AHIMA: Here’s how hospitals should document opioid abuse in the EHR | Healthcare IT News
AHIMA Develops Tip Sheet to Help Docs Document Opioid Abuse
November 13, 2017 by Heather Landi
According to the Centers for Disease Control and Prevention (CDC), every day, 91 Americans die from an opioid overdose. Many health IT leaders believe that health information management, including proper documentation and interoperability of electronic health records (EHRs), can play a vital role in addressing the opioid epidemic.
The American Health Information Management Association (AHIMA) released an opioid addition documentation tip sheet to help healthcare providers better document the use and abuse of opioids.
When an individual using or abusing opioids visits a physician or other healthcare provider, that medical professional is responsible for accurately recording information about the patient’s opioid use in their EHR. However, without nationally adopted communications standards for health information exchange, that documentation is often not shared across healthcare systems and state lines, allowing those with opioid addictions to seek the drugs from multiple physicians without their knowledge, AHIMA officials said.
“There are seven characteristics of high quality clinical documentation. If a provider learns how to document using these characteristics to guide their documentation habits, they will provide trustworthy documentation,” AHIMA officials stated.
According to the tip sheet, those characteristics that best define optimal EHR charting are: clear, consistent, complete, reliable, precise, legible and timely. AHIMA’s tip sheet lays out characteristics of clear EHR charting alongside hypothetical examples of what clinical documentation for potential opioid abusers would look like if they were followed.
Harnessing Claims Data to Bring Structure and Coherence to Opioid Trends and Treatment
Tuesday, September 25, 2018 1:30 PM – 2:15 PM
Miami Beach Convention Center (MBCC) – Ocean Drive Ballroom A-D
This session will show how claims data can be analyzed to discern current trends in the opioid crisis, different approaches to addressing it, and which treatment protocols are most impactful. The presentation will uncover varying increases in opioid-related diagnoses, including opioid dependence, opioid abuse, and opioid-related overdoses, as well as the influence of demographic factors such as age and gender, associated costs, demand of specific services, how the opioid crisis affects various regions and the different treatment protocols prevailing in different states. This information will bring structure and coherence to the audience’s understanding of the opioid crisis. Further, audience members will learn how they can apply current, geographically specific claims data to inform strategic decision-making in their own hospitals and health systems, such as decisions associated with expansion, clinical affiliations, triage policies and network participation.
Robin Gelburd, JD
Robin Gelburd is the president of FAIR Health, a national, independent, nonprofit organization with the mission of bringing transparency to healthcare costs and health insurance information. A recipient of the 2016 Dig|Benefits Technology Innovator Award, bestowed by Employee Benefit News, Ms. Gelburd has been invited to speak to organizations across the country on topics of critical importance to employers, employees, healthcare professionals, and institutions, health plans, third-party administrators, consultants, researchers and other healthcare stakeholders. She has published numerous articles on topics, such as data analytics and quality, healthcare cost transparency, consumer engagement, and protection, among many others. Prior to being recruited as president of FAIR Health, Ms. Gelburd served for eight years as general counsel of a medical research foundation comprising approximately 30 premier academic medical centers, hospitals, and research institutions in New York. Before becoming general counsel, she was a health law partner at a New York City law firm representing a broad array of healthcare-based clients. Earlier, she worked as a litigation and corporate associate at the international law firm Morrison & Foerster. Ms. Gelburd began her legal career as a federal appellate law clerk to the Honorable Francis D. Murnaghan, Jr. from the Court of Appeals, 4th Circuit.