Data Integrity
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Data integrity refers to the accuracy and consistency of stored and transmitted data that can be compromised when information is entered incorrectly or deliberately altered or when the system protections are not working correctly or suddenly fail. As EHR adoption expands to include data from multiple healthcare entities, more opportunities for human error exist. Poor screen designs that are confusing and cumbersome and lack of system training often lead to data entry errors. How this will be monitored and who is responsible for correcting inaccurate information will be an issue. Critical patient information, such as allergies, medical history, and medications, should always be validated and updated at each episode of care. Education on how to use the EHR should be provided to all staff before implementing a new system, when changes are made to an existing system, and during orientation for new employees. Stringent security measures that include audit trails, penalties for fraudulent activities, and detailed policies and procedures are other measures that protect data integrity.
Data integrity can also be affected if a system is not working correctly or suddenly fails. Unfortunately, users do not always recognize when a feature is not functioning, such as a broken alert or incorrect calculations, and this leads to inaccuracies in data. When an interface from one application to another is not working, this also may not be readily noticeable. For example, a physician is able to enter orders using CPOE, but the interface to the pharmacy department system fails and medication orders are not received or dispensed, or orders do not arrive in the laboratory and the blood is not drawn. A healthcare provider may discover the problem only when it is time to administer medications or when test results are not available. These kinds of problems ultimately affect patient care. If the interface resumes functioning, the orders may cross over, but depending on the time the order was placed, some data may be lost or corrupted or a new order may have been placed. Support mechanisms, such as the customer help desk maintaining automated, sortable records of issues reported, along with rigorous system testing, is extremely important to ensuring data integrity.