Ideally, the health data in an electronic record should be accurate, up-to-date and complete, "but unfortunately the real world is far from ideal,” the American Health Information Management Association (AHIMA) stated in a recent report.
According to the report, "High-quality data requires a very clear understanding of the meaning, context, and intent of the data – unambiguous and, ideally, standardized computable definitions of data that can form the basis for future safe decision making."
It seems a no-brainer but the report’s authors stated, “The ultimate goal of any HIE should be accurate identification of the patient,” adding that HIE patient identity is normally based on “the patient identifier as a cross-reference profile that matches patients by cross-referencing IDs; the patient demographics query profile, which queries a central patient information server; and patient administration management, knowing where the patient is, was, or is going.”
To ensure data integrity most completely, HIEs “should assign a unique patient/person identifier by using advanced record matching techniques – for example, probabilistic algorithms and manual processes – as needed,” stated Bailey-Woods and her colleagues, who wrote the report.
Industry standards that should be in place for protected data include system interfaces, algorithms, unique identifiers, business processes, data accuracy, data quality, training and medical devices. Industry standards regarding data quality could therefore produce tremendous benefits both in terms of monetary savings and quality of care.
"Quality information is essential to all aspects of today's healthcare system, so improving the quality of data, information, and knowledge is paramount as we transition from paper to EHRs," stated the report. "Many errors and adverse incidents in healthcare occur as a result of poor data and information. In addition to threatening patient safety, poor data quality increases healthcare costs and inhibits health information exchange, research, and performance measurement initiatives."
Health information management (HIM) professionals play a critical role, say AHIMA authors, by leading initiatives related to standards, technologies, education, and research that are vital for capture, use and maintenance of accurate healthcare data and facilitating healthcare’s electronic evolution.
No one denies just how crucial EHRs are to facilitating the evolution of healthcare. But mistakes can be fatal. Imagine two patients with the same name, one in for heart surgery and the other, for a knee replacement, or even patients with different names, both scheduled for amputations, and one patient’s surgery is performed on the other patient. You can’t say it happens all the time, but the possibility is certainly there.
That’s why it’s so critical for EHRs to be as accurate as possible.
Even giant GE Healthcare is not without problems in the accuracy department. Last October it admitted that flaws in its electronic medical records software reporting functions could throw off results from reporting tools that many customers rely on to produce reports necessary to prove Meaningful Use.
Edited by
Brooke Neuman
