Journal of AHIMA - May 2011

The Patient’s Role in Ensuring Legal
EHR Data Integrity

By Deborah Kohn, MPH, RHIA, FACHE, CPHIMS

FOR NEARLY 40 years I have served as an HIM and health IT professional, but for my entire life I have been a healthcare pa- tient. My understanding of the processes that create medical records has helped me identify system and human mistakes in my own records. Consequently, I know well that the strength of an organization’s legal EHR depends on the accuracy of its information-generating systems and how that information is re- produced for providers and patients. Data integrity is vital to maintaining legally sound and court- ready EHR information. While routine audits of processes help, patients can also be a valuable partner in ensuring records are accurate and reproduced in human-readable format.

There are several benefits to developing processes for patients to make amendments to their medical records when mistakes are discovered. While changes to the record should be carefully considered, patients are usually more in touch with their care than busy healthcare professionals and HIM managers. Patients should be encouraged to review their medical data—through electronic portals or PHRs—for errors.

Open communication channels for patient-suggested record amendments should be maintained. Beyond the impact on patient safety and quality care, a correct medical record is a more legally sound medical record.

Digital Portals, PHRs Offer Windows to Mistakes I’ve learned over the years the benefits and disadvantages of electronic health records. As a “power user” of many EHR systems over four decades of HIM/HIT work, I’ve seen EHR systems and components come and go. But interacting with EHR systems as a patient provides a different perspective and uncovers unique flaws.

I have maintained an analog PHR since the 1970s. Recently my healthcare providers have begun forwarding digital lab, radiology, and other files through a patient portal. As such I am in the process of converting pertinent portions of my analog PHR to a digital format. As part of this process I verify that my analog and digital health record information is correct. If the information is not correct, I contact the provider or provider organization to amend the information.

Many organizations have implemented EHRs, digital PHRs, and visit summary applications, and patients are beginning to use these systems. However, most patients don’t know they can ask to amend their records. When releasing paper copies or uploading information to their patient portals, providers should encourage patients to report any incorrect information they view in their records.

In addition, organizations with these systems must contend with requests for corrections to system flaws, poor configurations, and outstanding training issues from outside of their internal users. External users such as health information exchanges will be requesting corrections to health records, system flaws, and poor configurations.

HIM and health IT professionals should make fixing these issues a priority, since the legal implications of any unintended consequences that come from faulty EHR usage can be overwhelming.