AHIMA endorses guiding principles for patient documentation

The American Health Information Management Association (AHIMA) kicked off its annual convention and exhibit Oct.1 in Chicago with a call for improved and unified health information governance to standardize electronic health record (EHR) use.

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AHIMA officials announced that they are ready to work with providers, health plans, quality organizations and vendors as well as the Department of Health & Human Services (HHS) to establish clear principles to guide patient documentation.

Aspects of health information governance will be addressed throughout AHIMA’s meeting this week. Additionally, AHIMA will bring together industry leaders to discuss data integrity at its Health Information Integrity Summit: The Quest for Safe, Usable, Quality Data in EHRs, Nov. 8-9, in Chicago.

“Unified data governance principles will help promote accuracy and consistency and reduce ambiguity,” said AHIMA CEO Lynne Thomas Gordon. “AHIMA stands ready to work with HHS, the Centers for Medicare & Medicaid Services and other groups to establish the guidelines that will accurately and fairly represent performance and outcomes of care. Data governance and data integrity have been and will be a critical part of AHIMA’s strategic plan, and we will continue to lead the discussions and the solutions developed in this field.”

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Since 2003, AHIMA has urged federal regulators to adopt a national set of coding guidelines for hospital reporting of emergency department and clinic visits.

Recent concerns that EHR implementation could lead to fraud further highlights the need to establish standards that address data integrity, patient safety, quality measurement as well as traditional concerns regarding billing fraud, AHIMA officials said.

In 2005, the AHIMA Foundation led the initiative to develop a report for the Office of the National Coordinator for Health Information Technology that provided recommendations on what the industry must do to prevent potential abuses in EHR documentation.

“We urge the government to truly investigate the depth of the recently reported problems so we can determine the scope of the issue and take steps to fix it,” said Thomas Gordon. “We will continue to ask our members to share the experiences they have with us so we can develop possible solutions.”

AHIMA officials said they will analyze the latest feedback from its members as well as the findings from the AHIMA summit and expects to provide additional recommendations in early 2013. [See also: EHRs, correct data can up the ante on proper antibiotic prescribing]

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