A recent study found that using EHRs improved documentation adherence and performance measures in patients with IBD.

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EHRs Improve Documentation for
IBD, Finds Study
A recent study found that using EHRs improved
documentation adherence and performance measures
in patients with IBD.
Medical Transcription Services
United States

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Inflammatory bowel disease (IBD) involves chronic inflammation of the digestive tract.
There are two types of IBDs -- Crohn's disease (CD) and ulcerative colitis (UC). While CD
can affect any part of the gastroesophageal (GI) tract, UC is confined to the large bowel.
Medical transcription companies that help gastroenterologists with documentation in
electronic health records (EHRs) are well-versed in the terminology and treatments related
to these and other disorders of the digestive system. Becker’s GI and Endoscopy recently
reported on a new study in Gastroenterologywhich found thatusing EHRs improved
documentation adherence and performance measures in patients with IBD.
Concerns with Documentation of IBD Quality Measures
Poor documentation of IBD Quality Measures is a matter of concern. A study published in
Clinical Gastroenterology and Hepatology in 2016 found that gastroenterology practices
demonstrated poor documentation of quality measures established by the American
Gastroenterological Association (AGA) in 2011 for patients with inflammatory bowel disease.
The researchers reviewed charts of consecutive patients seen at an academic practice (367
patients), a community practice (217 patients) and a private practice (199 patients) for
compliance with eight outpatient measures. The results were as follows:
• The study found appropriate documentation of all eight core measures for only 46
patients (5.8%) in all three centers combined (24 patients in the academic practice,
none in the clinical practice and 22 in the private practice).
• The most evaluated and documented core measures were: screening for tobacco
abuse (89.6% of all patients), the location of IBD (80.3%) and assessment for
corticosteroid-sparing therapy (70.8%).
• The measures least likely to be assessed were: pneumococcal immunization
(16.7%), bone loss (25%) and influenza immunization (28.7%).
The researchers concluded that interventions are necessary to improve reporting of quality
measures for IBD.
EHR Adoption enhancesIBD Documentation Compliance
Recent research published in Gastroenterology found that customizable EHRs improve
documentation compliance of quality measures for outpatient IBD care.

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The researchers compared patient charts before and after EHR adoption. They randomly
selected 50 patient charts from consecutive outpatient IBD visits from Sept. 1, 2015
through June 30, 2016 and 50 outpatient IBD charts from Sept. 1, 2016 through June 30,
2017 after EHR adoption.
The team reviewed that charts to assess documentation adherence with the Physician
Quality Reporting System for IBD care, including documentation of influenza and pneumonia
vaccination, tobacco screening and cessation, evaluation of latent tuberculosis, hepatitis B
status and bone loss risk assessment. The Becker’s GI and Endoscopy article summarizes
the key findings of the study as follows:
• The addition IBD-specific EHRs improved documentation of administration, refusal or
prior receipt of both the influenza and pneumonia vaccines from 19.4 percent before
EHRs to 59.5 percent after.
• EHR adoption improved tobacco cessation intervention documentation from 28.6
percent to 77.8 percent after.
• Documentation after EHR implementation was 100 percent for latent tuberculosis, up
from 66.7 percent before.
• Hepatitis B and screening tobacco use documentation remained at 100 percent after
EHR adoption.
• For patients at risk for bone loss related to steroid use, the documentation ratewas
12.5 percent, up from zero percent pre-EHRs.
The researchers concluded that the customizable EHRs improve documentation adherence
toquality measures for outpatient IBD care.
Gastroenterology Medical Transcription Services to Maintain EHR Documentation
Integrity
EHRs improve documentation compliance to quality measures andaccuracy of the complete
health record is necessary to ensure documentation integrity. Errors in the medical record
can compromise patient care, care coordination, quality reporting and research, and also
lead to fraud and abuse. Outsourcing medical transcription helps gastroenterology practices
maintain documentation integrity.

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Medical transcription outsourcing companies have evolved with the widespread adoption of
EHRs. With the availability of speech recognition technology, physician dictations are
converted into electronic text that is parsed and mapped to particular data fields. Proper
safeguards are necessary to reflect an accurate picture of the patient’s condition, at
admission as well as how it changes over time. Providers need to review and edit all data to
ensure that the patient visit is properly recorded with the relevant details.
Healthcare providers can team up with transcription services to integrate dictation into their
EHR. In fact, AHIMA notes that organizations using voice recognition without a validation
step in place are experiencing significant data quality problems and documentation errors.
Medical transcriptionists review and edit dictated information in a timely manner help
providers, promoting accurate and quality documentation in EHR systems. Partnering with a
reliable gastroenterology medical transcription company can help practitioners ensure
compliance with quality measures.