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Preserving Documentation Integrity
Ensuring the integrity of HR documentation is important to help prevent fraud, waste, abuse, and improper payments. It is critical that EHR systems include software capabilities aimed at ensuring that integrity. The 2015 final rule for Health IT certification, effective January 2016, adds 45 Code of Federal Regulations Section 170.315, which codifies several important integrity features. See subparagraph (d)
Privacy and Security for complete description. Some highlights include:
User authentication and access management/authorization;
• Auditable events and tamper resistance, including a record of the audit log and encryption status, who changed the statuses and when, and the limited number of users who are authorized to change those statuses;
Optimal security settings are set by default;
Inability to change, overwrite, or delete audit log events;
Ability to detect if the audit log has been altered; and Ability to time-out access after a specified period of nonuse. [6]
Providers and others are encouraged to customize their HR systems to include these software features.
The requirement to have an audit log operational whenever the HR technology is
available for updates or viewing was recommended in a report commissioned by
ONC[7] and by HHS-OIG in its 2013 report on hospital EHR technology. [8] According to HHS-OIG, the HR system audit log should always be operational, should be stored as long as clinical records, and should never be altered. [9]
Another method of ensuring HR documentation integrity is to develop administrative and clinical documentation policies and procedures and standards of conduct that provide a framework for proper use. Policies and procedures with clearly defined roles and responsibilities, as well as identification of specific individuals accountable for the
Documentation Integrity in Electronic Health Records
accuracy and integrity of information, will help preserve the integrity of documentation in EHRs. Periodically monitoring and auditing HR documentation, establishing clear channels for reporting errors in documentation, and promptly correcting any known errors are also effective ways of mitigating HR documentation integrity risks.
Providers and others are encouraged to present targeted training on policies and procedures related to properly using HR software features, specifically those that protect HR documentation integrity. Training should communicate individual responsibilities and the capabilities and functions of the HR system to each individual who works with EHRs. The training should also explain responsibilities for maintaining the integrity and accuracy of information. [10]