Maintaining Documentation Integrity in Electronic Health Records: Information Governance and Patient Identification
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Some weeks ago, Jane began suffering debilitating headaches, shortness of breath, nosebleeds, and heart palpitations. As these symptoms grew unbearable, Jane sought out a doctor at the local family healthcare facility. Note, Jane has attended this facility for nearly five years.
Upon her doctor’s arrival into the examination room, he opened the facility’s electronic health record (EHR) system to review Jane’s history. The doctor noticed that Jane’s EHR looked sparse, but as the doctor had never met Jane previously, he assumed Jane was new to this particular healthcare facility. The doctor ultimately diagnosed Jane with hypertension and administered medication to her. However, Jane experienced a severe allergic reaction to the medication the following day, for which she was kept in inpatient for a night.
In the end, it was discovered that the hospital was known to have a faulty EHR system, and that the facility had duplicated her profile. This duplication resulted in Jane’s information and original medical information being erased. Thus, the doctor accidentally administered a medication that the original record noted contained an active ingredient to which Jane was severely allergic.
Jane is now considerably ill, with two large medical bills to pay.
EHR Background
With the development of automated medical technologies, the usage of electronic health record systems is on the rise. EHR systems’ features can certainly improve the standard of care, as they enhance data documentation and communication between healthcare professionals. However, the unregulated use of these features can result in issues ranging from unmerited up-charges to deaths.
For this reason, it is imperative that hospitals and the healthcare professionals within them maintain documentation integrity. Documentation integrity is defined as the practice of appropriately inputting or fixing defaulted data, and rectifying information in instances of fraud, to ensure the validity and actionability of a patient’s notes. Notably, documentation integrity can be jeopardized if errors exist in its primary components of information governance, patient identification, record amendments, authorship validation, and documentation validity.. Thus, as this series progresses, we will accomplish the following:
System Errors
Given the complexity of documentation integrity’s components, they may be better understood when split into two branches — system error and human negligence. Hence, this section will review the facets of documentation integrity that constitute system error. System errors occur when EHR systems’ automated features disallow accurate information entry or inaccurately fill-in information. More specifically, this type of error can impact information governance and patient identification.
Information Governance
Information governance, as described by the American Health Information Management Association, is “the accountability framework and decision rights to achieve EIM.” EIM, or enterprise information management, is the infrastructure that verifies the reliability and practicability of a patient’s information. Thus, information governance and documentation integrity by association can be harmed by template documentation obstacles, cloning (copy-pasting), and dictation errors. Specifically, template documentation challenges increase errors in EHRs, as some EHR systems’ templates are unsuitable for specific medical problems such as long-term illnesses. Then, cloning compromises information governance when EHR systems’ present the following options for medical professionals to choose: “make me the author,” “demo recall,” “copy and paste,” and “smart phrases” inaccurately document patient notes. Finally, dictation errors that violate information governance arise in EHR systems that include voice recognition tools but lack identity verification procedures. For example, Jane’s doctor may have mispronounced Jane’s last name which resulted in her profile never appearing. Hence, there are a few reasons why system errors may result in a fault in information governance. In addition, system errors can lead to an inability to effectively and efficiently identify a patient.
Patient Identification
Patient identification is regarded as the process of verifying that patient notes have been assigned to the correct patient to ensure that a patient will be treated under the correct, actionable body of information. To that extent, patient identification also entails maintaining patients’ privacy, protected by HIPAA. Poorly-programmed EHR systems have high patient misidentification rates that compromise documentation integrity because their faulty automated codes typically duplicate patient records within their hospitals’ electronic indices or link demographic information to the wrong patients.
Human-Driven Behavior
Shifting gears, EHR record amendments and authorship validation form the human negligence-based branch of documentation integrity.
Amendments
According to AHIMA’s “Amendments in the Electronic Health Record,” EHR systems must allow, and record, “addendums, corrections, deletions, and patient amendments” in EHRs. Additionally, systems must also have a protocol in place that can control details regarding amendments — when they need to be executed, what requires amending, and who can make amendments. The functionality of such features is to mitigate the issues of healthcare fraud and healthcare abuse. Specifically, healthcare fraud is defined by AHIMA as, “intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, to the entity or to some other party.” Then, healthcare abuse is regarded as any incidents or practices which do not fall under the accepted medical or business practices, and can result in unnecessary consequences to patients.
Authorship Validation
Authorship validation describes the act of attributing an entry of patient information to an individual or entity, along with the time at which the entry was made. Authorship validation is especially crucial to medical practices, as multiple contributors exist, and verifying the origin of a unit of information is crucial to achieving documentation integrity. Thus, authorship validation can be achieved through maintaining audit trails that list users’ names, the applications used to edit a patient’s notes, a description of the edit that was made, and timestamps for edits. The importance of audit trails to authorship validation lies in the fact that audit trails can prevent misinformation from being spread, fraud, or abuse.
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