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Editor's Note: This practice brief supersedes the March 2007 practice brief "Assessing and Improving EHR Data Quality."
QUALITY HEALTHCARE DEPENDS on the availability of quality data. Poor documentation, inaccurate data, and insufficient communication can result in errors and adverse incidents.1 Inaccurate data threatens patient safety and can lead to increased costs, inefficiencies, and poor financial performance. Further, inaccurate or insufficient data also inhibits health information exchange (HIE), and hinders clinical research, performance improvement, and quality measurement initiatives. The impact of poor data on care is only increased by the implementation of ICD-10-CM/PCS, the "meaningful use" EHR Incentive Program initiatives, and the introduction of payment reform models such as accountable care organizations (ACOs)- all of which emphasize the need for more specific and meaningful data collection, sharing, and reporting.
A meaningful electronic health record (EHR) improves the ability for healthcare professionals to enact evidence-based knowledge management and aids decision making for care. EHRs can have a positive impact on quality of care, patient safety, and efficiencies. However, without accurate and appropriate content in a usable and accessible form, these benefits will not be realized.
This practice brief discusses the challenges of maintaining quality data in the EHR and offers best practice guidance for ensuring the integrity of the healthcare data. It is designed to support and guide organizations, health information management (HIM) professionals, and providers to better assess, improve, and support the management of electronic health information.
New Focus on Data Capture Required
The ability to share electronic health information both internally and externally with healthcare organizations has been accepted as a method to improve the quality and delivery of care.2 Data integrity is critical to meeting these expectations. A single error in an electronic environment presents a risk that can be magnified as the data transmits further downstream to data sets, interfaced systems, and data warehouses.3 Accurate data leads to quality information that is required for quality decision making and patient care.
The quality of data contained in an EHR is dependent on accurate information at the point of capture- the data source. Clinical documentation also plays a key role in data quality. Clinical documentation practices need to be developed and standardized to facilitate accurate data capture and encoding. In an EHR, it is imperative...