Hey Health IT Emperor:
What’s That
You’re Wearing?
By Reed D. Gelzer, MD, MPH, CHCC
When it comes to the newest trends in electronic health records, ASC managers need to consider their options carefully. Otherwise, they may find that their state-of-the-art records are, like the clothing the famed emperor wore in the age-old Hans Christian Andersen tale, really “nothing at all.”
Something fascinating has happened with electronic health records (EHR). The new health information technology (HIT) fashion trends have brought forth a wave of new and old tailors eagerly championing their fall and winter EHR fashions for those adventurous sorts we call early adopters. These stalwart folks are being joined by a growing number of practices, ASCs and hospitals that are embracing these new tools to solve old problems. They are seeing their way clear to invest in these wonderful new informatics fabrics to improve our collective dress, our comfort and our confidence in the inevitability of our vision of better health care for tomorrow. We all recognize and enthusiastically embrace the many promises of digital records and the promises of what they will bring to health care. Solid evidence also suggests that health care improves when more timely and more comprehensive information is available on demand. There is a punch line though. As in the traditional Hans Christian Andersen tale about the emperor who wore no clothes, what if some substantial part of the value is, indeed, “in the eye of the beholder?” That question becomes even more important if the “beholder” is suffused with the beauty of the vision and not necessarily attentive to this basic question which is, in this case, Are these electronic health records in fact medical records? As with the emperor’s new clothes, what you see when you look at the new recordkeeping systems that are available can depend, in part, on your point of view. Style and fashion are perfectly acceptable priorities in some places and at some times, but not necessarily at ASCs examining new recordkeeping systems. Let’s look at the situation most
About the Author
Gelzer, is a co-founder of Advocates for Documentation Integrity and Compliance (ADIC), an education, advocacy and consulting company. He can be contacted at r.gelzer@snet.net.
The advice and opinions expressed in this article are solely those of the author and do not represent FASA policy or opinion in any way.
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ASCs and other health care providers are in—running a busy organization, trying to help people, and in the normal course of business simply trying to provide accessible, accurate, high-quality information to caregivers who need it when and where they need it. With this in mind, let us look at the general rules of health care information and avert our gaze from the HIT emperor for a moment to ask, What is a medical record? First, let’s ask someone who knows medical records rules, like a registered health information administrator or someone who works in health law. Fundamentally, a medical record is the rendering of all the things done in the name of a patient’s care into some form of documentation. Does the “form” that information takes matter? Yes it does. Usually, if you write something down on a piece of paper (or into a computer), it is just another bit of writing with no particular significance, utility or validity than perhaps your standard grocery list. Under our laws, however, those recorded notes achieve special status, as medically–legally valid business records, if those notes were made under defined circumstances and according to certain rules that we regularly live and breathe in the paper (non-electronic) world and, perhaps
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unknowingly, assume without recognizing just how critical they are. The rules, according to the article “Maintaining a Legally Sound Health Record (AHIMA Practice Brief ),” which appeared in a 2002 issue of the Journal of AHIMA (Vol. 73, No. 8) and can be found at http://library.ahima. org/xpedio/groups/public/docu ments/ahima/pub_bok1_ 014041.html, are as follows: The record was documented in the normal course of business (following normal routines). The record was kept in the regular course of business. The record was made at or near the time of the matter recorded. The record was made by a person within the business with knowledge of the acts, events, conditions, opinions or diagnoses appearing in it. Follow these rules and, voilà, your notes have now become acceptable as business records. We have certain ways of assuring that these rules have indeed been followed. In the paper world, some of the basics include that we write in non-erasable ink, we assign dates and, sometimes, times to the entries to show we recorded the information in a timely manner, and we make changes by identifying erroneous information that we leave readable and intact. We don’t do things like tear pages out of the medical chart or leave big empty spaces that invite backfilling later. The advantages of keeping records on computers have been recognized for some time, but imaginative people are always turning old and new tools to new uses that are both good and bad. That means we also have to have a means of assuring that the computerized record also adheres to the basic rules of business records. There are no Wite-Out® or erasure smudges on the computerized medical record to reveal an illegitimate fabrication, so we ask for proxies and adaptations of the key principles of authenticity and integrity instead. Rules of evidence then base their integrity on the veracity of these new tools by assessing things like the following (as described in the AHIMA Practice Brief mentioned earlier): the type of computer used and its acceptance as standard and efficient equipment the record’s method of operation the method and circumstances surrounding the preparation of the record, including the source of information on which it is based the procedures for entering information into and retrieving information from the computer the controls and checks used as well as the tests made to ensure the accuracy and reliability of the record the information has not been altered These are the well-established ground rules for computerized business records and represent the fundamental requirements for the validity and integrity of an electronic medical record. Seems pretty straightforward, right?
