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AHDI Track

Improving Patient Quality of Care and Safety with the EHR

The ability to extract and analyze data collected with the EHR can lead to significant improvements in the delivery of quality care for our patients and improvement in patient safety. 

We have a new generation of physicians who have grown up with computer technology. They are enthusiastic about the possibilities this technology can bring. They are not interested in chasing paper charts. They are concerned with improved patient care, achieving greater efficiencies and reducing healthcare costs. This will become even more important with the recent Supreme Court decision upholding the Patient Protection and Accountable Care Act.

It is in this setting of growing demand for improved clinical outcomes, quality patient care and safety that healthcare documentation specialists are poised to play a vital role. Documentation is the foundation necessary to drive quality.

The Institute of Medicine defines quality as the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge.1 In today's world, quality is measured by the outcomes achieved. Quality in patient care is safe, effective, patient-centered, timely, efficient and equitable.

What determines if a patient receives quality care? The answer depends on who is defining quality. The healthcare provider believes quality care has been delivered when the outcome is a positive one. The patient believes quality care has been received when the treatment has been successful and is satisfied with the overall experience. The payer (for example the insurance company) believes quality care has been achieved when the outcome is positive, the treatment provided has been cost-effective, and unnecessary testing or duplication of services has been avoided.

How does the use of an EHR in a hospital or ambulatory setting improve patient quality care and safety? The goals of "Meaningful Use" of the EHR are clearly geared toward achieving better outcomes and improving quality of patient care. Improving quality, safety, efficiency and reducing health disparities; engaging patients and families in their health care; improving care coordination; and improving population and public health while continuing to maintain privacy and security of protected health information is the goal. MU is about improving health and transforming health care.

MU has been divided into three stages to allow successful implementation over time. Currently, we are in Stage 1, which emphasizes data capture and sharing. Information needs to be electronically captured in a coded format that can be used to track key clinical conditions. Communicating and exchanging this information with other healthcare providers to ensure coordination of care is essential. Methods for reporting clinical quality measures and public health information must be built.

A brief examination of the measures in Stage 1 of MU shows their influence on improving quality and safety of patient care.

Computer physician order entry allows the direct input of medication orders in a digital and structured format. As the order is entered, clinical decision support is available to assist the physician in his decision-making. Alerts are generated about possible drug interactions. The functionality of implementing drug-drug and drug-allergy checks is important in preventing and eliminating adverse events. 

Recent studies have shown that e-prescribing leads to improved outcomes with potential savings of $140 billion over the next 10 years.2 Electronically transmitting prescriptions eliminates the dangerously scrawled, handwritten prescription where drug name, dosage and instructions can be misread, leading to errors in medication management. E-prescribing also helps to monitor drug therapy and usage.

Providing a patient with an electronic copy or clinical summary of their health information within three business days of their visit will increase the likelihood that the patient and family members will become more engaged in their healthcare and participate more fully with better compliance.

Fulfilling the goals of coordination of care requires the capability of exchanging key clinical information with other providers while at the same time protecting and maintaining the privacy and security of that information.

Reporting on the clinical quality measures (CQM) is an indicator of the quality of care that patients receive. Required measures include weight management, pairing of the tobacco usage assessment and a tobacco cessation intervention, and hypertension or blood pressure management. Alternate measures could include the Hemoglobin A1c blood test for diabetes, an eye exam and a foot exam. The HemoglobinA1c indicates the degree of control of glucose, while the eye examination can indicate the presence of a condition called diabetic retinopathy. Diabetic retinopathy has shown a significant jump over the past 10 years because of the rising incidence of diabetes in the U.S.3

As for the future, the new rules for Stage 2 of MU are scheduled for release later this summer and are expected to raise the bar for the criteria in Stage 1. The ultimate goal is improving clinical outcomes with better patient care and safety while increasing overall efficiency and controlling costs in our healthcare system.

The healthcare documentation sector is being transformed by the changing healthcare environment. Now is the time to address the increasing complexities in healthcare documentation that are being driven by the rapid changes in technology and the need for quality and accuracy of documentation.  Faster turnaround times must be met while at the same time lowering the costs associated with documentation.

The Association for Healthcare Documentation Integrity (AHDI) is leading the way in preparing the workforce of healthcare documentation specialists to successfully transition to future roles that are growing out of the increasing use of the electronic health record. High standards of education, professional credentialing and practice are necessary components as the role of healthcare documentation specialists evolves.  

Ann Donnelly is the owner of Transmedical Services Inc. in Miramar, Fla., and AHDI District 6 director.

1.    National Research Council. "Front Matter." Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001.

2. Health Management Technology. E-prescribing shown to improve outcomes, save billions. April 2012. 22-23.

3. Hellmich, N. Diabetes epidemic brings spike in related eye disease. USA Today. June 20, 2012.

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