Journal of AHIMA - March 2011

A Perfect Tool for the EHR

The healthcare industry is undergoing a digital revolution. The result will likely be vast changes in how people interact with medical records.

The continuity in care movement, for example, is pushing practitioners to use the EHR as the main medium for communication with other providers. Administrators are relying on medical records to measure the success of quality improvement projects in real time. Patients are now getting a chance to view their medical records online, gaining a new understanding of their diagnosed health. Finally, patients may have a complete medical record across all practitioners through the possibility of health information exchange.

With all these changes, the medical record is under stress to serve the increasing demands of numerous stakeholders. A record that was formerly a PCP’s personal notes is now of interest to specialists, administrators, researchers, government officials, payers, patients, and the hospital next door. Further, every stakeholder brings to the table a new set of demands for information. As a consequence, tolerance for inaccurate, inconsistent, or ambiguous parts of the medical record is rapidly decreasing and the need for standardization across the medical record is knocking at the door. The problem list exemplifies this trend.

Lawrence Weed was truly a visionary who created a perfect
tool for the EHR. Yet, the variations in today’s problem list
Available online in the AHIMA Body of Knowledge at
www.ahima.org.

Casey Holmes ( cholmes@hsph.harvard.edu) is a master’s student at the Harvard School of Public Health.

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Increasing demands for health data are lowering the tolerance for inaccurate, inconsistent, or ambiguous parts of individual medical records.

make it unusable as a resource to further improve patient care. In order to reap the benefits of upcoming decision support and population management tools, as well as meet the larger trends in medicine, healthcare centers need to address the issues in content and utilization as well as develop the policies and tools to standardize the problem list.

Part 1 of this article, “The Problem List beyond Meaningful Use: The Problems with Problem Lists,” appeared in the February issue. ¢

If so, contact

Gwen Hughes,

Director, e HIM Consulting at 312-229-7159 or ghughes@care-communications.com.

Notes

1. Wangsness, Lisa. “Electronic Health Records Raise Doubt.” The Boston Globe, April 13, 2009. Available online at www.boston.com/news/nation/washington/ articles/2009/04/13/electronic_health_records_raise_ doubt.