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Well, here is where we need to advance the gift of a little modesty and decorum by assuring ourselves, our peers and our neighbors that the emperor, while perhaps straying a bit into irrational exuberance over his new clothes, is nonetheless well intentioned and sincere. That said, he is, sadly, naked. How naked? Well, again it depends on how wide you care to open your eyes. For example, the article titled “The Search for the Elusive Electronic Medical Record System: Medical Liability, the Missing Factor,” which appeared in the Journal of Medical Systems in February 1997, states, “At a recent electronic medical records (EHR) conference, participants attending a software development workshop were asked if they had their systems reviewed from a medical–legal standpoint by a malpractice insurance carrier. In response to this inquiry, not one software vendor raised their hand to indicate this had been accomplished or even contemplated.” More recently, the functional standards development process of Health Level 7, a standard-setting organization that defines it mission as “providing standards for the exchange, management and integration of data that support clinical patient care and the management, delivery and evaluation of
Additional Resources
American Health Information Management Association web site: www.ahima.org. Amatayakul, Margret, et al. (1998). Comprehensive Guide to Electronic Health Records, New York: Faulkner and Grey, Inc. (Currently out of print but available in reference libraries.) Amatayakul, Margret, et al. (2001). Definition of the Health Record for Legal Purposes (AHIMA Practice Brief). Journal of AHIMA, 72(9), 88A-H. [Update pending in that journal in the 4th quarter of 2005. —Ed.] Certification Commission for Health Information Technology web site: www.my.cchit.org/ Health Level Seven (HL7) web site: www.hl7.org/ehr/ healthcare services,” has taken up the question of what are the key functional attributes of the legal EHR. Additionally, the American Health Information Management Association (AHIMA) has convened a working group to add to its already robust public library of policy briefs on guidance
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on the legal EHR. In these contexts, well-informed, conscientious people deeply involved in these issues as vendors, health information managers, transcriptionists, attorneys, practice consultants and providers wrestled over these questions, demonstrating that these matters are not a necessary component of every EHR’s design and that this omission still requires the due diligence of every purchaser and user. In the meantime, at the internationally known Medical Record Institute’s most recent Toward an Electronic Patient Record conference, a mock trial was conducted to rule on the validity of the EHR as a legal record. The jury verdict was that as a legal record, the EHR was not quite ready. (In honor of his host, the Medical Records Institute, the “judge” overturned the verdict.) Interestingly, in discussion after discussion, a common theme emerges: those who purchase EHR technology often fail to include a health information management expert in the selection process. Many are the laments of buyer’s remorse once an ASC’s compliance staff is allowed to see under the hood of the newly acquired EHR system. An ASC may be particularly subject to pressures from owner partners, particularly hospitals that want the ASC
to use the same system that they do. Physicians using the ASC may also seek a system similar to the one they use in their offices or local hospitals. Well-meaning people may vouch for others’ EHR technology, but buyers must perform their own due diligence since EHR providers rarely screen their own systems for even basic medical–legal compliance. With the wealth of EHR vendors out there, requiring, at the least, that the purveyors of those systems attest to their ability to meet the standard requirements of normal business records and, at best, that they comply with the regulations that govern your state’s medical record, will actually help you speed your ASC’s selection process by requiring real cloth only. While no provider can guarantee that everyone will use its system correctly, it must at least support the ability to distinguish a legal record from one that, for example, can be easily falsified or altered after the fact. To illustrate that point, consider that several systems can demonstrate that an entry was changed but cannot demonstrate whether that change was a simple repair of a spelling error or the rewrite of an entire note. A plaintiff ’s attorney is not likely to choose the more generous possibility of those two choices.
