Improving EHR Data Integrity can Optimize Patient Outcomes

Improving EHR Data Integrity can Optimize Patient Outcomes Experts point out the automated functions of electronic health records are compromising the quality of clinical documentation and patient care

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As a responsible medical transcription company, we are committed to ensuring the accurate and timely capture of patient information in the electronic health record (EHR).

Recent studies stress the importance of EHR data integrity to enhance and optimize patient care.

In the value-based care environment, the ability of quality measures to provide an accurate picture of the patient care experience depends on the availability of reliable data. In addition to quality reporting, provider data is critical to payer responsibilities ranging from claims reimbursement to performance measurement, and customer relationship management.

EHR Intelligence reported on a clinician EHR usability study which highlighted the challenges involved in clinical documentation. Conducted by the National Institute of Standards and Technology (NIST), the study reported the issues faced by the participating clinicians related to: •

EHR data integrity as a result of copying and pasting information

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Entry of the wrong data into the wrong record as a high potential risk

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Over documentation, leading to challenges in accessing “accurate, relevant and timely information on a patient” at the point of care.

NIST identified the EHR copy-paste functionality as the culprit. In fact, we had reported on research from the University of California San Francisco Medical Center which found that up to 80 percent of the content in a typical progress note is copied or imported by clinicians which affects the validity of the notes. The NIST study concluded that the EHR copy-and-paste tool “has introduced overwhelming and unintended safety-related issues into the clinical environment.”

In 2013, a workgroup convened by the American Health Information Management Association (AHIMA) called for safe electronic documentation practices to ensure proper patient care. The workgroup pointed out that the electronic record should provide a clear idea of the patient’s condition at the time of admission as well as the changes that occur over time. EHR Intelligence cites from the report: “The provider must understand the necessity of reviewing and editing all defaulted data to ensure that only patient-specific data for that visit is recorded, while all other irrelevant data pulled in by the default template is removed.”

The workgroup also pointed out that automated EHR functions could compromise the integrity of clinical health data. They maintained that this concern should be addressed

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quickly before widespread deployment of health information exchange (HIE) to prevent “erroneous, incomplete, redundant, or untrustworthy data and records”.

Studies have also suggested measures to ensure the integrity of clinical documentation.

The NIST report made recommendations related to: •

Improving EHR design to improve visibility of information being selected for copy and paste to prevent inadvertent copy-pasting of certain areas of information versus all information

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Integration of EHR functionalities to reconcile that copied information was read consciously and edited by a clinical provider to acknowledge attribution of source information

The American Medical Association (AMA) and American Medical Informatics Association (AMIA) have also recommended changes to EHR design to enhance the integrity of clinical documentation.

AMA has called on EHR developers to design EHRs that reduce the cognitive workload on end users. Many providers feel that reading, writing, thinking and navigating the EHR system is not well balanced. The AMA notes that unlike paper charts, EHRs capture data in the structured format of drop-down menus and templates which can compromise the creation of a coherent narrative.

AMIA highlights the importance of simplifying and speeding EHR documentation, and makes two main recommendations: •

Decreasing data entry burden on clinicians by involving other members of the care

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documentation burden led clinicians to use the copy-and-paste functionality, which impaired EHR documentation.

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Separating data entry from data reporting: The AMIA points out that the patient’s story can be captured effectively only through narratives. Purely coded templates fail to do this and the resulting documentation has limited relevance to the patient’s unique circumstances. This also posed a barrier to effective clinician communication.

AMIA opines that EHR documentation requirements led to structured data being preferred to unstructured data.

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EHRs offer benefits ranging from quick and easy access to clinical data and alerts to avoid medical errors to care coordination and improved billing and coding. However, proper EHR documentation is necessary to realize these benefits. The lack of data integrity arises mainly due to the automated functionalities of EHRs. Copy-paste can leads to irrelevant and erroneous information which would compromise patient safety and care. Outsourcing medical transcription is a viable option to ensure accurate EHR data entry. Experienced medical transcription companies capture the first-person clinical narrative accurately, something that EHR documentation options cannot accomplish.

The use of medical transcription along with EHRs can ensure the integrity of clinical documentation and enhance patient care and safety.

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