With medical records now existing almost entirely in the digital sphere, care providers and practices must develop strategies to protect and maintain that data. And while conversations about the security of such data are common, data integrity in healthcare is an equally crucial concern for anyone dealing with electronic health records (EHRs) and electronic medical records (EMRs).
What Is Data Integrity in Healthcare?
Data integrity refers to the accuracy and reliability of data—not just at the time of creation, but throughout the entire lifetime of the data. For healthcare organizations, it refers specifically to the maintenance of patient data, including patients’ personal information, their test results, clinical notes, and so on.
Data integrity—or data quality—depends on health records being updated as soon as new information becomes available. It’s also important that the data is only recorded by authorized individuals.
Integrity not only requires that employees add the correct personal and clinical data to patient records, but that they add it as soon as it becomes available.
Failure to maintain the integrity of patient records can have serious implications for the practices that hold the data, and for the patients themselves. These implications can range from simply inconveniencing patients to HIPAA violations and the delivery of improper or dangerous patient care.
What Causes a Loss of Data Integrity in Healthcare?
A loss of integrity can be the result of anything from seemingly innocuous errors—an unauthorized staff member mistakenly updating a patient’s email address, for example, or a doctor failing to add her notes to a patient’s file—to a serious security breach that causes data theft.
Even something as simple as the incorrect email address update mentioned above could prevent a patient from receiving important health information or appointment updates, or it could lead to their information ending up in the wrong hands.
Luckily, there are practices that practitioners and administrators can put into effect that make maintaining data integrity in healthcare simpler and more reliable than simply trying to avoid human error.
Health Information Management That Maintains Data Integrity
A trusted healthcare IT consulting firm can make upholding data integrity in healthcare a relatively simple, straightforward task.
Healthcare IT consultants generally recommend adhering to the following practices to ensure that you maintain data integrity:
Develop an IT Infrastructure That Supports Data Integrity
An effective digital infrastructure—including the right software and apps for your needs—will make the other practices listed much easier to follow. Consultants who can point you in the direction of the optimal software and cloud computing solutions are invaluable at this stage.
A strong infrastructure will rely on certified EHR technology. It should be secure, easily accessible across various platforms, and should include mechanisms that help your team avoid common mistakes. You’ll also want a clinical decision support system in place that provides useful insights to all decision-makers within your organization.
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One possible pitfall, for example, involves using an EHR system with inadequate drop-down menus that make it easy for healthcare providers to incorrectly label patients’ diseases or fail to be as specific as possible.
Incomplete information is the same as incorrect information and therefore constitutes failed data integrity.
Make Sure Patient Records Are Easy to Read, Well-Attributed, and Organized
Developing practices for recording and storing patients’ personal and health information will make it harder for your team to add incorrect information to patients’ files. They should note the time and date that they recorded the data and they should identify themselves as the person who recorded it.
Train Your Staff on Best Practices
Next to the right IT infrastructure, your team is your best defense against the loss of data integrity. They should be intimately familiar with your practices related to observing and recording patient information.
You should also instruct your employees to record new health information accurately and immediately after observation and to complete the electronic exchange of information in a way that is secure and prevents loss of integrity.
Conduct Regular Audits to Ensure Your Team Is Following Process
Regular assessments are the best way to ensure that:
- Your team is following all of the above practices.
- All data is, indeed, accurate.
- There are no threats to your data integrity that you must address.
The security and integrity of data are both absolutely vital to ensuring patient safety—and protecting yourself from the consequences of misconduct.
Manage EHR Like a Pro
Working with a firm that specializes in data integrity in healthcare makes this process as simple as utilizing the software and methods that the firm has handpicked for you.
With the right tools and systems in place, you’ll be able to enjoy the peace of mind that comes with knowing that accurate, up-to-date, well-protected information about your patients is available with the simple click of a mouse.