Healthcare Technology Featured Article

April 19, 2023

How to set up an electronic records management system in five steps

Electronic health records (EHRs) have already become an essential tool for most healthcare organizations across the US. For example, according to the American Hospital Association (AHA), up to 98% of healthcare providers use EHRs.

However, legacy EHR solutions need more interoperability and better usability. As a result, healthcare providers rely on EHR optimization to solve these issues or, in case the problem is severe, turn to IT vendors for custom EHR software development.

EHR can be a valuable source of information about a patient's health, but to use it effectively, you need to ensure proper EHR data management. So how to do it with reasonable effort and time investments? We'll figure it out.

What is electronic records management?

Electronic health records management is a largely automated process encompassing a range of tasks related to the work with structured and unstructured data on patients’ health. These tasks include:

  • Comprehensive health data collection
  • Secure health information storage
  • Medical data processing
  • Patients’ health data analysis and review for errors

Electronic health records usually host large sets of structured and unstructured data to help clinicians deliver necessary personalized care to every patient.

Step-by-step implementation guide

Electronic records management is a continuous and multi-step activity.

Step 1. Designing a data governance strategy

The data in the EHR should not be a dead weight, stored unused in the provider's systems or the cloud. To ensure the good performance of EHR systems, a data governance strategy is required.

In the healthcare industry, data governance is a set of approaches that help providers achieve engaged participation from their staff and represent the interests of the entire organization in using data for making critical decisions. An important part of healthcare data governance is monitoring data quality to ensure that the organization successfully achieves its desired outcomes and gains business value from data management activities.

Besides, a well-designed data governance strategy also encompasses how a provider can share data with other providers while complying with HIPAA and ensuring their patients' data safety. Additionally, such a strategy can foster the use of IT technologies and electronic records management software.

Step 2. Adopting a suitable EHR management solution

Several solutions can help turn paper-based health records management into an electronic format.

First, these are tools for automated data entry or virtual scribes. Powered by NLP and voice recognition technologies, these automated assistants have become an excellent asset for EHR systems, as they make EHR input stress- and hands-free. Dictating electronic records data to virtual scribes, clinicians reduce inaccuracy and errors, further speeding up the recording process.

Another solution that complements EHR management is clinical decision support software (CDSS). It helps clinicians to prevent errors in prescriptions and medical histories. For example, the Food and Drug Administration (FDA) receives 100K medication error reports annually. CDSS can prevent the majority of such errors.

Integrating the solution with a health record system during EHR implementation or later is possible. This effort can help clinicians ensure proper Rxnorm coding for drugs, lab results with clearly set ranges, and correct detection of high-risk patients (also known as flagging).

Step 3. Performing regular data cleanups

The quality of data in EHR systems deteriorates with time as some patients change their residence, name, and healthcare provider. Therefore, incorrect and insufficient data in an EHR system can lead to inaccurate insights from analytics and a decrease in patient outcomes and experience.

To prevent this, providers should regularly examine the EHR system, detect inaccurate data and data gaps, delete faulty entries, and fill in the missing information. However, it is time-consuming, so a provider can consider using professional data quality assurance services.

Step 4. Adding social determinants

The pandemic has demonstrated that neither doctors' recommendations nor the current health status drive patients' health behavior. Instead, according to the health impact pyramid, it's socioeconomic factors, including poverty, education, housing, and inequality

If socioeconomic factors are the cornerstone of health choices, adding them to the EHR solution can be beneficial. Adding social determinants can foster better analytics and the subsequent development of diverse engagement programs. The effort can also help with the initiatives that mitigate socioeconomic challenges for specific patient populations.

Step 5. Training employees

Though EHR solutions simplify medical professionals’ work, the satisfaction rate among clinicians, nurses, and other medical workers is considerably low. According to the KLAS report EHR Satisfaction in Providers with Complex Work Arrangements 2022, up to a third of health professionals name EHRs among their burnout contributors.

When working with an EHR solution, doctors have to deal with issues that hamper their daily clinical work. These are typically data errors and contradicting data on the same patients across different EHRs. To reduce such effects, it is necessary to conduct preliminary employee training, taking into account their level of computer literacy. You can also select expert users among employees to help others learn the ropes of the EHR solution.

What’s more, it won’t hurt to employ communication technologies for EHR training. For instance, Vidant Health in Greenville, North Carolina, successfully resolved the complex task of providing EHR training to doctors traveling across care locations, KLAS reports. Their method consists of video instructions centered around typical clinician workflows. Besides, clinicians attend three-hour-long, setting-specific (inpatient, ambulatory, or emergency department) classes, and those working in multiple settings must attend each related class.

Closing thoughts

Today, EHR is considered a universal tool for storing information about patients, helping clinicians manage patients’ health and prevent adverse health events. Nevertheless, these tools still present difficulties for doctors due to faulty data – duplicates, erroneous entries, or blank spaces.

To use EHR solutions to the fullest, healthcare providers should proactively manage patients’ health data. They can build an effective health record management process by implementing regular data cleanups, arranging employee training, and following other best practices.

Get stories like this delivered straight to your inbox. [Free eNews Subscription]


FREE eNewsletter

Click here to receive your targeted Healthcare Technology Community eNewsletter.
[Subscribe Now]