# Presentation: 544009

## AHIC / ELECTRONIC HEALTH RECORDS WORKGROUPDecember 4, 2007

- Recommended Requirements for Enhancing Data Quality in Electronic Health Records
- Reed D. Gelzer, MD, MPH, CHCC
- Chair, Prevention Workgroup
- Advocates for Documentation Integrity and Compliance

## Enhancing EHR Data Quality – Today’s Presentation 

- History
- Overview
- Gaps Identified
- Recommendations Overview
- Specific Requirements
- Requirement 5: Evaluation and Management (E&M) Coding (especially 5.2)
- Requirement 6: Proxy Authorship
- Questions and Discussion

## Enhancing EHR Data Quality – Today’s Presentation 

- History-Report is one of a series
- AHIMA Report 1 on Computer-Assisted Coding
- AHIMA Report 2 on the User of HIT to Enhance and Expand Health Care Anti-Fraud Activities
- RTI/AHIMA Recommended Requirements for Enhancing Data Quality in Electronic Health Records
- (See accompanying file “Excerpt from Fraud 2”)
**	****Document is “Law Enforcement Community's Priorities for EMR Function Supports for Management of Health Care Fraud” as excerpted from ONC Health Care Anti-Fraud Project Task Order HHSP23320054100EC **
- (See RTI/AHIMA “Recommended Requirements...” report’s Executive Summary pp. ES1-ES7 (pp. 11/115 to 17/115))

## Overview: Fraud Burden is Staggering and Growing

- 	“Fraud has a significant impact on the U.S. health economy. The National Health Care Anti-Fraud Association (NHCAA) estimates that “...***of the nation’s annual healthcare outlay at least 3% – or $51 billion in calendar year 2003 ***was lost to outright fraud.”  Other estimates by government and law enforcement agencies place the loss as high as 10% of our annual expenditure, or $170 billion.”*

***Excerpt from the Executive Summary of the **_Report on the Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities_**, Prepared for: The Office of the National Coordinator, U.S. Department of Health and Human Services, September 30, 2005.  Reports available through: http://www.hhs.gov/healthit/hithca.html**

## Overview: Law Enforcement/Auditor Priorities 

_**From Second Fraud Report**_
- Law Enforcement Community's Priorities for EMR Function Supports for Management of Health Care Fraud*
- *Excerpted from ONC Health Care Anti-Fraud Project Task Order HHSP23320054100EC

- Completeness
- Accountability
- Access and Availability
- Traceability
- Auditable (verifiable)
- Identification
- Authentication
- Biometric Authentication
- Non-repudiation
- Integrity
- Storage and Security
- Record Retention
- Reliability
- Digital Certificate
- Digital Signature
- Electronic Signature
- Public Key Infrastructure

## Enhancing EHR Data Quality – Project Overview

- Project purpose:  Enhance Data Quality in Electronic Health Records (EHRs) including the development of  model anti-fraud requirements for EHRs.
- Project contractor:  RTI International with AHIMA
- Project led by a Model Requirements Executive Team (MRET):  Industry experts in private and public sectors (see Slides 6 and 7).
- Validate the recommendations through public comment.

## Enhancing EHR Data Quality – Project Overview (cont.)

- Work with the Health Information Technology Standards Panel (HITSP) to identify existing and new standards needed to meet model functionalities and requirements.
- Work with the Certification Commission for Health Information Technology (CCHIT) to map model functionalities and requirements for health care anti-fraud to CCHIT certification criteria.

## Model Requirements Executive Team (MRET)

- _Leadership_
- Donald W. Simborg, MD, MRET Chairman
- Susan Hanson, MBA, RHIA, MRET Executive Coordinator
- Michelle Dougherty, RHIA, CHP, AHIMA Liaison
- A. John Blair, III, MD, Taconic IPA, Inc., Chair of the MRET Retrospective/Prospective Workgroup
- Reed Gelzer, MD, MPH, Advocates for Documentation Integrity and Compliance, Chair of the MRET Prevention Workgroup
- _Membership_
- Robert Burleigh, CHBME, Brandywine Healthcare Services
- Rebecca S. Busch, RN, MBA, Medical Business Associates, Inc.
- Bonnie Cassidy, MPA, RHIA, Cherry, Bekaert & Holland, LLP
- Christopher Dorn, United Health Group/Ingenix
- Jamie Ferguson, Kaiser Permanente
- Byron Hollis, Esq., Blue Cross/Blue Shield of America

