Part B Insider (Multispecialty) Coding Alert

Most EHR systems don't let you track who made changes

The most common electronic health records (EHR) systems fail to provide a good audit trail that would allow you to figure out who changed what.

Problems: Many EHR systems allow "canned" documentation that a provider cuts and pastes from a previous visit or a template, according to a study of roughly 30 products by consultants Pati Trites and Reed Geltzer with Advocates for Documentation Integrity and Compliance in Augusta, MI. And with many systems, you can't even find a record showing that the provider used "canned" documentation at all.

Many systems don't show which provider made a change to a record, and when. On paper, it's easy to tell if someone scribbled on a chart or used liquid paper to erase something. But there's no liquid paper on a computer screen, explains Trites.

Other systems will allow you to send a record to billing even though it may be missing vital documentation, says Trites. "That happens in the paper world every day, but this is supposed to be a better way," she says. If you automate a bad system, it just allows you to go wrong faster, she notes.

Potential solutions: Since Trites and Geltzer started studying EHR products three years ago, many vendors have started making improvements. They're re-testing the major systems, and so far they've found some improvements. One major system just removed the ability to plug in "default" documentation, she reports.

Trites and Geltzer are working with some Quality Improvement Organizations (QIOs) and vendors to compare the vendors' products to their standards.

Legal nightmares: The real problem with many EHR products is that they wouldn't stand up to the civil rules of evidence in court, warns Trites. "These records aren't going to hold up in a civil proceeding," because you can't tell who altered them and on what date, she warns.

Bad practices: In one doctor's office, a nurse routinely filled out documentation before the doctor arrived for the day--and before the patients had actually come in. Afterward, the doctor would sign off on the documentation, which was all "cloned" from previous records, says Trites.

Mixed bag: Some systems will allow a good "audit trail," but still allow "cloned" documentation, warns Trites.

Good example: If you change a record, the IT system at Central Utah Multi-Specialty Clinic draws a line through the old wording and adds the date and time of the change, according to IT Director Jamie Steck. "If you're talking about a clinician, you're going to want to know why they changed it," he explains.

Since CUMSC installed its EHR system, carriers have audited its files several times, and the EHR's audit trail has made the process much easier, says Steck. When carrier reps come in, CUMSC can give them access to a computer terminal and explain how to search for the information they need. That way, they don't waste CUMSC employees' time, says Steck.

Do this: Have someone who's familiar with health information management (HIM) principles help you select a system, advises Trites.

You should have policies and procedures that spell out how your practice deals with information, and have everyone sign off on them, advises consultant Norman Brooks with Lee-Brooks Consulting in Chicago.

Make sure that your system has an audit trail and that you can access it without being a programming whiz, advises Trites. Make sure your system doesn't delete audit information at the end of each day. Ask whether your system will meet Health Insurance Portability & Accountability Act standards, Trites stresses.

Also, ensure that employees don't use each others' computers and accounts so that you can tell which employees made which changes, advises Brooks.

So far, vendors aren't willing to build security and accountability into their products, until customers demand them or the vendors get sued, says Trites. "It's the vendor's responsibility," she notes, "but the physician's going to sit in the courtroom."