Information Integrity in Ambulatory Care

Keep up with the latest on information governance as this key strategy emerges for addressing a myriad of information management challenges in healthcare. This blog will highlight the trends and opportunities IG presents for ensuring information is treated as an organizational asset.


By Nicole Miller, MS, RHIA

 

When information governance (IG) first became the buzz word in healthcare it seemed like it was not very well understood and there was much to be learned. The healthcare industry has moved past that initial reaction and is ready to embrace this new reality of information governance. Information governance is meant to be a benefit to organizations and not to be a burden. Information governance covers all information types—not just clinical records—and has a variety of benefits, but for the specifics of this article, IG is important for organization reporting, information integrity, and working towards achieving interoperability in healthcare.

Information governance is an enterprise-wide initiative that must be present in all departments to support an organization’s strategic goals. Interoperability is one of those goals. In many cases, patient care starts in an ambulatory care facility and is transitioned to inpatient care. Often, the information gathered by the ambulatory care provider is not readily available for the inpatient care provider. Interoperability proves to be an issue and hindrance for the most efficient patient care. That is when having an information governance program in place can be beneficial in seeing that the patients’ information will be easily transitioned.

Information integrity is another term often heard in healthcare and is an important outcome of an information governance program. Information integrity refers to how accurate, consistent, and trustworthy information is throughout its entire lifecycle. Records that have integrity allow organizations to make more informed business and clinical decisions based on the higher quality information. Organization leaders will have more trust in their decisions and will see the benefits as change is implemented.

Larger healthcare organizations have started to embrace IG, but the smaller ambulatory care providers are still easing their way into the process. Healthcare organizations, no matter how big or small, need to implement information governance as a way to ensure information integrity. Interoperability between the various department types, as well as the various healthcare organization types, heavily depends on the integrity of the information being transmitted. IG is not one-size-fits-all, and all healthcare organization types should implement and maintain an IG program so that information can flow seamlessly in and out.

Information integrity can be achieved by developing policies and procedures for documentation requirements. Specifically for health records, providers must follow these policies and procedures each time they add new information to the record. This will ensure accuracy and consistency as patients see multiple providers and these providers insert their additions to the patient’s record.

Patient care often starts in the ambulatory care setting before a patient is actually admitted as an inpatient. Although ambulatory care organizations are smaller in size, they play an important role in the patient care path. Information governance allows information to maintain its accuracy, consistency, and integrity throughout its lifecycle. That is why it is so critical for ambulatory care organizations to implement and maintain IG, since we often see the lifecycle of patient information begin here. If the information produced by ambulatory care organizations is not trustworthy or reliable, it is possible that other providers can make poor clinical decisions for the patient care path based on the poor information that is in that patient’s record. Information governance provides a strategic framework that ensures an organization’s information retains its integrity and can be used for better decision making.

Although there are many ways to get started with IG, ambulatory care organizations may consider the following items as a good starting point:

1. Update all organization policies and procedures that have to do with information

2. Ensure that effective technology is in place to:

–a. Protect all electronically stored information

–b. Securely transmit information to and from the organization

–c. Measure performance and quality indicators

3. Master patient index cleanup to reduce duplicate record rates

4. Ensure the organization is meeting all state and federal regulations

 

Addressing some of these starting points could aid in better information sharing practices. As we discussed, interoperability is a primary goal in the healthcare industry. The reach for interoperability wouldn’t be unreasonably far if all healthcare organizations followed IG best practices and really strived to streamline their workflow processes and operations. With patient care in mind, it is important to follow these best practices for the integrity of the patient’s record to lead to higher quality patient care and satisfaction.

There are two very important aspects discussed above: information integrity and information governance. Information governance has the reputation that tends to scare organizations away. Larger organizations have started to come out of the shadows and take on information governance, but smaller organizations such as ambulatory care organizations are still getting on board with IG. Patient care starts with ambulatory care and these organizations should be the front runners when it comes to information integrity and information governance. Patient care should be a team effort for both small and large organizations as they both play a significant role in a patient’s care path. As the organizations, especially the smaller ones, develop and adhere to information governance programs, the healthcare industry will see a tremendous shift in the overall quality of care and the processes used for delivering that care. The first step is to provide more guidance for the ambulatory care organizations to help them get started with their information governance programs.

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