Resolution for Professional Guidelines/Best Practices For Electronic Documentation

Submitted By the Tennessee Health Information Management Association
Endorsed By the Missouri Health Information Management Association and Pennsylvania Health Information Management Association

Background

AHIMA has a long history and established role in promoting documentation practices that ensure data integrity in medical records, both paper and electronic. Health information management (HIM) professionals recognize that achieving quality data rests in large part on standardized documentation practices; this is integral to achieving the goal of quality healthcare through quality information. Articles, toolkits, and practice briefs have been published and many other initiatives have been undertaken by AHIMA to identify and promote documentation practices that result in reliable, accurate information and data.

As electronic health record (EHR) systems have become more widely implemented in all healthcare settings, these systems have developed/employed various methods of supporting documentation in electronic records. Common online (blogs, online newsletters, listservs) and in the print media are complaints and concerns about the integrity, reliability, and compliance capabilities of automated documentation processes. Several published articles in the Journal of AHIMA establish guidelines for preventing fraud in EHR systems. Documentation practices are without question within the domain of the HIM profession, in paper and in electronic records.

Preamble

Whereas, the quality of healthcare across the continuum rests on the integrity, reliability, and accuracy of health information across the continuum;

Whereas, there exist various methods of documentation in electronic records that, in the absence of appropriate HIM (e-HIM in the electronic environment) best practices, can potentially create unreliable health information for patient care and other uses of the data;

Whereas, assuring the integrity of health information is the professional obligation HIM professionals;

Whereas, AHIMA represents HIM professionals who serve the industry in all healthcare settings;

Whereas, AHIMA must be recognized in the industry as the premier organization for assuring the integrity of health information;

Therefore, be it

Resolved, That AHIMA should provide authoritative resources to develop and standardize professional guidelines/best practices for e-HIM documentation by:

  • Identifying and prioritizing volunteer workgroups and practice councils to create best practices for electronic documentation; invite vendors and documentation/compliance specialists from our alliance groups to participate;
  • Promoting the recognition/adoption of the best practices by EHR developers and certifying organizations;
  • Developing a plan for disseminating the best practices through the regional extension centers established by ARRA
  • Issuing a call to action for our volunteers and aligned organizations to advocate for and support the dissemination of the best practices;
  • Leveraging the AHIMA Foundation to increase research of evidence-based best practices for e-HIM documentation.

Approved by the 2009-10 House of Delegates, October 4, 2009, Grapevine, Texas