Health care experts are increasingly enthusiastic about big data’s potential to effect major change in the way we care for patients, determine pricing, conduct clinical trials and use medical records for research. Many are focused on electronic health records (EHRs), which certainly contain a wealth of data. The issue with EHR data, whether it’s being used for big data projects or research on narrowly defined populations, is integrity in the way it’s captured. In this white paper, we’ll discuss the four EHR documentation practices that health information management (HIM) professionals consistently identify as problematic (default, design, duplication, and dictation—the four D’s). Next, we’ll look at the effect data quality and integrity can have on clinical research findings. Finally, we’ll explore best practices such as intelligent reasoning and look at their role in conducting successful research that includes medical record (chart) abstraction when the medical records are maintained electronically.
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