We all know that accuracy, quality, and completeness of data is the essence of a Health Information Professional’s work product, but what are the processes that we utilize to enable the integrity of the data?
Let’s start with the capture of data…
Are health care professionals aware of the standards that have been set forth by Health Information professionals in terms of documentation and classification? Are templates reviewed? And if so, who is reviewing the templates and how often?
Do we conduct reviews of both inpatient and outpatient information on a concurrent basis?
Do we embrace our patients providing input to our records to ensure that the records are accurate?
Are we able to determine which providers copy, paste, and conduct reviews to ensure accuracy?
Here are my thoughts…
As we move into Meaningful Use, Genetics, ICD-10 and new payment models the integrity of the record has never been more important.
We should establish Data Governance models to support the accuracy, quality, and completeness of our data. Health Information departments should establish processes to support amendments in order to enable quality improvement of our data and monitor trends such as the origin of the information.
We should continuously monitor our systems to assess the impact on our data integrity when systems are upgraded or algorithms are changed. We need to establish best practice for the life cycle of a document, classification of documents, as well as rules for metadata the most recent Journal of AHIMA discusses many of these issues and provides guidance.
In-patient and out-patient information must be reviewed on a regular basis to ensure that the integrity of the information is compliant with the highest of standards in order to serve patients, promote accurate billing, conduct research, and support accountable care organizations, population health management and improvement
What do you think?