Investigation into Discrepancies in Patient Lab Data- A Quality Assessment of the Clinical Data Repository (CDR)
Is data integrity affected if inaccurate data are not in the legal medical record?
The integrity of data is still affected even when there is no inaccurate data in the legal medical record. From the case study, most of the medical staff, up to 90% and 94% of nursing staff, access the patient lab data from the CDR, which is not considered a legal medical record. The director of the Health Information Services (HIS) at the hospital shows concern for the data quality of the CDR records, and with good reason. After conducting a search, both manual and computer search, it is evident that roughly 12 out of 250 records are not in the CDR. Yet this in CDR is used by most medical practitioners in the institution. This data inconsistency in the CDR can cause issues with data integrity, even with accurate data in the legal medical record.
Looking further into the scenario, the records of lab values made on paper in the permanent medical records of patients were not sent to the nursing flow during the patients’ stay. Even if the records in the permanent files were all accurate, the data would still potentially lack integrity since nurses would operate blindly on some patients whose records were not available in the CDR. This way, they could enter values in the system which are inconsistent with the lab reports. The failure to update the lab values in the CDR could cause integrity to suffer.
Finally, the CIO mentions that the mismatch of data in the system was a result of the problem which had occurred with the interface between the lab and the CDR during the last two months when the inconsistencies were recorded. The CIO was quite confident that the CDR was working perfectly. The shows that inconsistent data values can also result from errors from the CDR even if the legal medical record has the correct data.
References
Harman, L. B. (2006). Ethical challenges in the management of health information. Jones & Bartlett Learning.
ORDER A PLAGIARISM-FREE PAPER HERE
We’ll write everything from scratch
Question 
Scenario 8: Threat to Integrity of CDR
“Mark Wagner, the director of Health Information Services (HIS) at GHCC, is concerned about the quality of the data being stored in the CDR. He has recently completed both a manual search and a computer search for patient lab values as a part of a quality assessment study. He noticed several (approximately 12 of 250) lab reports in the patient’s paper medical records were not found in the CDR. He also noticed that most of the discrepancies occurred over a two-month period ending last month. He approached Sarah Jones, the data resource manager, and asked her to investigate.
Investigation into Discrepancies in Patient Lab Data- A Quality Assessment of the Clinical Data Repository (CDR)
After examining the collected data, Sarah felt the problem was significant enough to approach her immediate supervisor, the CIO for GHCC. Although the CDR was not the “legal” medical record for GHCC, it was the record used by most nurses and physicians while the patient was in the hospital. The standard operating procedure while a patient was in the hospital was for the clinicians to access the CDR for current lab values. Paper records of lab values were filed in the patient’s permanent medical records file but were not sent to the nursing floors during the patient’s hospital stay. Reeducating clinicians to use the CDR to view lab data was viewed as an implementation “success” by the CIO and by the clinical information systems steering committee. The most recent figures for CDR use showed that more than 90% of the medical staff and 94% of the nursing staff accessed the CDR for patient lab data. Sarah’s primary concern was that patient care could suffer if lab data were not being uploaded correctly to the CDR. She also wanted to make sure that the appropriate mechanisms were in place to ensure the integrity of the CDR data.
After Sarah presented her concerns about the discrepancies in the lab data, the CIO indicated that he was not concerned about the discrepancies noted. He explained that the CDR had been extensively tested and that he was confident about the integrity of the data housed within the system. He further explained that there had been a problem with the interface between the lab system and the CDR during the period in question. He stated that the problem had been fixed, and he saw no reason to investigate any further. When Sarah shared the data from the HIS director, the CIO commented that “everyone knows how unreliable paper records are.” He went on to explain why the data from the direct interface were more accurate. He also stated that the percentage of error was not enough to worry about anyway. As Sarah’s supervisor, he told her to drop her investigation into the discrepancies. He was particularly concerned about giving the clinicians any more reasons to resist using the current CDR system. He felt there were enough CDR/EHR implementation problems without making problems for this successful area.”
Question
“Is data integrity affected if inaccurate data are not in the legal medical record?”
Please see the rubric. Review the document for more details.