Importance of Addressing Gaps in EHR Documentation and Data Capture

Importance of Addressing Gaps in EHR Documentation and Data Capture

EHR data capture should be consistent with the clinical documentation to promote the delivery of quality care and also ensure proper medical billing.

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The aims of EHR implementation are to standardize care, improve physician communication, and enable accurate diagnosis and treatment of disease. However, a new multi-university study led by researchers in Cleveland University reports that though EHR technology has positive outcomes, there are still many challenges and implementation issues that need to be addressed. One of the most significant problems of EHRs is the gaps in data capture.

Strategies to Avoid EHR Documentation Gaps Proper clinical documentation is crucial for healthcare providers as well as patients.

Healthcare data needs to be correlated to billed medical services, and patients expect accurate, comprehensive health records. Electronic Health Record (EHR) systems enable physicians to record and track healthcare data accurately so that it is accessible and available to patients and other healthcare facilities. But, in practice, EHRs have potential for documentation gaps and physicians need to take care to avoid them. EHR data capture needs to be consistent with the clinical documentation produced. Here are some important measures that can ensure proper capture of patient information: 

A report published by Anders, a CPA and advisory firm recommends that physicians perform a documentation gap analysis through a sampling of different visit types and procedures. The document generated can be compared to the data entered in the patient record to see if there are any gaps. The experts list several examples of documentation gaps: personal reminder notes, safety alerts, marked boxes for finding, free-text boxes, pop-up template items and missing the check boxes. They recommend that physicians and their teams evaluate the potential for these gaps, prioritize them, and address the issue by checking with the EHR vendor for updates or fixes.

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Another expert says that medical transcription can ensure proper capture of all information from a patient encounter. President of the Association for Healthcare Documentation Integrity Jay Vince says that physicians can ensure that all the captured information is placed the relevant context in the electronic health record through “dictation and transcription, speech recognition technology, or from free text typed by the provider." In fact, most physicians with hectic schedules do rely on professional medical transcription service companies that provide EHR-integrated documentation solutions. The medical transcription services provided by these

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companies include proofreading clinician entries to ensure that the patient story is available in a structured and manageable format. 

A study published in the Journal of the American Board of Family Physicians in 2015 noted that the availability of resources to customize and upgrade systems to support integrated care delivery, tracking, and reporting is critical to optimize EHR use. EHR vendors are critical to success and they need to work in cooperation with healthcare providers to design EHR products that support the goals of integrated care along with proper template-driven data documentation and reporting. This will also improve EHR functionality and interoperability.

Detailed Data Capture Crucial for Payment and Compliance Data in EHR is used by professionals other than physicians such as medical coders and clinical documentation improvement (CDI) specialists. These professionals need to use data in the patient record on a daily basis. Therefore, physicians should that all the diagnostic and treatment information is entered in the EHR. Moreover, medical claims approval also depends on the submission of accurate and detailed data.

Documentation of patient care in the medical record is the basis of national quality and incentive programs such as the National Committee Quality Assurance Patient-Centered Medical Home Recognition Program, Health Care Effectiveness Data and Information Set quality measures, and the EHR incentive programs of the Centers for Medicare and Medicaid Services (CMS). This is another reason why professional clinical documentation support by reliable medical transcription companies continues to be relevant to drive EHR improvements and promote the delivery of high-quality, affordable care.

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