AHIMA Pushes for More Focus on Clinical Documentation in EHRs

At a Health IT Policy Committee hearing on Wednesday, the American Health Information Management Association warned that inadequate focus on clinical documentation could compromise the use of electronic health records, Health Data Management reports (Goedert, Health Data Management, 2/13).

Challenges

Michelle Dougherty, director of research and development at the association, told the committee that there are three main challenges to clinical documentation and record management in EHR systems:

• Meeting health care providers’ business requirements for patients’ record of care;
• Managing, preserving and disclosing health records; and
• Focusing on data quality, information integrity and documentation practices to achieve policy goals related to EHRs.

Dougherty said, “It’s crucial to address data quality and record integrity now before health information exchanges become widespread” (AHIMA release, 2/13).

Recommendations

AHIMA offered several recommendations for addressing clinical documentation in EHRs, including:

• Advancing health care information management and governance;
• Implementing health IT standards for record management and evidentiary support;
• Re-evaluating medical record regulations and policies to ensure consistent and contemporary requirements; and
• Tapping the expertise of health information management professionals to advance EHRs (Health Data Management, 2/13).