Medical Device Daily

Boosting efficiency and improving billing accuracy – while at the same time preventing and detecting fraud – should be a top priority in governing the use of electronic health records (EHRs), according to a new report by RTI International (Research Triangle Park, North Carolina) for the office of the National Coordinator for Health Information Technology for Health and Human Services.

The report recommends 14 requirements designed to increase efficiency and improve billing accuracy for clinicians using EHRs.

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

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

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 fraud.

Stephanie Rizk, survey manager at RTI and the project’s manager, told Medical Device Daily in an email that the report “outlines the process used to provide the Office of the National Coordinator with a set of recommendations that, if adopted, would increase the quality and safety of the data collected in electronic health records.”

According to the report, the U.S. spent $1.98 trillion on healthcare in 2005, and by 2016 healthcare expenditures are expected to surpass $4.1 trillion.

“If adopted, these recommendations will strengthen current standards and provide new efficiencies to clinicians who use electronic health records in their practices,” said Robert Kolodner, MD, National Coordinator for Health Information Technology for HHS. “Updating the current criteria to include more of our recommendations will provide an opportunity to reduce costs associated with inaccurate billing and potential healthcare 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, the report said.

While the focus of the recommendations is on enhancing accuracy, including the detection and prevention of fraud, the report says: “By and large, clinicians are not engaged in fraudulent activities. Not all improper payments are the result of fraud, and not all unusual billing patterns are fraudulent. However, certain documentation practices, such as data errors, mistakes in coding, and confusion regarding billing codes and procedures may result in improper payments.”

The report also says that the recommended requirements are “aimed equally at reducing such erroneous documentation practices, preventing improper payments, and improving supporting documentation for legitimate claims submissions.”

Rizk told MDD that the project represents a proactive effort to prevent and detect fraud rather than a reaction to an existing problem.

“With the move to electronic health records, prevention and detection of fraud will be an important component to ensuring that it does not become more costly to the healthcare system in the future,” Rizk said.

EHRs will be able to benefit clinicians, patients and payers by reducing human error and improper payment, according to the report. 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.

“Although requirements that enhance data accuracy might overlap with current EHR certification criteria, thought must be given specifically to the criteria that will help combat both large- and small-scale suspected fraud, as well as accentuate the potential benefits of these systems with regard to reducing improper payment and human error,” the report says.

“While a component of combating fraud is the ability to trace and audit information that may be used in prosecution, these same functionalities can be used to ensure information validity over time, which can protect both clinicians and patients.”

Rizk said that the intent of the project was to use current requirements to the “greatest extent possible” to ensure minimal changes in the workflow for clinicians.

“With EHRs we have the opportunity to create an environment where it is easier for clinicians to provide care to patients without worrying about issues such as improper usage of the data,” she said.

RTI offers research and technical solutions to governments and businesses worldwide in a variety of areas, including health and pharmaceuticals.