Data integrity is becoming a focal point of many hospitals that have recently gone live with their multi-million dollar electronic medical record (EMR) systems. While moving from paper to electronic medical records helps hospitals improve EMR accessibility and portability, it does not do much in the way of removing human error. This becomes a potential “garbage-in, garbage-out” issue as hospitals now look to the next step of their EMR evolution: the health information exchange (HIE).
Now is the time for hospitals to look at improving the clinical documentation quality in their EMRs. Otherwise, hospitals may be putting their patients at risk by having inaccurate data in EMRs, despite the best of intentions. As this article by Kyle Murphy at EHR Intelligence discusses:
“Without safeguards in place, records could reflect an inaccurate picture of the patient’s condition, either at admission or as it changes over time,” the AHIMA [American Health Information Management Association] workgroup wrote. “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.”
What’s more, the authors of the EHR documentation guidance emphasized the urgency of addressing how the use of automated EHR functions could compromise the integrity of clinical health data.
“Data quality and record integrity issues must be addressed now, before widespread deployment of health information exchange (HIE),” they maintained. “Poor data quality will be amplified with HIE if erroneous, incomplete, redundant, or untrustworthy data and records are allowed to cascade across the healthcare system.”
Read the entire article here: Improving Clinical Data Integrity through EHR Documentation
There are many ways that hospitals can reduce the significant human errors that can be caused in EMR data entry. One method to achieve this is to automate data entry as much as possible. Natural language processing technologies will help by offering real-time transcription for clinical documentation. Automated data capture systems, such as iRISupply, can also provide high quality data by integrating RFID data capture technology directly into your EMR.