## Model Requirements Executive Team (MRET) (cont.)

- _Membership (continued)_
- Lawrence Hughes, JD, American Hospital Association
- Richard Ingraham, SAS US Commercial
- Holly Louie, CHBME, BSN, Practice Management, Inc.
- Matthew McMullen, PhD, JD, Centers for Medicaid & Medicare Services
- Blackford Middleton, MD, MPH, Partner’s HealthCare Systems, Inc.
- Wes Rishel, Gartner Group
- Louis Saccocio, National Health Care Anti-Fraud Association
- James Speros, JD, Veterans Health Administration
- Susan Turney, MD, MS, Wisconsin Medical Society
- Alan Yuspeh, JD, MBA, Hospital Corporation of America

## Project Results – 14 Recommendations

- Audit Functions and Features
- Provider Identification
- User Access Authorization
- Documentation Process Issues
- Evaluation and Management (E&M) Coding
- Proxy Authorship
- Record Modification after Signature

## Project Results – 14 Recommendations (cont.)

- Auditor Access to Patient Records
- EHR Traceability
- Patient Involvement in Anti-Fraud
- Patient Identity-Proofing
- Structured and Coded Data
- Integrity of EHR Transmission
- Accurate Linkage of Claims to Clinical Records

## Gaps in Organizational Charters and Mandates

**In the course of MRET Discussions with HITSP and CCHIT Leadership, it was highlighted that neither entity had fraud management/prevention or medical-legal integrity as a component of their respective mandates.**

## Why are the recommendations important?

- Universal interest in valid, accurate, trustworthy health care information.
- Protects clinicians and patients by providing supportive functions to validate that correct procedures were used and identifying or highlighting outliers before they become serious issues.
- Raise the visibility of basic electronic documentation validity issues in the marketplace for buyers and sellers to take into account in evaluating currently available functions and capabilities.

## Requirement 5

***Requirement 5: Evaluation and Management***
***    ******(E&M) Coding  ******(page 4-11 or 47/115 in report)***
- 5.1 The system shall be capable of prompting for omitted necessary administrative data or codes. This could include the capability to prompt a physician if the selected E&M code is not consistent with the documentation in the encounter note.
- 5.2 Prompts that are driven by E&M administrative processes shall not explicitly or implicitly direct a user to add documentation. This does not apply to prompts for additional documentation for E&M levels already achieved, for medical necessity or for quality guidelines/clinical decision support.

**Notes:**
Rationale:
This is new wording for CCHIT requirement 237 of the ambulatory functional requirements, which states, “The system shall prompt for data required to determine appropriate administrative (evaluation and management) codes if such data is not present in encounter data.” It is appropriate for EHR-S to calculate an E&M code from the encounter data that has been entered and to indicate the basis for that calculation. However, it is not appropriate to suggest to the provider that certain additional data, if entered, would increase the level of the E&M code, nor is it appropriate for the payer to have autoadjudicated down-coding based on similar coding logic without a data-generated basis. The wording of the current CCHIT requirement, although unintended, could be interpreted as allowing for these situations.

It is also well documented that E&M codes can vary significantly from one individual coder to another without any ill intention. Underlying this requirement should be an understanding that these inconsistencies in and of themselves are not an indicator of fraud, and that record analysis must be able to account for variances. The use of a prompt merely alerts the individual providing the code of possible inconsistency and thereby may become an extremely helpful tool to provide some consistent guidance to clinicians.

## Requirement 6

***Requirement 6: Proxy Authorship ******(page 4-11 or 47/115 in report)***
- 6.1 Retain date/time/user stamp of original data entry person when data entered “on behalf” of another author.
- 6.2 If an assistant is used to enter data that will subsequently be signed by a provider, retain the date/time/use stamp of the data entry person as well as the provider.

**Notes:**
Rationale:
A provider’s staff can obtain information from a patient and put the information into the clinical record, or the provider can obtain the information from a patient and have the staff record the information on his/her behalf. It is important to be able to distinguish which of these mechanisms, if either, was used and by whom.

## Discussion and Questions

Time permitting:
New 2006 eDiscovery Rules
(see Practice Brief)

**Time permitting:**
**New 2006 eDiscovery Rules**
**(see Practice Brief)**