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AHIMA/FORE Research PrioritiesThe FORE research priorities, while focused on eight specific items, remains broad enough to include many specific research questions. These priorities will guide the research projects FORE will conduct internally and seek collaborators and funding for. It will also be used as one of the criteria for award decisions for the FORE Grant-in-Aid Award program. Research in these areas is deemed essential, in part, because it will assist in the effective training of the future health information management and informatics workforce.
Examine best practices for efficient, effective and legal electronic health record management for the following functionality:
Sample Research Questions:
These functions may have been challenging in a paper-based environment and are even more so in an electronic environment. This list is not meant to be exhaustive, but to include those which are most difficult to manage and present the highest risks for the organization in terms of record integrity and possible impact upon quality of care delivery. Organizations using electronic health records are currently developing their own policies and procedures in spite of the fact that there are not standards and each organization may use a different system. The study of best practices would provide a framework for their policies and procedures. Examples from those working with EHRs that might be considered include the replication of incorrect information throughout a record because of the widespread use of copy and paste or pull forward with no audit trail to show where it began making it almost impossible to correct; inconsistent methods for making corrections between different clinical systems; documentation corrections made after a clinical decision was made utilizing the incorrect information with no trail to show what the previous documentation was or when it was changed; and authorship functionality which allows one provider to subsume all documentation as his or hers, among others.
Best practice identification and validation are needed immediately. Healthcare is an information-intensive process with the data used for many purposes. This research would have a very high impact and would include policy implications. Consistency in the management of the data and information are the only way to ensure its integrity.
Explore the legal, regulatory and statutory issues around maintaining and exchanging the electronic health record
Sample Questions
Legislation, regulation, statutes and case law have not kept up with the changing needs of organizations adopting electronic health records and the electronic exchange of health information. Without adequate research of these issues patients, practitioners, and healthcare organizations are at risk. Patients may be at risk if clinicians are hesitant to record information or prohibited from exchanging information because the law and regulations are not fully understood. Provider organizations can be at risk, especially if they inappropriately include data and information from other organizations in their legal records. This exploration has the potential to reduce significant confusion in the industry.
Research data collection requirements (content and best practices) to support a) high quality patient care, as well as b) meet administrative reporting needs such as public health, quality measurement, fraud management, and pay-for-performance.
Sample Question
Currently there are no nationally accepted standards for either data content or collection specifications above and beyond those required for selective administrative reporting. Beyond these requirements, more detailed data are often utilized by organizations for clinical guidelines and, more recently, are required in response to quality measurement and pay-for-performance incentives. This research is not intended to specify clinical measures or quality measures, but to specify data collection requirements so that data requirements for patient care can converge with secondary use data needs. For example, there are known data requirements for managing diabetes patients such as HbA1c lab results, foot exams, eye exams, etc. Research on the data needed for patient care should assist in reducing adverse outcomes, while providing quantitative feedback on structured vs. unstructured data entry. Carrying the research into the secondary uses of data will ensure those needs are met and, ultimately improve code sets and administrative data for a wide range of applications. This research will identify what data should be added to the existing code sets or abstraction mechanisms.
Study inter-rater reliability agreement rates at the disease condition, clinical service, or lower level for U.S. current or pending national standard terminology and classification systems (such as ICD-9-CM, ICD-10-CM, CPT, SNOMED CT, LOINC, etc.)
Sample Questions
This research is foundational to the use of coded healthcare data in the United States. Determining which disease conditions and clinical services to evaluate could be done by frequency of terminology use on claims, the frequency with which a disease or services is reported or studied in the literature, quality measures, public health (the conditions included in Healthy People 2010) and biosurveillance. This research will identify what is difficult to code as well as where the code system itself is inadequate or the system is not such that industry can use it reliably. The results of this research will inform all future analyses, clinical or administrative, conducted with the selected codes. It will also inform the future development and evolution of classification systems.
Explore the potential of the electronic health record to revolutionize the way in which health information is created, utilized, exchanged and maintained to maximize clinical utility, including outcomes such as quality of care and patient safety, while minimizing resource use, such as personnel time and effort.
Sample Questions
This item combines re-engineering EHR workflows and processes with assessing the impact of the EHR on patient safety. Health care costs continue to outpace general inflation with little or no documented improvement in the service delivered. The shift from paper to electronic documentation is often not more than reproducing the paper forms and processes in an electronic environment. In some instances this may enable the use of tools such as clinical decision support which have been shown to improve patient care and patient safety. Unfortunately, in many cases, it does not. This is unacceptable. The use of the EHR should foster momentous changes in both the efficiency and quality of health care delivery along the lines of that seen with the adoption of electronic banking and cellular telephone technology. Current design flaws and the ensuing workarounds to compensate for them must be identified with new models for care delivery developed now. Methods for diffusing the models efficiently, especially in educational curriculum must be found. It is not certain that the system can survive 10 years beyond best-scenario full EHR adoption, potentially until 2024, as Dr. David Brailer recently indicated in an interview, http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.2.w236.
Examine models and methods for the real-time and retrospective assessment of data quality.
Sample Questions
High quality data are essential for an efficient, effective EHR and health information network. This research involves the deconstruction of all data creation, collection, handling and management activities to identify all points where decisions to accept the data are made or hand-offs of data occur. Methods for the real-time and retrospective assessment of all required data should be developed, as well as models specifying sample size calculation and acceptable error rates. Understanding and ensuring the quality of the health care data is essential to an effective health care system and the continued management and improvement of that system.
Study retention and archiving rules for data types not a part of the legal record, for example, audit logs, emails, alerts and prompts, etc.
Sample Question 1. Which data types and mediums in the EHR are not included in the legal record, but need to be maintained?
The creation and use of new types of data leads to a general state of confusion. Presently each health care provider is developing their own retention and archiving rules. Standardization would benefit patients and providers. This research is expected to begin with an in-depth analysis of practices, costs, and analysis of applicable laws and case law from the health care and other industries. It is important for costs to be included since the amount of data being created in the course of health care delivery increases in the electronic environment and there are costs associate with retaining and archiving the data. Following the analysis, an expert panel could be utilized to recommend desired practices. Computer simulation and modeling could used to define costs and benefits of different implementation scenarios of the practices. For example, a desired recommended practice might be to maintain all of the identified data in an easily accessible form for a minimum of two years after the date of service. While this might be optimal from many perspectives, it may prove to be cost-prohibitive for many providers.
Develop guidelines for establishing health records, whether electronic or hard copy, for the correct person. The rights and responsibilities of all stakeholders must be delineated. Sample Questions
1. What practices are required to verify patient identity? 2. How should the record of a victim of medical identity theft be handled? The consequences of incorrect medical identification extend far beyond the exceeding insurance use limits to dangerous care delivery complications. For example, someone stealing a medical identity may change allergy or other alerts on a record which could result in an allergic reaction or worse for the true owner of that medical identity. Methods for accurately verifying and protecting medical identity, practice guidelines for providers and payers when medical identity theft is discovered and defined rights for those victimized by this crime must be established.
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