HealthyData Blog
In healthcare, there are so many regulations and technologies to stay current on. In our HealthyData blog, you will read everything from CMS meaningful use to EMR news, clinical best practices and QAPI program initiatives.
The leading voices in healthcare are talking about the next big thing on the horizon. That would be CHR (Comprehensive Health Record). But what about the unfinished business that still exists for healthcare records? How do you incorporate the data from incoming external documents that bog down clinics and hospitals? This data comes from faxes, paper, and scanning workflows.
In most healthcare institutions, medical procedures are associated with orders or encounters. An order (or standing order) can be defined as rules, regulations, protocols, or procedures prepared by the professional staff of a hospital or clinic and used as guidelines in the preparation and carrying out of medical and surgical procedures. An encounter can be defined as a health care contact between the patient and the provider who is responsible for diagnosing and treating the patient.
The Centers for Medicare & Medicaid Services regulates laboratory testing performed on humans in the U.S. through the Clinical Laboratory Improvement Amendments (CLIA) to ensure quality laboratory testing. CLIA sets high standards for quality control, validation of data and tests, equipment calibration, proper training and certification of users and clear end result reporting that meets proper lab data requirements.
In my previous post, the fourth in a series of seven blog posts that discuss some of the misconceptions about lab interfaces and intelligent clinical data extraction software, I addressed the belief that if a hospital has an in-house laboratory, all test results will be integrated with the patient record in the EMR.
As with every study, the article laid out the limitations of this particular study, which focused on blood pressure only, before getting into the detailed results of their work. The seven limitations they named were quite typical, including possible duplicate data and possible non-reporting of improved patients, but the limitation that seemed most unnecessary and raised my blood pressure indeed was, “Sixth, incentive program CQM reporting was based only on the data available in the EHR system of the health care provider. If a patient transitioned to another provider, such as a specialist, the original EHR might not have subsequent, possibly improved, blood pressure values recorded.”
In the course of a clinical research project or trial, researchers must gather patient data and records and prepare them for adjudication and analysis. In keeping with the spirit of HIPAA and PHI regulations, the organization conducting this research or trial likely wishes to control access from both within and outside of its firewall to ensure that any potential for breach of this personal information is strictly curtailed.
In our first three blogs of this series, we discussed how educational outreach can lead to opportunities to facilitate more effective patient care locally and strengthen relationships with referring providers. We have focused on the structure of these efforts; now we will focus on the provision of these services and how to differentiate your efforts from others to ensure your investment pays dividends.
In our next series of blogs, we will discuss the concept of outreach and how programs can use it to improve not only their volumes, but also their outcomes. Outreach can be simplistically defined as the act of reaching out to a group. It may also be defined as a systematic attempt to provide services beyond conventional limits to a particular segment of the community. In this blog, we will concentrate on the former definition, namely, reaching out to different groups to grow our program.
