EHRs Improve Documentation for IBD, Finds Study

EHRs Improve Documentation for IBD, Finds Study

A recent study found that using EHRs improved documentation adherence and performance measures in patients with IBD.

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Inflammatory bowel disease (IBD) involves chronic inflammation of the digestive tract.

There are two types of IBDs -- Crohn's disease (CD) and ulcerative colitis (UC). While CD can affect any part of the gastroesophageal (GI) tract, UC is confined to the large bowel.

Medical transcription companies that help gastroenterologists with documentation in electronic health records (EHRs) are well-versed in the terminology and treatments related to these and other disorders of the digestive system. Becker’s GI and Endoscopy recently reported on a new study in Gastroenterologywhich found thatusing EHRs improved documentation adherence and performance measures in patients with IBD. Concerns with Documentation of IBD Quality Measures Poor documentation of IBD Quality Measures is a matter of concern. A study published in Clinical Gastroenterology and Hepatology in 2016 found that gastroenterology practices demonstrated poor documentation of quality measures established by the American Gastroenterological Association (AGA) in 2011 for patients with inflammatory bowel disease.

The researchers reviewed charts of consecutive patients seen at an academic practice (367 patients), a community practice (217 patients) and a private practice (199 patients) for compliance with eight outpatient measures. The results were as follows: •

The study found appropriate documentation of all eight core measures for only 46 patients (5.8%) in all three centers combined (24 patients in the academic practice, none in the clinical practice and 22 in the private practice).

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The most evaluated and documented core measures were: screening for tobacco abuse (89.6% of all patients), the location of IBD (80.3%) and assessment for corticosteroid-sparing therapy (70.8%).

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The measures least likely to be assessed were: pneumococcal immunization (16.7%), bone loss (25%) and influenza immunization (28.7%).

The researchers concluded that interventions are necessary to improve reporting of quality measures for IBD. EHR Adoption enhancesIBD Documentation Compliance Recent research published in Gastroenterology found that customizable EHRs improve documentation compliance of quality measures for outpatient IBD care.

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The researchers compared patient charts before and after EHR adoption. They randomly selected 50 patient charts from consecutive outpatient IBD visits from Sept. 1, 2015 through June 30, 2016 and 50 outpatient IBD charts from Sept. 1, 2016 through June 30, 2017 after EHR adoption.

The team reviewed that charts to assess documentation adherence with the Physician Quality Reporting System for IBD care, including documentation of influenza and pneumonia vaccination, tobacco screening and cessation, evaluation of latent tuberculosis, hepatitis B status and bone loss risk assessment. The Becker’s GI and Endoscopy article summarizes the key findings of the study as follows: •

The addition IBD-specific EHRs improved documentation of administration, refusal or prior receipt of both the influenza and pneumonia vaccines from 19.4 percent before EHRs to 59.5 percent after.

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EHR adoption improved tobacco cessation intervention documentation from 28.6 percent to 77.8 percent after.

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Documentation after EHR implementation was 100 percent for latent tuberculosis, up from 66.7 percent before.

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Hepatitis B and screening tobacco use documentation remained at 100 percent after EHR adoption.

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For patients at risk for bone loss related to steroid use, the documentation ratewas 12.5 percent, up from zero percent pre-EHRs.

The researchers concluded that the customizable EHRs improve documentation adherence toquality measures for outpatient IBD care.

Gastroenterology Medical Transcription Services to Maintain EHR Documentation Integrity EHRs improve documentation compliance to quality measures andaccuracy of the complete health record is necessary to ensure documentation integrity. Errors in the medical record can compromise patient care, care coordination, quality reporting and research, and also lead to fraud and abuse. Outsourcing medical transcription helps gastroenterology practices maintain documentation integrity.

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Medical transcription outsourcing companies have evolved with the widespread adoption of EHRs. With the availability of speech recognition technology, physician dictations are converted into electronic text that is parsed and mapped to particular data fields. Proper safeguards are necessary to reflect an accurate picture of the patient’s condition, at admission as well as how it changes over time. Providers need to review and edit all data to ensure that the patient visit is properly recorded with the relevant details.

Healthcare providers can team up with transcription services to integrate dictation into their EHR. In fact, AHIMA notes that organizations using voice recognition without a validation step in place are experiencing significant data quality problems and documentation errors.

Medical transcriptionists review and edit dictated information in a timely manner help providers, promoting accurate and quality documentation in EHR systems. Partnering with a reliable gastroenterology medical transcription company can help practitioners ensure compliance with quality measures.

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