With the spotlight squarely on the physician office in national initiative to promote widespread adoption of electronic health records (EHRs), many physicians and practice managers are currently...
With the spotlight squarely on the physician office in national initiative to promote widespread adoption of electronic health records (EHRs), many physicians and practice managers are currently (or soon will be) focused on the selection and implementation of this information technology, which promises greater efficiency and the potential for improved payment and enhanced quality of care. However, it is well documented that the ability of information technology to fulfill these promises is heavily dependent upon a complex set of people and process issues that one ignores at his or her own peril.
When implemented well, EHRs can no doubt increase day-to-day office efficiency and facilitate workflow, but the downstream uses of the information contained in the EHR offer the greatest potential for supporting improved payment and enhanced quality of care. Companies selling software applications and EHR systems often do not include information management processes in either the build or services associated with buying and implementing their products. This often overlooked process is critical for meeting the needs of the practice and ensuring successful long-term utility. As a critical business process, information management must be built into the system if the practice is to realize full benefit from its investment.
Information management means ensuring the availability of high-quality data and information that can be used for multiple purposes, both anticipated and unanticipated, during its life cycle. Information management in the context of the EHR is referred to as electronic health information management (e-HIM) by the American Health Information Management Association (AHIMA).
The cornerstones of e-HIM are data quality management and records life cycle management. There are some important questions to consider:
• Can your EHR provide data with the quality and granularity necessary to benefit from proposed pay-for-performance programs? Can it do this without causing you to incur additional costs and/or procure additional resources for necessary data collection?• Can it manage and track referrals to and from other providers? What about providing the information needed in the event of a payer audit or legal action?• Can your EHR contribute to improvements in quality by facilitating communication with patients? Provide necessary data in the event of a drug or device recall? Support reporting for public health or disease management purposes?
Data Quality Management
Most systems technically possess the ability to collect and report health data. However, their actual ability to do so is affected by the quality of data that is collected and reported. Achieving and maintaining high-quality data is critical and is an ongoing need that will require effort long after the initial EHR implementation is completed.
Managing data quality involves evaluating the following characteristics of data:
• Existence: Does your EHR collect and maintain all required data?
• Validity: Does the EHR allow only data within acceptable ranges or domains?
• Consistency: Does the same data element have the same values even when stored in multiple locations?
• Timeliness: Is the data available when needed and at optimal points in your workflow or business processes?
• Accuracy: Does the data represent what it is meant to represent? Does it provide a correct description?
• Relevance: Does the data support the needs of your business?
There are many strategies for managing data quality, one of the most important being the use of a data dictionary. Data dictionaries standardize definitions and help to ensure consistency of use of terms and concepts. Multiple users of the system within the practice will have the same understanding of each field or data element, thereby supporting internal data quality. Taking this one step further, EHR vendor's systems can incorporate the use of standard terminologies in their products that can be mapped against the organization’s data dictionary. This helps to ensure common meanings as data is exchanged externally.
In addition to meeting the needs of individual provider practices, data quality management is critical in ensuring that usable, understandable data can be exchanged among disparate EHRs. The goal of interoperability and exchange of data throughout the healthcare delivery system cannot be achieved without ongoing commitment to data quality management and adherence to standards for capturing, defining, and transmitting data. Industry work in developing and refining these standards is well under way.
Electronic Records Life Cycle Management
In addition to data quality management, another important process often neglected in the selection and implementation of EHRs is “records management.” Concerned with ensuring a high level of integrity for the express purpose of meeting business and legal needs, electronic records management focuses on managing the life cycle of the record and preserving information for evidentiary purposes.
It requires defining the boundaries of the EHR, especially when integrated with other applications such as practice management or decision support systems—identifying what information is part of the health or medical record and what is not. For example, are patient-generated records that have been scanned into your EHR part of your legal record? Are alerts and reminders that may have been ignored or overridden included when a subpoena for “any and all” records is received?
The digital nature of electronic health information makes it both easily modifiable and easily transmissible via networks. These two characteristics can pose significant challenges to maintaining the integrity of the information. Specific issues such as authentication, authorship, and handling of errors and amendments can take on a whole new meaning in the context of digital information.
Records management informs decisions about a large and diverse set of business needs, such as how to proceed when transitioning from paper charts to electronic records; protocols to manage e-mail communication with patients; retention and archiving of electronic data; and when, if ever, to convert information back to paper.
Traditional business and health records management concepts and processes must be evaluated and applied in this relatively new world of the EHR. Business process redesign and a solid understanding of the change management process are critical for understanding and implementing a sound health records management program. Physician practices will need to analyze and assess all downstream uses of the EHR and see those uses reflected in decisions about selection, purchase, and implementation.
Strategies for Success
One of the most important activities in the process is to ask tough questions of the system supplier and include their commitments regarding data quality and records management in the written contract. Make sure you are comfortable with the answers provided before going any further.
When selecting a system, carefully evaluate aspects of the system that will allow for optimal information management. At the bare minimum, this will include:
• Ensuring that the user interface facilitates accurate and timely data capture.• Supporting the organization’s data dictionary.• Using data standards, including standard terminologies, as appropriate.• Integrating data flow with clinical workflow.• Auditing trails that show details related to changes in the data.• Ensuring solid electronic or digital signature authentication.• Incorporating business rules for archiving inactive records.Keep Current on Industry and Public Policy Initiatives to Foster Adoption of EHRs
As these efforts continue, we will see more standardization of the functionality of EHRs, some of which will address data quality and records management. One of the early initiatives, certification of ambulatory care EHRs by the Certification Commission on Health Information Technology, will provide an increased level of assurance that a particular EHR software product includes the required functionality to support physicians and practices in selection of an EHR. Certification criteria are evolving, however, and are only part of the selection decision. QualityNet is another useful resource for small and medium primary care practices seeking to ensure data quality as EHRs are implemented.
Obtain Legal Counsel or Business Advice From Professional Associations for Information Practices That May Be Mandated by State or Local Law
Information practices related to release of information and records retention, statewide registries, and required reporting at the state level can often be obtained from medical professional societies, healthcare licensing bodies, or the state's health information management association. AHIMA maintains a list of state HIM associations and contacts on its website.
Judicial standards for discovery and admissibility of electronic records are beginning to change to keep up with the information age. Consult with an attorney knowledgeable in this area or your malpractice carrier to ensure that the way your electronic record system is implemented and operates will support legal and business needs.
Utilize Available Educational and Information Resources for Data Quality and Records Management
AHIMA maintains an extensive library of standards and best practices for managing health information in the EHR. Available resources address: transitioning from paper to electronic health records; legal health record requirements; electronic health records management; external data reporting issues such as regional health information organizations and patient identity; and data quality management, including the use of data dictionaries. These resources can assist with staff education and planning needs as physician practices implement EHRs. For more information, visit www.ahima.org/infocenter.
The information contained in the EHR is a strategic resource for ensuring clinical quality and meeting the business needs of the practice. Only by incorporating rigorous information management processes that result in data quality and plan for record life cycle management will the practice be able to take full advantage of this resource. It is critical to consider information management needs during the selection and implementation phases of an EHR.
Lydia Washington, MS, RHIA, CPHIMS, is currently with the Practice Resources section of AHIMA. A former director of health information management, she is a contributor to AHIMA's practice briefs on moving from paper to electronic health records and the legal health record. Contact her at firstname.lastname@example.org.