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Hey Health IT Emperor: What’s That You’re Wearing? continued from page 24
We may all lament the absence of specific standards for EHRs and eagerly await their arrival, but their arrival may be facing challenges of its own. In the first public release of draft standards issued for public comment by the Certification Commission for Health Information Technology, the audit requirement was considered of only “medium” importance and the attached comments provided by the organization’s Functional Committee say it expects many users would turn the audit functions off anyway. This suggests a period of adjustment will be needed before the typical electronic record will robustly embrace the evidentiary requirements of computerized business records that are already well established outside this field. Fortunately, evaluations of existing products do show that some EHR designers have paid close attention to these matters, and many in the industry are looking forward to the day when these conscientiously designed, actual e-medical records achieve their appropriate recognition in the marketplace. That is to say, when people stop buying medically–legally “invisible” IT fabric to fit their organization’s needs, this technology will begin to prove truly important. In due time, industry insiders expect that the naked will become increasingly apparent. In the meantime, they are strongly encouraging everyone to include input from their health information managers in their requests for information and product evaluations. Smaller organizations that don’t have health information managers on staff are encouraged to include questions that can be constructed from reviewing publicly available health information management documents such as the AHIMA Practice Brief “Maintaining a Legally Sound Medical Record” cited above. More specifically: 1. Three elements are critical to EHR implementation success—planning, project management and leadership. In planning your facility’s EHR project, and in evaluating products, make sure you have your medical records leadership and compliance officer involved from Day 1. (If your ASC does not have trained health information management specialists on staff, contact the AHIMA web site provided in the box on page 23 and search for “Component State Associations” to find assistance in your region.) 2. Provide all participating decision makers with access to information on basic medical records principles and risk mitigation to help orient all to computerized business records’ requirements. Much can be found in the publicly accessible AHIMA web site and its “Practice Briefs” such as the ones referenced in this article. 3. Do not choose your EHR system with disproportionate weight placed on other facilities’ choices. Remember, at your ASC, the due diligence responsibilities and duties
are yours alone. Furthermore, older systems that have been deployed longer may be less likely to have exercised due care in incorporating health information management principles in their design. 4. If you buy a system, know how to use it right, and train all users to use it right. Even the best-designed system, if misused, can degrade the integrity of your medical records. 5. Medical records requirements vary state to state, so make sure you (and your vendor) know yours, as well as the requirements from relevant certifying and oversight entities. 6. Caveat emptor [Let the buyer beware]. As always, read all contracts closely and know what you are buying, including the system’s ability to meet your ASC’s requirements as a legal record. When medical records are involved, don’t be caught naked. Make sure your ASC’s EHR program produces records that qualify as legal medical records in all of the critical roles that medical records play within your business and clinical operations. Consider briefly the impact on your ASC and its staff if your records system cannot support the basic requirements of medical records: Your ability to meet the challenges of external auditing by payers is degraded, possibly putting you at risk of accusations of fraud. Your ability to present a malpractice defense is degraded, which puts you at risk of higher litigation costs and losses. Your tools to evidence your ASC’s administrative due diligence duties may place your directors and officers at a liability risk. Your ASC’s accreditation may be endangered by a system that cannot support fundamental requirements such as the following, which are cited in the 2005 handbook of the Accreditation Association for Ambulatory Health Care: “protect(ion) from loss, tampering, alteration, destruction or inadvertent disclosure” [show that] “Reports, histories and physicals, progress notes…are reviewed and incorporated into the record in a timely manner” [allow unimpeachable proof of ] “authentication and verification of contents by health care professionals” Clearly, all of these matters merit the fullest attention of every ASC and your professional peers. The role of entities such as FASA that are advocating for more specific standards on these matters will become increasingly important. Please support FASA’s continuing work to investigate and illuminate these topics on your behalf.
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