Historically, a patient’s electronic medical record was a way for the healthcare team to keep an account of the patient’s care. Over time, the record has become integral to sharing information with care teams across organizations, documenting quality care, ensuring accurate and timely payment of services, and detailing treatment plans across the care continuum.
Today, the patient is a primary consumer of their own health information. Real-time or near real-time access to upcoming appointments, medications, results, notes, and information to guide decision making is expected. With just a few clicks, their record is at their fingertips. Silos of data are no longer an option, and the exchange of data is no longer a luxury but a core element. By interacting with medical information, patients are empowered to be engaged in their care, share their information with others, and be a steward for the integrity of their longitudinal health record.
Advocates for patient centered medical records
As architects of data, healthcare IT has the opportunity to embrace the challenges that come along with multiple EHR platforms and help to lead the paradigm shift to a patient centric medical record. Improvements in interoperability continues to happen in the background of enterprise EHRs and clinical information systems. Members of a multi-disciplinary team (including health information management, healthcare IT, interoperability and compliance teams, and clinical leadership) focused on the clinical and patient care facing aspects of data collection and exchange are instrumental in helping ensure an accurate and timely healthcare record.
Provide ongoing education about interoperability and data sharing regulations
Timely and accurate data is integral to quality patient care and ultimately patient centered medical records.
Challenge: Incorrect data on a patient’s medical record can have lasting implications. For example, documenting a patient as a smoker is data that will follow the patient across visits and organizations, creating confusion and possibly adjusting plans of care. Plus, inaccurate data can erode patient confidence in the healthcare organization.
Best practices:
- Make data correction a priority.
- Encourage data review at time of entry and empower staff to quickly correct errors.
- Have a defined process to rectify and communicate updates to data exchange partners.
- Help care teams and employees stay informed on interoperability and data sharing regulations.
Optimize notes in patient records
Notes can be an effective way to communicate information about a patient.
Challenge: A note that only states “Patient resting. No requests at this time” could easily be converted to a discrete element. However, notes such as these in a patient’s chart can require sifting through more notes than perhaps necessary in order to find relevant information.
Best practices:
- Engage leadership to evaluate note writing practices by groups of users.
- Look for notes with information that can be captured in another manner.
- Review Note templates.
- Validate that templates are accurately pulling from other parts of the system on a regular basis.
- Confirm that linked information is functional and adds value to the note.
- Review for compliance, because guidelines have changed as EHRs have matured. Information previously required may no longer be necessary. The first review cycle will likely be time consuming, but maintenance should be easier.
Optimize data exchange
Take a comprehensive look at using EHR data exchange as a way to convey a patient’s story across the care continuum.
Challenge: Changes with regulations, processes, workflows, system upgrades and more can affect the capture of clinical data. Care providers have to spend too much time looking in multiple locations within the chart to find information needed for patient care.
Best practices:
- Create a work group to ensure that your EHR data exchange meets the letter of the regulations.
- Ensure care teams understand what data is being shared with patients and exchanged with other entities.
- Look for areas and workflows that can become more integrated to accurately convey the patient’s story over time.
- Collaborate with a multi-disciplinary team and examine data flow and templates to save care givers time so they no longer have to access multiple locations within the chart.
Often healthcare IT leaders are uniquely positioned within a healthcare system to drive best practices and collaboration with multi-disciplinary teams. The value of improvement efforts around data quality and EHR navigation is quite simple: supporting the delivery of quality of patient care.
