Challenges in Obtaining Complete Medical Record Data

By Lesley Brown, SVP of Product Management at Halfpenny Technologies

As previously discussed the potential benefits to health plans of compiling a complete picture of their member’s health status are abundant.  The more data and information you have about your members, the better help and guidance you can give them to ensure they receive the most appropriate and best care without redundant replication of services.  And without unnecessary cost!

Being able to obtain a comprehensive medical record for a member from a physician’s practice is one avenue that health plans can take to enrich their member’s health records.  Yet, technical and business challenges aside, being able to gather a comprehensive or full medical record from an EMR can be difficult.  Experience has demonstrated that all too often much of the key clinical information about a patient is missing from the “structured” components of Electronic Health Records.  And this occurs even when data is retrieved using “industry” standard formats such as the HL-7 C-CDA template and document structure.  This missing clinical data ranges from lab result interpretations, medication detail around frequency and dosing, allergy information to physician signatures.  An additional challenge is the inability to distinguish and interpret between actual missing data in a record from “null” data elements such as “no information documented” or “no known information”.  This absent information can be very challenging to find and retrieve from within an EHR system.  Experience has shown that reliance on “industry standards” such as the C-CDA templates isn’t sufficient.  Add in the fact that many different EMR’s are in use today by physician groups and hospitals, and these medical record systems are built in a proprietary way, making the challenge of finding that missing or incorrect information different between EMR systems and hence physician practices.  As a result of these challenges, healthcare providers who would like to gather clinical data in order to compile a more complete picture of their member’s health are faced with a project that is time consuming, extremely expensive, frustrating and can often result in disappointment and incomplete personal health information.

Looking to obtain a complete medical record on your members?  Halfpenny Technologies has been in the clinical data exchange business for more than 15 years and over that time have built reusable interfaces that connect to 90%+ of the top EHR vendors and LIS/HIS systems.  Halfpenny Technologies comprehensive clinical data exchange platform uses a multi-faceted methodology to obtain clinical record data.  We do not rely solely on the use of the C-CDA standard.  Halfpenny Technologies completes a quality assessment at each data retrieval stage identifying how full or complete a medical record is and highlighting missing sections or data elements.  We can then work with our customers to identify ways to ensure that clinical data is being acquired and stored correctly.  Halfpenny Technologies’ vendor agnostic approach allows the receipt of any EHR medical record data format and in return health plans can receive clinical data in the layout of their choice. Our continued investment in innovative solutions has uniquely positioned the company as a national provider of clinical data exchange solutions to the health care industry.

 

Advertisements

One thought on “Challenges in Obtaining Complete Medical Record Data

  1. This was really educational on the type of challenges that people can face when retrieving clinical data. It sounds times consuming. I imagine it would be easier to hire a company that offers retrieval services.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s