Scenario 8: Threat to Integrity of CDR
The discussion case , entitled “Threat to Integrity of CDR” should be available on the “Discussions” board as part of this week’s course activities. This case describes issues associated with the data integrity of the clinical data repository, or CDR, maintained by a large tertiary care facility. The case features a single question that focuses on accuracy issues in legal medical records.
“Mark Wagner, the director of Health Information Services (HIS) at General Health Care Center (GHCC), a large tertiary care facility in the southeastern United States. Mark is concerned about the quality of the data being stored in the clinical data repository or CDR. He has recently completed both a manual search and a computer search for patient lab values as a part of a quality assessment study. He noticed that several (approximately 12 of 250) lab reports found in the patients’ paper medical records were not found in the CDR. He also noticed that most of the discrepancies occurred over a two-month period ending last month. He approached Sarah Jones, the data resource manager, and asked her to investigate.
Sarah Jones, RHIA, was recently hired into the data resource management position at GHCC and was responsible for coordinating the clinical, administrative and technology aspects of the current CDR. Sarah has a bachelor’s degree in health information management and a master’s degree in information systems. After examining the collected data, Sarah felt the problem was significant enough to approach her immediate supervisor, the CIO for GHCC. Although the CDR was not the “legal” medical record for GHCC, it was the record used by most nurses and physicians while the patient was in the hospital. The standard operating procedure while a patient was in the hospital was for the clinicians to access the CDR for current lab values. Paper records of lab values were filed in the patient’s permanent file in medical records but were not sent to the nursing floors during the patient’s hospital stay. Re-educating clinicians to use the CDR to view lab data was viewed as an implementation “success” by the CIO and by the clinical information systems steering committee. The most recent figures for CDR use showed that more than 90% of the medical staff and 94% of the nursing staff accessed the CDR for patient lab data. Sarah’s primary concern was that patient care could suffer if lab data were not being uploaded correctly to the CDR. She also wanted to make sure that the appropriate mechanisms were in place to ensure the integrity of the CDR data.
After Sarah presented her concerns about the discrepancies in the lab data, the CIO indicated that he was not concerned about the discrepancies noted. He explained that the CDR had been extensively tested and that he was confident about the integrity of the data housed within the system. He further explained that there had been a problem with the interface between the lab system and the CDR during the period in question. He stated that the problem had been fixed and he saw no reason to investigate any further. When Sarah shared the data from the HIS director, the CIO commented that “everyone knows how unreliable paper records are.” He went on to explain why the data from the direct interface were more accurate. He also stated that the percentage of error was not enough to worry about anyway. As Sarah’s supervisor, he told her to drop her investigation into the discrepancies. He was particularly concerned about giving the clinicians any more reasons to resist using the current CDR system. He felt there were enough CDR/EHR implementation problems without making problems for this successful area.”
Question
“Is data integrity affected if inaccurate data are not in the legal medical record?”
