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Best Practices to Modify Electronic Health Records While Maintaining Record Integrity

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Copyright 2018
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Gain peace of mind that your organization has the right practices in place to ensure the integrity of medical records even if they must be amended.The HITECH Act of 2009 offered financial rewards to encourage the widespread adoption of electronic health records (EHRs). To further encourage acquisition of a particular EHR system, vendors had incorporated convenience features, such as cloning and auto-fill. Some vendors touted that certain convenience features ensured compliance with documentation standards to support higher reimbursement. In 2015, the HHS Office of Inspector General (OIG) reported that EHR convenience features were jeopardizing patient record integrity and leading to fraudulent claims for higher reimbursement. Several additional studies in 2017 continued to highlight these risks as well as patient safety concerns. This topic will help health information management (HIM), compliance and legal professionals recognize and address EHR integrity issues that place patients and providers at risk. The material will explain best practices to reduce these risks. You will also learn about recommendations made by the American Medical Association and the National Institutes of Standards & Technology (NIST). Failing to have adequate EHR documentation policies and procedures along with user training could contribute to patient harm and lead to hefty fines and penalties under specific laws. This information is critical to an effective compliance program.


Margaret Young Levi, Wyatt Tarrant & Combs LLP Kathie M. McDonald-McClure, Wyatt Tarrant & Combs LLP

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