based on the previous post please write 150 words each to these two peers i have selected.
1)Background: Nearly 5% of the laboratory values found in the paper record were not included in the Clinical Data Repository (CDR), as per the data obtained by the HIS director. The concerning matter, in this case, is that most of the providers simply use the CDR (which is incomplete & unreliable) and don’t study the paper record. On the other hand, the CIO is delighted that the physicians are well-off & confident with the use of CDR in the hospital’s evolution toward the final adoption of the EHR. Thus, the CIO does not want Sarah to tell them again that paper records are still the legal record and reveal her findings indicating paper record comprises more complete data than the CDR.
Response: According to AHIMA’s requirement for the integrity of documentation is the accuracy of a complete health record, and if the integrity of data is questioned, then the information may be regarded as erroneous or even fraudulent behavior. (Arrowood et al., 2013) Furthermore, quality of care and patient safety will be compromised & negatively impacted like wrong treatment or adverse events, with the incomplete or incorrect information accessed, especially while treating a patient. (Carayon & Wood, 2010) For instance, the error in the laboratory testing process can adversely impact patient care entailing increment in healthcare cost & decrease patient satisfaction through unnecessary redraws, delay in reporting, improper treatment, and misdiagnosis. (Kaushik, 2014) As per a study, more than 70% of the clinician decisions are based on the information obtained from lab test results, as the physicians depend on accurate lab results for proper disease diagnosis and guiding therapy. (Datta, 2005)
Conclusion: Therefore, even though the erroneous, incomplete, redundant, or untrustworthy is not in the legal medical records, it should be addressed promptly as it is the one that physicians are relying on which could be resulting in poor data quality and hampering patient safety adversely.
References:
Arrowood, D., Choate, E., Curtis, E., DeCathelineau, S., Drury, B., Fenton, S., . . . Hall, T. J. J. o. A. (2013). Integrity of the healthcare record. Best practices for EHR documentation. 84(8), 58-62.
Carayon, P., & Wood, K. E. (2010). Patient safety – the role of human factors and systems engineering. Stud Health Technol Inform, 153, 23-46.
Datta, P. J. A. f. A. o. t. L. (2005). Resolving discordant specimens. 60.
Kaushik, N. (2014). Pre-analytical errors: their impact and how to minimize them. StackPath. https://www.mlo-online.com/home/article/13006606/preanalytical-errors-their-impact-and-how-to-minimize-them.
2) After Mark uncovered that there were some lab values missing from the clinical data repository (CDR), Sarah set out to find more. She thought the issue was significant enough as it can affect patient care. Although the CDR is not part of the legal health record, it is the record being used by medical staff. If the information in the clinical data repository is incorrect, it is possible that patient’s health could be at risk. According to AHIMA (2011), the legal health record is only a subset of the patient’s entire record, however, it is the legal business record of the patient. It is what the organization releases when a legal request is made. Although the CDR is not considered to fall into the “legal health record” category, it is where important data is stored and input. Therefore, the integrity of the information stored in it is of grave importance. The University of Chicago Illinois (2021) explain that information stored by health care organizations is only beneficial if it is accurate, no matter where it is stored. The data uncovered to be incorrect is only about 5% of the laboratory reports over the course of two months. However, when put into numbers, that is 12 patients that could potentially be affected by this inaccurate information. This could have duplicate lab work, inaccurate treatment, or even an adverse event for the patient. The ACLA (2014) reports that approximately 70% of medical treatment decisions are made using lab work results. If a healthcare provider at General Health Care Center accesses outdated lab results, this could lead to providing the incorrect treatment or even a misdiagnosis. For example, a doctor may order a fasting glucose test on a patient to monitor their glucose levels. If the information is missing from the patient’s record, the patient may need to go through the testing again. Missing information delays getting results, adds effort and pain to the patient, in addition to the added costs to the patients and their insurance. Therefore data integrity is affected even though the CDR is not part of the legal health record. It is vital that all records of the patient are kept to date and that their integrity is safeguarded. One of the main reasons why technology was incorporated in healthcare was to prevent as much human error as possible and to provide the best quality care to the patient (ACLA, 2014).
References
ACLA (2014, April 17). Importance of clinical lab testing highlighted during medical lab professionals week. American Clinical Laboratory Association. https://www.acla.com/importance-of-clinical-lab-testing-highlighted-during-medical-lab-professionals-week/ (Links to an external site.)
AHIMA (2011, February). Fundamentals of the Legal Health Record and Designated Record Set. Journal of AHIMA 82(2). https://library.ahima.org/doc?oid=104008#.YRqVzYhKjIV (Links to an external site.)
University of Chicago Illinois (2021, July 22). What Is Data Integrity and Why Is It Important in Healthcare?. University of Chicago Illinois Health Informatics. https://healthinformatics.uic.edu/blog/data-integrity/
