2014 Clinical Documentation Trends: HIPAA Risk Assessments, ICD-10 Conversion And More

2014 Clinical Documentation Trends: HIPAA Risk Assessments, ICD-10 Conversion And More   

2014 Clinical Documentation Trends: HIPAA Risk Assessments, ICD-10 Conversion And More


This year is poised to be a big one for health care providers and clients. The health care industry is always changing as regulations are updated and technology becomes more advanced, but 2014 has a lot in store for managers and directors at hospitals and practices of all sizes.

Here are some trends to watch that will have a big effect on health care in the coming year.

Greater Awareness of the HIPAA Risk Assessment Requirement

Adult & Pediatric Dermatology, P.C., has agreed to a $150,000 payment as a result of its HIPAA breaches. APDerm will also have to put a corrective plan together to get its HIPAA compliance program back on track. This story is important because it’s the first time a covered entity has settled for not having policies and procedures in place to deal with breach notification provisions.

In this case, patient health information was stored on an unencrypted thumb drive that was stolen from an employee’s car and never recovered. And because APDerm hadn’t conducted a careful analysis of ePHI confidentiality or trained its employees in procedures regarding ePHI, the organization was fined by the U. S. Department of Health and Human Service Office for Civil Rights.

We’ve been addressing HIPAA risk assessments in recent blog posts. It’s difficult to overstate the importance of conducting a risk assessment at least once a year. The OCR recently said that in its pilot audit program, two-thirds of all entities audited did not have a complete and accurate risk assessment, and almost all had a security-related compliance issue.

Many HIPAA violations can be prevented with the help of effective risk assessments.

Increasing Urgency Surrounding the ICD-10 Conversion

According to CMS, health care practices of all sizes and small hospitals should have wrapped up internal testing (Level 1) and should be involved in external testing (Level 2) for a couple more months. But according to a survey by the Workgroup for Electronic Data Interchange, about 80 percent of providers said they didn't expect to begin testing before 2014, and that only half had completed an impact statement. If this describes your organization, you’re obviously not alone, but time is of the essence.

Besides the conversion itself, one of the biggest trends, especially in the first half of 2014, is going to be training people on ICD-10 codes and terminologies. The process is likely to take several months, and CMS recommends that organizations give themselves six to nine months to get everyone fully trained on ICD-10 coding before the Oct. 1 deadline.

Changes to CQM Reporting

Finally, beginning in 2014, eligible professionals and hospitals and critical access hospitals will be reporting clinical quality measures, or CQM, using 2014 criteria regardless of whether they're participating in Stage 1 or Stage 2 of the Medicare and Medicaid EHR Incentive Programs. According to CMS, All providers are required to report on clinical quality measures to demonstrate meaningful use.

We’ll be watching these trends and more as the year goes along and will bring you the latest news and updates about HIPAA, risk assessments, the ICD-10 conversion and other clinical documentation issues your practice might be facing.

If you need help with your HIPAA risk assessment, or have other questions about these issues and how they affect your practice's clinical documentation policies and procedures, contact us for more information.

Logan Solutions uses a combination of clinical practice expertise and technological skill to help physician practices throughout the U.S. implement, customize and improve their ERM and Dragon Medical software systems. Contact us to find out how our clinical-practice expertise can help your practice with its clinical documentation software needs.