EHR data capture should be consistent with the clinical documentation to promote the delivery of quality care and also ensure proper medical billing.

1. Importance of Addressing Gaps in EHR
Documentation and Data Capture
EHR data capture should be consistent with the clinical documentation to promote the
delivery of quality care and also ensure proper medical billing.
MEDICAL TRANSCRIPTION SERVICE COMPANY
8596 E. 101st Street, Suite H
Tulsa, OK 74133
Phone: 1-800-670-2809

2. www.medicaltranscriptionservicecompany.com 1-800-670-2809
The aims of EHR implementation are to standardize care, improve physician communication,
and enable accurate diagnosis and treatment of disease. However, a new multi-university
study led by researchers in Cleveland University reports that though EHR technology has
positive outcomes, there are still many challenges and implementation issues that need to
be addressed. One of the most significant problems of EHRs is the gaps in data capture.
Strategies to Avoid EHR Documentation Gaps
Proper clinical documentation is crucial for healthcare providers as well as patients.
Healthcare data needs to be correlated to billed medical services, and patients expect
accurate, comprehensive health records. Electronic Health Record (EHR) systems enable
physicians to record and track healthcare data accurately so that it is accessible and
available to patients and other healthcare facilities. But, in practice, EHRs have potential for
documentation gaps and physicians need to take care to avoid them. EHR data capture
needs to be consistent with the clinical documentation produced. Here are some important
measures that can ensure proper capture of patient information:
 A report published by Anders, a CPA and advisory firm recommends that physicians
perform a documentation gap analysis through a sampling of different visit types and
procedures. The document generated can be compared to the data entered in the
patient record to see if there are any gaps. The experts list several examples of
documentation gaps: personal reminder notes, safety alerts, marked boxes for
finding, free-text boxes, pop-up template items and missing the check boxes. They
recommend that physicians and their teams evaluate the potential for these gaps,
prioritize them, and address the issue by checking with the EHR vendor for updates
or fixes.
 Another expert says that medical transcription can ensure proper capture of all
information from a patient encounter. President of the Association for Healthcare
Documentation Integrity Jay Vince says that physicians can ensure that all the
captured information is placed the relevant context in the electronic health record
through “dictation and transcription, speech recognition technology, or from free text
typed by the provider." In fact, most physicians with hectic schedules do rely on
professional medical transcription service companies that provide EHR-integrated
documentation solutions. The medical transcription services provided by these

3. www.medicaltranscriptionservicecompany.com 1-800-670-2809
companies include proofreading clinician entries to ensure that the patient story is
available in a structured and manageable format.
 A study published in the Journal of the American Board of Family Physicians in 2015
noted that the availability of resources to customize and upgrade systems to support
integrated care delivery, tracking, and reporting is critical to optimize EHR use. EHR
vendors are critical to success and they need to work in cooperation with healthcare
providers to design EHR products that support the goals of integrated care along with
proper template-driven data documentation and reporting. This will also improve
EHR functionality and interoperability.
Detailed Data Capture Crucial for Payment and Compliance
Data in EHR is used by professionals other than physicians such as medical coders and
clinical documentation improvement (CDI) specialists. These professionals need to use data
in the patient record on a daily basis. Therefore, physicians should that all the diagnostic
and treatment information is entered in the EHR. Moreover, medical claims approval also
depends on the submission of accurate and detailed data.
Documentation of patient care in the medical record is the basis of national quality and
incentive programs such as the National Committee Quality Assurance Patient-Centered
Medical Home Recognition Program, Health Care Effectiveness Data and Information Set
quality measures, and the EHR incentive programs of the Centers for Medicare and Medicaid
Services (CMS). This is another reason why professional clinical documentation support by
reliable medical transcription companies continues to be relevant to drive EHR
improvements and promote the delivery of high-quality, affordable care.