Why Clinical Data Integrity Matters
Maintaining accurate data in a patient’s health record is integral to providing quality patient care and submitting valid reimbursement claims. From a clinical perspective, good data is instrumental to patient safety and can improve patient outcomes; from an administrative perspective, it can ensure compliant billing and prevent fraud.
The vanguard of recent advancements in HIT infrastructure, initiated by the HITECH Act (2009) and bolstered by the ONC’s roadmap to interoperability plan (2014), have expanded the capability of the electronic exchange of health information. Therefore the need for accurate clinical data has become increasingly more important because patient records are being exchanged electronically at higher rates than ever before.
How Clinical Data Becomes Compromised
From the wellspring of technological advancements arise challenges associated with the use of new systems and software. Both the National Institute of Standards and Technology (NIST) and CMS have identified copy-and-paste and auto-fill (such as templates and drop-down lists) functionality in EHRs as contributors to the following data integrity concerns: inaccurate patient information, over documentation (“note bloat”), and fraudulent claims.
During a 2015 study on EHR usability, NIST identified the reuse of data from functions such as auto-fill to be a major contributor to the lack of EHR data integrity. A follow-up study published by NIST in 2017 concluded copy-and-paste functionality “has introduced overwhelming and unintended safety-related issues into the clinical environment.”
The CMS Center for Program Integrity has issued numerous guidelines addressing the data integrity issues associated with using EHRs and is working with ONC to create standard protocols regarding the use of copy-and-paste and auto-fill functionality. The impetus for this recent coordination of efforts between CMS and ONC were annual reports from the Office of the Inspector General (OIG) warning of the growing problems of fraud, abuse, and waste due to improper use of these features within EHRs.
The American Health Information Management Association (AHIMA) further expands on this, stating medicolegal integrity issues could make clinics vulnerable to patient safety errors and medical liability and recommends healthcare organizations have procedures in place to govern the use of copy-and-paste and auto-fill functionality by clinicians.
Best Practices for Improving and Maintaining Clinical Data Integrity
Some built-in EHR functionalities (such as templates and text copy-and-paste), while designed for efficiency, can lead to the unintentional addition of information in a patient’s health record if used improperly.
To do your part in maintaining clinical data integrity, prevention is key and also the easiest approach to implement change. If using templates or auto-fill features in your EHR:
- Clearly define the situations in which templates or copy-and-paste are appropriate to use for patient visit documentation
- Review templates and auto-fill text for duplicated information and typos
- Remove retired ICD-10, CPT, and HCPCS codes from templates or any stored data lists in your system
- Discuss or reinforce the importance of clinical data integrity with clinic staff to create an environment of awareness and understanding
CEHRT and Clinical Data Integrity
Being a certified EHR lets clinicians know they are using a product they can trust because it has been rigorously tested to meet ONC’s technical and design standards. These standards make it possible for EHRs to share clinical data with any HIT system that supports the same standards. However, there are misconceptions about using CEHRT with regard to clinical data integrity.
Some clinicians have been led to believe that by using a certified EHR, they are safeguarded from data errors or have a guarantee of quality clinical data. A certified EHR—and HIT systems in general—do not verify if data is accurate for the patient or visit, only that it meets the structural standard for the data type. Ensuring the right information is entered in a patient’s health record is the shared responsibility of all contributors to that record.
Summary
- Quality healthcare—from patient services to billing—is dependent on quality data
- Clinical data integrity starts at the clinic: use the guidance provided as the basis for creating a comprehensive quality improvement process
- Knowledge is power: educate all staff about their role in clinical data integrity