Health information technology: medical record documentation issues in the electronic era

• Published in: Primary care Vol. 39; no. 4; pp. 633 - 642
• Main Authors: Dacey, Bill, Bholat, Michelle Anne
• Format: Journal Article
• Language: English
• Published: United States 01-12-2012
• Subjects: Accountable Care Organizations; Current Procedural Terminology; Documentation; Electronic Health Records; Health Insurance Portability and Accountability Act; Humans; Insurance Claim Reporting; Practice Management, Medical; Quality Indicators, Health Care; United States; United States
• DOI: 10.1016/j.pop.2012.08.001
• EISSN: 1558-299X

This article outlines the regulatory movement propelling physicians into the electronic health record environment and the subsequent emergence of quality issues in the medical record. There are benefits and downside risks for implementing electronic health records as part of the desire of a practice or institution to build patient-centered medical homes. The intersection of how a practice or institution collects and reports quality metrics using health information technology and subsequently submits claims for services rendered has created unforeseen challenges for which leadership must be aware and address proactively.