Did you know that the health information stored by your practice could be one of your most valuable assets?
Rheumatology practices currently own significant data resources from clinical, financial, and operational systems, but not many practices have turned these resources into information assets that can be used for effective decision making. Creating an information-management infrastructure to address the way your practice creates, consumes, and manages data can help you leverage the data owned by your practice to improve patient care, lower operational costs, improve revenue cycle management, and enhance your practice’s ability to respond quickly and effectively to changes in the healthcare environment.
Data Come from Many Sources
When “data” are mentioned in a healthcare context today, many assume that they exist in an electronic form. However, medical practice data exist in both paper and electronic systems and can originate from many systems. Today, health data exist outside of locked and static recording and storage mechanisms, and the patient medical record is evolving from labeled file folders to digital databases.
Tools like patient registries, electronic health record (EHR) systems, and health information exchanges are making data collection, management, and analysis more accessible for small practices. These tools empower providers to use information in medical records to support evidence-based patient care, regulatory compliance, quality-reporting initiatives, public and population health efforts, clinical research, and patient use of personal health records. Whether operating with an EHR or paper medical records, medical practices should consider data analysis and repurposing an essential part of operations.
Although there are tools available to support analysis and to maximize the value of your data, there are still significant challenges in managing the data and creating actionable information. Using paper medical records requires data to be manually abstracted and re-entered into systems that can then manipulate and analyze the information. EHR systems can streamline this process, but there are still usability issues with EHR data. These data are often captured in the form of a free text document or a scanned PDF, rather than as discrete identifiable data, making information difficult to find and analyze. The first step to effective information management is to assess the availability and quality of your data.
Collect Once, Use Many Times
As our health system evolves, so should our view of the medical record. With the increased complexity and costs of running a practice, an emphasis on highly coordinated and quality-oriented care, and a growing focus on the engaged and informed patient, the medical record has become more than an episodic documentation of care.
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.
By coordinating and combining data found in clinical, operational, and financial systems, you can begin to take a broad view of the state of your practice. This will help you analyze performance, recognize trends, and make better business and clinical-care decisions. Transforming data into information can also provide the insight needed to identify and strategically target areas for improvement in revenue cycle, practice workflow, and clinical-care delivery.
For more information on making the most out of data collected in your record systems, contact the ACR health informatics staff at [email protected].
