decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 4 (April)
Don’t overlook compliance concerns in rush to adopt EMR
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Article Overview
This article explains compliance risks associated with rapid EMR/EHR adoption in medical practices, especially where electronic systems support documentation and code selection. It is intended for physicians, practice managers, coders, compliance staff, and anyone responsible for documentation integrity, billing accuracy, and EMR workflow oversight. The article summarizes broad guidance from professional organizations and highlights the need for training, review, and periodic monitoring when using electronic record systems.
Why This Topic Matters
EMR/EHR tools can improve workflow, but they can also create documentation and billing compliance exposure if automated features are not monitored. Practices need to understand the governance and oversight issues involved before relying on electronic systems for coding support.
Article Sections
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EMR adoption and compliance risks
Introduces the rapid adoption of electronic medical record systems and the compliance concerns that can arise when billing support is built into documentation workflows. Discusses the broader need to avoid overreliance on automated features.
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Potential problem areas in electronic documentation
Describes common workflow features in electronic records that may create documentation and billing concerns. Focuses on general risks related to templates, defaulted content, and staff-entered information.
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Professional society guidance and oversight recommendations
Summarizes general recommendations from professional organizations for managing EMR/EHR use. Covers training, review processes, provider accountability, and periodic audits at a high level.
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Official resources
Lists external organizational resources related to EMR compliance and practice management guidance.
What You Will Learn
- How EMR/EHR adoption can affect compliance and documentation workflows
- What types of oversight issues are commonly associated with electronic record systems
- What broad guidance professional organizations provide for practices using EMRs
- Why training, review, and periodic monitoring matter in an electronic documentation environment
Who Should Read This
- Physicians
- Practice managers
- Medical coders
- Compliance officers
- Billing staff
- Clinical documentation staff
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