Hands On Help

Data Quality in EHRs-Not So Fast!

The importance of patient information in clinical research.

LESLIE: Since the early part of the last century when medical record keeping transitioned from patient registers with multiple patient histories, to one discrete record per patient, healthcare providers, researchers, administrators and policy makers have been frustrated by incomplete, inaccurate, untimely, fragmented, inaccessible, and often illegible medical record information. Since the 1960s, we have hoped and dreamed electronic health records (EHRs) would be the answer to solving those problems. Now we have EHRs and the problems are still with us. How frustrating is that?

PATTY: Your assessment is a little harsh, Leslie. We have seen some progress - documentation in EHRs is more legible, which has helped with accuracy. Accessibility is improved as more than one person can access a record at the same time. But I agree, there is still a long way to go to achieve nirvana, especially to reach the level of quality data necessary for the needs of today's complex healthcare environment.

LESLIE: The patient record has long been a mission-critical source of information for high-quality and efficient patient care, medico-legal purposes, reimbursement, education and research. The record must serve many masters; automating it without sufficiently addressing how people working in healthcare create and use information both during the care process and afterward has resulted in data degrading "work arounds," and much consternation in the healthcare community. While the impact of the EHRs on the physician-patient relationships has had pluses and minuses, the most serious EHR issue today is data quality. Everyone wants to know if they can trust the data in EHRs to make good decisions.

PATTY: I agree. Let's look at one important use of patient information that we see up close - clinical research. Our research staff recently attended the 19th Annual International Meeting of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR), where they heard a lot about how clinical researchers want "real world" evidence (RWE) to inform clinical decisions making. Denise Moline, RHIA, director of research services at Care Communications Inc. summarized it well in a recent blog post, "Electronic Health Records, Big Data and Real People". Denise, may we quote you?

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DENISE: Of course you can. The speakers at the conference mainly focused on the technical aspects of clinical research, including chart review, data abstraction and analysis to get real-world evidence. As I listened, I couldn't help but think about the real people behind the data and the processes. Here is part of what I wrote:

"My imagination is inspired.

Dr. Smith entered the medical profession with a passion for helping patients. While building her practice, she enjoyed several rewarding years, establishing solid relationships with her patients. However, in recent years she has found herself increasingly disillusioned and discouraged. Though she has enthusiastically adopted technology in all areas of her life and has moved from keeping medical records on paper to an electronic health record (EHR) system, she feels she was forced to adopt a poorly designed system due to government-sponsored mandates and pressures from health care payors. She had no choice but to implement these changes if she wanted to maintain her practice, but the EHR system is difficult to use, so Dr. Smith spends less time with her patients these days and more time completing tedious EHR forms.

Mrs. Jones has been a patient of Dr. Smith's for many years and was curious about the change from a paper medical record to a computerized record. Dr. Smith often seemed more focused on the computer than on her during their visits. Mrs. Jones knew Dr. Smith's practice was affiliated with her health plan, but not until she was seen by a specialist who was also part of this health plan did she realize how easy and helpful it was for her other doctors to access her EHR. Unfortunately, Mrs. Jones' most recent experience with the healthcare system in her local area has left her feeling disillusioned and discouraged. When she visited yet another specialist for an urgent medical issue, Mrs. Jones did not realize his practice was not affiliated with her health plan. Neither she nor her new doctor had access to her medical history, so Mrs. Jones had to delay critical treatment until she could find a way to do the paperwork and legwork required to get copies of the needed medical records.

Ms. Brown works as a clinical data abstractor in the Care Communications Research Services Department. During various research projects, she often reviews record copies from the health plan Dr. Smith and Mrs. Jones are part of. Ms. Brown and her colleagues have been abstracting and coding medical records for a wide variety of studies since before Dr. Smith began practicing medicine in the early 1990s, so she is intimately acquainted with how health care has been documented over the years and how medical records have changed with the advent of EHR systems.

During study-focused record review, Ms. Brown can easily recognize patterns in documentation that reflect physician frustration with the poorly designed EHR system. For example, notes may be copied verbatim for multiple encounters, including identical weights or vital signs that Ms. Brown knows will fluctuate from visit to visit. She alerts study researchers to such redundant data and asks how or whether it should be abstracted. She identifies discrepancies in documentation related to the study drug of interest and digs further in the record to determine the accurate data for abstraction. Ms. Brown also detects clues that study-relevant records for a patient are missing (perhaps because the patient was referred to a specialist outside her health plan), and she reaches out to the study team to determine whether these records should be sought.

Policymakers have ambitious dreams for sharing EHR data and using collections of big data for health care decision-making, but in order for some of those dreams to come true, such issues as EHR software functionality and interoperability, problems with the completeness and accuracy of medical records, patient satisfaction, and health plan data sharing will require the attention, engagement and intervention of real people throughout the health care system for years to come."

LESLIE: Thank you, Denise, for sharing some of the challenges of doing clinical research with today's EHRs. Ongoing feedback from you and your research colleagues will be crucially important to individuals responsible for managing and improving EHRs over the coming years. 

PATTY: Throughout the industry people are chomping at the bit to get their hands on "big data" to achieve the Institute of Medicine's vision of better quality care at a lower cost. Whether for use in clinical trials, health economic outcomes research, drug safety studies, or other important healthcare analytic activities, in the future, data extracted from EHRs will be the single most significant data source needed to have confidence in important patient care and health policy decisions.

LESLIE: We are past the era of merely analyzing claims data to understand what's happening on the ground. The stakes are higher than ever. To succeed in transforming the U.S. healthcare system, we need and want much more reliability from healthcare analytics. There is no way around mining data from the EHR - the source document that must become highly reliable.

Leslie Ann Fox is chief executive officer and Patty Thierry Sheridan is president, Care Communications Inc., Chicago. You can follow Leslie and Patty on their Twitter accounts, @FoxatCARE, and @pattytsheridan. Leslie and Patty invite readers to send their thoughts and opinions on this column to lfox@care-communications.com or ptsheridan@care-communications.com.

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