity information is collected and maintained.

Participants got a wide spectrum of exposure to the latest legal challenges they will be facing with EHR implementation from a panel of experts on cloud computing to a thorough discussion of the potential impact of proposed federal rule changes to the Accounting of Disclosures (AOD) section of HIPAA. Kelly McLendon, RHIA, CHPS, president of Health Information Xperts, LLC, outlined the present AOD and compared it to the proposed Accounting of Access that may be an added report healthcare providers willneed to make available to patients. The enormity of the cost and complexity of this prospect was not lost on the audience.

The importance of data integrity was an underlying theme in all of the other sessions. While the healthcare community is consumed with the race to implement EHRs and gain governmental incentives under the first meaningful use provisions, many providers are paying little attention to the second stage of meaningful use that will require interoperability. John W. Orth, CDIA+, and Claudia Egan, JD, reviewed Wisconsin’s effort to arrive at a health information exchange (HIE) and the significant challenges involved in the proposition. They told attendees that the requirement to “exchange and integrate electronic health information with and from other sources” implies common data standards and a high level of data integrity in order for all participants in the HIE to have confidence in the information being shared.

The conference was probably a little too heavy on HIE presentations. Judging from the basic concerns of the attendees, HIEs are probably in the distant future for their organizations and for small providers, and may not be applicable for years.

Closer to the concerns of the audience was a presentation by Paul R. DeMuro, JD, MBA, CPA, partner of Latham & Watkins, LLP  In “Accountable Care, A Survey of Legal Issues in the Context of New Technologies and Biomedical Informatics,” DeMuro made a compelling case for switching to value-based purchasing of EHRs. In other words, looking for EHRs based on their ability to generate qualitative vs. quantitative data, a characteristic that would help providers examine the effectiveness of preventing and/or treating diseases such as diabetes. He reviewed the idea behind patient safety organizations and the need to build EHRs to enhance patient safety rather than the current focus on revenue cycle types of information (ie, how many patients with which diagnosis for what cost or profit).

On the opposite side of the slate, Adam H. Greene, JD, MPH, partner of Davis Wright Tremaine LLP, and formerly of Health and Human Services, discussed the nonclinical uses of the health record, explaining that it is more and more the electronic business record of healthcare entities that must increasingly pay attention to the integrity of its content. He moved the EHR through a continuum, seeing the future as an HIE that will eventually evolve into a “learning health system.” Touching on who actually owns this newer, larger health record, Greene gave a review of all the federal agencies, including the Office of the National Coordinator for Health Information, the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, and the National Institute for Standards and Technology, eager to tap into this information.

Greene pointed out the weakness of EHRs in behavioral health medicine, noting that in this niche the information will become part of the larger, more shared EHR of the future. He stated that without sufficient care in the structure of EHRs, the exposure of sensitive patient information may have a “chilling effect” on their further development.

Rounding out what turned out to be an exciting and informative meeting, other speakers focused on the increasing importance of having a more universal standard for patient identifiers and on the need to stress the identifier’s integrity as a ground for all HIE. Some sessions outlined the changes to release of information and how much more complex this once-routine process has become.

In the closing panel session, Scott A. Monteith, MD, FAPA, a physician and medical informaticist for Behavioral Medicine Associates, PLLC, spoke of the number of “paper shadow records” and “work arounds” resulting from the inadequacy of EHRs and told the audience that his organization has a weekly meeting (2 to 2.5 hours) to review release of patient information due to the complex hybrid environment (paper/electronic). One of the hidden icebergs in the EHR ocean may be the failure of those in charge of HIM departments to provide sufficient guidance in the new murky release waters of today. Just like patient registration, HIM may need more highly trained and educated release of information staff.

In short, no one left this valuable conference without considerable food for thought.

— Sandra Nunn, MA, RHIA, CHP, is a contributing editor at For The Record and the enterprise content and information manager at Presbyterian Healthcare Services in Albuquerque, N.M.