To remain competitive in today’s healthcare environment, view recording data in the medical record in terms of the full information lifecycle. This cycle begins with the capture of data that is complete, accurate, and appropriate for the primary use of patient care, while effectively supporting secondary use such as care coordination, revenue-cycle management, external reporting, and patient engagement. “Collect once and use many times” is the motto here.
The quality of the data entered into the record determines the quality of the decisions that can be made with that information. Review encounter templates and develop standards for documentation. It may be helpful to think through how information from the record will be used, and identify key pieces of information that support secondary uses such as public and population health efforts, clinical research, health information exchange and care coordination, and patient use of the record. Are all relevant data points captured and documented in a way that is accurate, consistent, and complete? Does the record effectively tell the patient’s story and support care transitions? Does the record effectively demonstrate the quality of the care provided and support the calculation of quality measures? Are there gaps that need addressing?
After identifying the current state of data collection and documentation, determine an approach to fill the gaps. It’s important to prioritize and take a stepwise approach to your data quality initiative in order to give your patients the most valuable and pertinent information. Identify those high-value items that you want to address, such as data contributing to clinical quality measures or meaningful data that will be made available to patients through a clinical summary.
As an example, consider the assessment of disease activity. Upon review of the medical records for patients with rheumatoid arthritis (RA):
- Do you consistently document disease-activity assessment?
- At what point in the workflow is this information captured, and by whom?
- Do the individuals responsible for capturing the information have a clear understanding of when to document a disease-activity assessment, for what patients it is necessary, and how to record it? Is there suitable supporting information documented to provide context to the assessment, e.g., medications or patient lifestyle factors that might influence the outcome of the assessment?
- If the record was made available to the patient, or provided to another rheumatology provider or member of the care team as part of a transition of care, would he or she be able to identify the disease-activity assessment data and use them for continuity of care?
- Is disease-activity assessment documented in a way that can be used to calculate clinical quality measures?
If your health information is documented in a way that allows it to be transformed into actionable information, you are taking the first step to positioning your practice as a strong and financially viable organization that consistently delivers quality care.
