New recommendations to improve existing standards for electronic health record systems

Aug 13 2007

A new report prepared by RTI International for the Office of the National Coordinator for Health Information Technology (ONC) recommends 14 functional requirements that would serve to increase efficiency and improve billing accuracy for clinicians using electronic health records (EHRs).

The recommendations were developed by a team of experts and reviewed by more than 75 health care industry leaders, practitioners and organizations. RTI researchers also worked with the American Health Information Management Association (AHIMA), and leading statistical software companies SAS and SPSS.

Many of the recommendations are designed to improve existing standards for electronic health record systems. Others work to create additional requirements to improve oversight of billing accuracy and detect potential improper payments.

"If adopted, these recommendations will strengthen current standards and provide new efficiencies to clinicians who use electronic health records in their practices," said Dr. Robert Kolodner, ONC's National Coordinator for Health Information Technology. "Updating the current criteria to include more of our recommendations will provide an opportunity to reduce costs associated with inaccurate billing and potential health care fraud."

Among the recommendations are steps to strengthen audit functions, improve patient identification and verify provider identification, thus improving efficiency and reducing the likelihood of inaccurate payments. Such steps may assist with the management of anti-fraud efforts.

Electronic health records can benefit clinicians, patients and payers by reducing human error and improper payment. They can also help detect and deter improper billing by documenting that correct procedures were used, highlighting abnormalities before they become serious issues, and providing patients with a clear understanding that their health records are being disclosed only to authorized users.

The researchers also suggest that plans need to be developed to ensure that the recommendations are implemented into the infrastructure for the nationwide health information network, which will provide the foundation for interoperable, secure and standards-based health information exchange nationally.

The report will be forwarded to the Certification Commission for Health Information Technology for consideration during the 2008 certification criteria cycle.

The report can be viewed at http://www.rti.org/pubs/enhancing_data_quality_in_ehrs.pdf