Get an electronic medical record (EMR) audit to answer these 3 questions

Get an electronic medical record (EMR) audit to answer these 3 questions

Most forest parks are developed with a nature trail or a pathway that allows visitors to properly enjoy the natural environment. A nature trail provides people with cues like signs, trees, small plants, and other markers to show how these elements relate to each other. These markers are essential to informing visitors on how to tread through such a densely populated environment without disrupting it.

Audit trails for electronic medical records (EMR) work in a similar way.

What is an EMR audit trail?

Like nature trails, EMR audit trails essentially function as trackers and guides for those who use electronic medical records. Healthcare professionals who handle patients’ protected health information (PHI) heavily use EMR systems and, as such, are the ones who leave “trails” in them.

An audit trail, also referred to as an audit log, provides important details such as who has accessed a computer, the date and time of access, and access activity. Some examples of data found in an EMR audit trail are:

  • The type of action performed, including adding new data, modifying or deleting data, viewing a part of a record (e.g., a medical chart), printing out a copy of a record, or leaving a query or a note on a medical record
  • Date and time of access
  • User identification
  • Patient identification
  • Identification of the patient data accessed

Every medical practice in Phoenix, Scottsdale, and Tempe, whether it be a hospital or a small private clinic, uses EMR solutions. EMR systems store large amounts of data, making them extremely valuable that they need to be protected at all costs.

Related reading: 3 Essential EMR integrations for healthcare practices

Everyone who works in the healthcare industry should know that hacking into healthcare systems is tremendously lucrative for cybercriminals.

In fact, healthcare data is 50 times more valuable than Social Security numbers and credit card information.

That’s because a single medical record doesn’t just contain a person’s medical history comprising medications, treatment plans, diagnoses, and the like; it also contains a person’s Social Security number and other sensitive information.

And unlike credit card numbers or bank account numbers, medical records contain information that is associated permanently with an individual.

For that and other reasons, EMR systems must be protected using robust healthcare security solutions and be secured against erratic and unauthorized modification, deletion, or falsification.

EMR audit trails play a critical role in protecting PHI and complying with industry standards. With audit trails for electronic health records in place, healthcare organizations can keep track of any changes, and healthcare workers can view chronological listings of all changes made to every record.

Having an EMR audit can answer the following questions for healthcare organizations

1. Is the medical practice compliant with HIPAA?

With the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009, healthcare practices have largely handled electronic, rather than paper-based, medical information.

Before that period, making changes to medical records was done mostly by hand; ditto most authentication processes performed by healthcare providers authorized to make alterations. That changed with the introduction of EMR to the healthcare industry, which made electronic changes to medical records the norm.

And as the healthcare industry adopts more innovative technologies, tracking an increasingly large volume of healthcare data has consequently become more difficult for healthcare practices.

EMR audit records help simplify data tracing and are primarily used to comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations to secure patients’ PHI.

HIPAA specifically mandates that healthcare providers who use EMR must implement systems that involve reviewing and auditing medical record access and monitoring unauthorized access.

In other words, compliance with HIPAA requirements entails the use of audit trails. Audit trails are useful in determining whether there has been a security incident in the system, and more importantly, to track data modifications. EMR audit trails are key to ensuring your practice’s compliance with HIPAA, which aims to restrict access to PHI on a “need to know” basis.

2. Is the medical practice on top of its billing and clinical documentation processes?

The key to addressing this concern is knowing how often a hospital audits EMR. Simply put, healthcare practices must conduct regular EMR audits, which may be done at least once a year — it all depends on the practice’s unique needs.

Conducting EMR audits makes it easier to discover lost revenues and under-documented services. These occurrences commonly happen in primary care providers, where clinical documentation problems may arise from the failure to document billing for counseling services, immunizations, and other outpatient or ambulatory services.

Audits make it easier for clinicians to classify the complexity level of a patient's condition, which in a way, helps ease billing and documentation processes.

What’s more, audits help identify outliers, protect against missing and false billing claims, sort out medical billing and coding problems, and identify billing deficiencies and improve payment processes.

3. Are hospitals well-equipped to participate in an investigation?

With an EMR audit system in place, data is properly sorted and displayed on accessible workstations. This transparency can be particularly useful in investigations. EMR audit trails are used in investigations that concern medical cases, medical malpractice, personal injury, potential security incidents, or similar lawsuits and investigations.

Audit trails may provide clues as to when an X-ray file or a lab report was accessed by a physician. This information will be crucial in, for example, a medical malpractice lawsuit investigation in which the liability of a medical provider is being determined.

Without audit trails, a medical practice would be ill-equipped to participate in an investigation. That said, a healthcare practice must obtain audit trail information and present it in a way that will aid the investigation. Note that in some cases, audit trails may be unreliable and useless as they are often intelligible only to medical staff that use the EMR system.

This is where the participation of a healthcare practice’s IT partner or EMR vendor becomes crucial. In an investigation requiring access to medical audits, an IT specialist who offers healthcare IT solutions would be able to identify and demonstrate which documents are useful and which ones are not.

It’s common to run into problems concerning EMR systems and HIPAA audit trail requirements. That’s why healthcare organizations must work with a medical IT specialist like Solution Partner. If you’re a healthcare provider in Phoenix, Scottsdale, Tempe, and the surrounding areas, get in touch with us to learn how you can optimize your healthcare IT systems.

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