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EMR Healthcare Compliance

Healthcare compliance is a complex field that focuses primarily on the privacy of sensitive patient information. A secondary consideration is the adherence to the best practices – as outlined by governing medical association bodies – with respect to treatment protocols. The reason a review of the now employed best practice of healthcare compliance is becoming so important is easily explained against the backdrop of the growing popularity that electronic medical records (EMR) are experiencing.

In the past, a patient file was largely composed of paper reports, doctor’s notes, nurses’ chart entries and lab results – all neatly stapled into a growing folder; the best practice at the time was meticulous indexing and filing. For electronic records, the best practices demand the use predefined codes. This, in turn, requires the employment of a well-trained and highly skilled medical coding professional.

The problem of healthcare compliance arises when a physician does want to incur the cost of hiring such a professional. As a result, the office receptionist or secretary is often encouraged to follow a doctor or nurse devised list of likely coding data that fits the office’s needs best; practice makes perfect and over time it is hard to distinguish the difference between a medical coder’s work and the secretary’s data entry.

Problems will likely not crop up until it is time for a healthcare compliance check. As the medical office must now show that it relies on officially sanctioned best practices, the absence of coding expertise can make it difficult to find and supply the data required. In addition to the problem associated with finding data, there is also a good chance that the use of a receptionist or secretary as a data input person is not the best practice.

For example, the Health Insurance Privacy and Portability Act of 1996 (HIPAA) is quite specific about the practices it will accept with respect to the training a person must have when entrusted with sensitive medical data. This training protocol itself must be showcased during a healthcare HIPAA compliance audit. Other areas or reporting include computer security, workstation confidentiality – a common problem when receptionists are also doubling as data entry staff – and of course basic personnel training on privacy issues.

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