HIT Policy Committee: Certification, legal definition, more discussed for documentation

Billing and legal concerns can get in the way of clinical uses of documentation, according to a hearing held on the subject on February 14. The HIT Policy Committee discussed the hearing and its next moves during its April 3 meeting.

Clinical documentation is important and has many primary and secondary users, said Paul Tang, MD, MS, VP, CMIO of the Palo Alto Medical Foundation and committee vice chair. The preoccupation with billing and legal issues plus the implementation of productivity tools may cause a risk of overuse or inappropriate use and may impact the accuracy of the information and make it difficult to find important information within the great volumes of data.

Most of these concerns are anecdotal and there is little to no quantitative evidence about how big a problem this is, Tang said. "There is not necessarily a strong correlation between quality of documentation and quality of care."

To manage the issues, the clinical documentation work group made several recommendations, including moving documentation measures from a Meaningful Use (MU) menu item to a core measure.

On the legal side, a legal definition of the medical records is needed, Tang said, and there is potential for a certification requirement. In the event of malpractice litigation, electronic records need some way to prove what information was viewed in the context of care. "There are a lot of times where there’s a lot of documentation going on because of misunderstanding of what actually needs to be there. There is an excess amount of documentation. There are opportunities to do better education on what needs to be there. It was a very rich day of testimony about the challenges and the possible opportunities," he said.

The work group also discussed some way to identify who put what information in where and at what time—analogous to track changes in a Microsoft Word document. "That would help the reader understand the voracity, the context of the information and the changes made in a copied and pasted section of text," he said. Readers could see the provenance of the data which may or may not be appropriate, "but at least the reader would know."

More research is needed to determine a better way for clinicians to find the most important information within all the documentation, Tang said. The work group proposed that the standards committee look for ways to prescribe certification criteria.

Tang said the consideration is to include more detailed clinical documentation requirements as an MU objective, but Farzad Mostshari, MD, ScM, national coordinator of health IT, asked the group to hold off on recommendations for Stage 3.