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Improving Clinical Data Integrity through EHR Documentation

What You Need to Know

In this article, we will cover everything you need to know about the role of EHR documentation in improving clinical data integrity.

Overview

No matter what industry you are evaluating, data is a hugely important component of operations. Additionally, the reliance on data is ever-growing. As many as 79 percent of business owners say that they expect their reliance on data to be even more important in driving major decisions in the coming year. In healthcare, data doesn’t just drive major decisions; it stands as the foundation for operational efficiency and high-level patient care. EHR (electronic health records) make recording patient data easy, but data entry is one thing and clinical data integrity bears an entirely different level of importance. 

When healthcare organizations have such a reliance on patient data, that data must hold a high level of integrity to be effectively utilized. According to one study provided by Medical Director, 90% of those surveyed reported that data integrity was one of the most important attributes when accessing patient health records. Take a look below at data integrity, why it is important, and how PrognoCIS can help.  

Clinical Data Integrity

What Is Clinical Data Integrity in Healthcare? 

Clinical data integrity is a phrase used to refer to the reliability, consistency, and accuracy of stored patient data. Data integrity must be maintained from the point patient information is input into an EHR and throughout the life span of that data. Therefore, in terms of healthcare, patient data must be continually monitored and maintained. Patient data can include patient information and personal details, clinical notes, test results, health summaries, and many other bits of information commonly included in patient records.

Why Is Maintaining Data Integrity Important in Healthcare?   ​

Maintaining Data Integrity Important in Healthcare

Lacking data management and maintenance can have severe implications for both the patient and the provider, such as:  

  • Impediments to quality patient care  
  • Lacking data integrity could lead to duplicate procedures and testing 
  • Heightened claims denials by payers  
  • Inadequate reporting and challenges with program participation (e.g. value-based care incentives or bonus payments) 
  • Heightened risk of medical errors or adverse events  
  • Higher costs and lower operational efficiency  

What Causes a Loss of Data Integrity in Healthcare?  

A report published in 2021, Data Integrity Trends: Chief Data Officer Perspectives, showed that most organizations utilize data extensively. However, these organizations also struggle with data integrity. Therefore, the question then becomes, why is maintaining data integrity such a trying feat? Factors that can affect data integrity in healthcare can be widespread. From who has access to input data to the type of EHR a provider is using, many items can influence data integrity. Other influential factors can include:  

  • Lacking staff training on how to use EHR for data input  
  • Not using assigned workflows within an EHR  
  • No data integrity measurement efforts like data observability  
  • Lacking data governance initiatives  
Female doctor working with laptop computer in her office for electronic medical record

Why Do We Need Data Accuracy? 

In healthcare, the integrative use of EHR systems has the potential to enhance patient care and provider efficiency. However, the potential of EHR benefits rests on patient data that has been entered and maintained with integrity in mind. Therefore, data integrity is exceptionally important.  

If clinicians do not have access to accurate data, this can interfere with how they provide patient care. For example, if a patient has a severe reaction to a medication but the data to notate this information in a patient’s EHR is not well-captured, this could lead to patient injury. Accurate, timely data in modern practice ensures a gold standard of patient care across different clinicians and platforms.  

How Does an EHR Help Improve Data Quality and Integrity?  

Digital EHR documentation can help improve data quality and integrity compared to physical data in a number of ways. EHR documentation can help to deter problems with input errors or lacking legibility in patient files. 

EHRs can also improve the amount of data collected during patient interaction. For example, a well-designed EHR will have prompts that guide staff members and clinicians to enter certain data points during an appointment that may be relevant during the claims submission process. This data can also be automatically cross-referenced in other pertinent files, which can mean less paperwork for the clinician. Using an EHR could also reduce the number of claims denials and reduce the burden of clinical reporting agendas.    

How PrognoCIS Can Help 

When you have the best EHR in place, improving data integrity can be an easier effort. For example, PrognoCIS EHR has onboard features like streamlined workflows, stable complementary modules like Medical Billing and Practice management, and more. In addition, PrognoCIS EHR is customizable to ensure the platform is most effective at collecting data in a specific niche of healthcare.  

With PrognoCIS, clinicians can seamlessly transfer data between one another and handle data conversion in different formats without affecting integrity. Also, the software has excellent patient privacy features and protective measures to maintain top-notch data security.  

Frequently Asked Questions (FAQs)

Using programs and reports to periodically run internal audits to detect data issues helps to preserve data integrity.

Ensuring accurate data in your healthcare organization is essential. Having ongoing staff training and putting in place a data security program that will prevent unauthorized access can help.

Data integrity in EHR is having up-to-date, accurate, and reliable information. The information must maintain its integrity when replicated across different data points.

Patient identification and information as well as clinical input are some types of data integrity in healthcare.

Data integrity is critical to healthcare because it helps the organization operate efficiently, patients are accurately identified and get the best possible care, and billing claims are submitted with accurate information preventing denials. 

There are four primary pillars to maintaining data integrity. They are the key steps for using, entering, sharing, and storing data in an EHR.  These steps are… 
1.Entity integrity  
2.Referential integrity  
3.User-defined data integrity  
4.Domain integrity

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Takeaway Message

Clinical data integrity is undeniably an important topic in healthcare. If you believe your EHR does not support your efforts to maintain data in the most effective way possible, it may be time for a change. Reach out to discuss how a change to PrognoCIS EHR could help with data integrity 

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