The Compliance Concerns of Electronic Health Records

The Compliance Concerns of Electronic Health Records

An electronic health record (EHR) helps physicians and healthcare providers by providing a continually updated, real time representation of a patient’s medical history. Hospitals, clinics, and other physicians can easily access this online database to simplify the research process that typically precedes a diagnosis or treatment. It’s important to distinguish an EHR from an electronic medical record (EMR), which is a digitized patient chart typically used as a resource within a single medical practice. Unfortunately, EHR technology comes with a number of compliance risks, and physicians need to be aware of these caveats in order to avoid making mistakes that could land them in trouble with regulatory agencies, or the insurance companies that reimburse them for their services. Here are the top three compliance risks to be aware of when implementing EHR technology:


1. Upcoding Leads To Billing Mistakes

First and foremost, physicians and staff need to be well trained in using their EHR system in order to avoid a common mistake called upcoding, which entails inputting the wrong codes and charging the insurance company or Medicare for services that weren’t actually rendered. Ultimately, making these mistakes on a regular basis or even a few times could lead to an unwanted audit, so it’s important to be adequately trained and competent in using the medical billing solution chosen by the practice. Sites like provide useful advice and tips on medical coding compliance. Through hands on development, RevenueXL has been able to identify and correct the most common compliance risks associated with EHR.

2. Copying and Pasting Documentation

Aside from selecting the wrong code, many physicians and medical staff also make the mistake of copying and pasting information over from other charts, leading to redundant information. When this happens it’s possible for the office to accidentally bill twice for the same services. Furthermore, redundant information may make the severity or current status of an illness look worse than it actually is, leading to unnecessary treatment measures. Any information added or modified in an EHR should be thoroughly reviewed before being saved and submitted to the database.

3. Using Templates Improperly

Another common mistake that compromises the accuracy of EHR and leads to a significant compliance risk is the use of pre-designed templates when adding to or creating a patient’s EHR. For this reason, it’s important to have all templates reviewed by a medical coder before putting them into regular use. It’s also imperative that templates be used responsibly by taking the time to personalize the EHR for each diagnosis or complaint. Overall, healthcare professionals should avoid the set it and forget it mentality when using medical coding and billing software.

The Consequences of Careless Coding

Ultimately, failing to take compliance risks into consideration and making careless coding mistakes can lead to complaints, audits, and even lawsuits. These are serious situations and any practice that uses EHR technology should be aware of such concerns before committing to use any system. For this reason, it’s important to only deal with software providers who offer comprehensive training and are known for having extensive coding expertise, rather than simply opting for a popular solution and trying to figure it out independently.