Health Information Compliance Alert

Published on Wed Apr 21, 2010 PDF

An EHR can make your life easier, if your staff training is comprehensive.

Your electronic health record (EHR) may be helpful in filling in documents on your behalf -- but make sure it isn't filling in more than it should.

As most practices are aware, the American Recovery and Reinvestment Bill of 2009 offers annual bonuses to practices that show "meaningful use" of EHRs over a five year period starting in 2011. In 2015, practices that aren't meaningful users will face penalties.

As your practice gets its feet wet in adopting EHRs, keep these quick facts in mind to ensure that you aren't overstepping the EHR boundaries.

When you originally set up your EHR, your practice probably enabled the use of templates, which can be timesavers -- if your practice is trained properly on how to use them.

"Some electronic health records allow providers to bring portions of the chart notes over from a previous visit and into the current visit's notes," says Stephanie L.Fiedler, CPC, ACS-EM, director of revenue management with YAI in New York, N.Y.

This can be helpful when you're revisiting issues such as the patient's family history, which often won't change from one visit to the next. However, other issues should not be carried over to subsequent visits.

For instance: "If a patient is presenting for a follow-up to a recent visit where he had bronchitis and the physician carries over information from the previous visit, the current HPI might be checked off to say that the patient has a severe cough or the ROS may say the patient has a fever," Fiedler says. "But then if he indicates later on in the note that the patient's bronchitis is resolved, he has just contradicted himself with the HPI or ROS that he carried over from the prior visit."

To make sure you don't fall into this trap, ensure that your EHR doesn't automatically carry over information. Instead, have it prompt the physician and ask whether he wants to bring the information into the current record, and then train the doctor on which data should be carried over.

"I've seen a lot of contradictory information in followup chart notes for this reason," Fiedler says. "If you don't train the doctor on how the system functions and what to look for, or if the doctor is allowed to not pay attention, they'll get busy and the EHR documentation of the visit will be contradictory and look inappropriate to coding properly and on review you end up looking disorganized."

Before you can qualify for CMS's EHR bonus incentives, you'll have to ensure that you're using a certified EHR system that qualifies under CMS's "meaningful use" definition. This leaves many practices in a quandary,because they want to start using EHRs, but don't know which products CMS will ultimately certify.

If you have already purchased an EHR system, don't panic. "Any product that doesn't qualify today has time to come around and improve," says Karla M. Westerfield, COPM, business manager with Southeast Wyoming Ear, Nose and Throat Clinic in Cheyenne, Wyo.

If you're browsing for an EHR system, keep meaningful use issues at top of mind. "These are important questions to ask any vendor," Westerfield suggests: "How do you plan to achieve the meaningful use criteria as those goals mature?

Are you willing to guarantee you will meet the criteria?"

If the EHR vendor can't answer the questions, seek one that can.