Data Reconciliation Challenges in Health Care

By Michael Stearns MD, CPC, CRC, CFPC

An Overview

Electronic healthcare information is most frequently generated by electronic health record (EHR) applications. Under ASTP’s certification requirements, EHRs must support the exchange of core clinical data elements defined in the United States Core Data for Interoperability (USCDI), including problems, allergies, medications, procedures, and immunizations, (PAMPI) and other essential patient information. The data is typically exchanged between provider organizations in electronic messages using standardized documents (e.g., C-CDA) or, increasingly, via HL7® FHIR® (Fast Healthcare Interoperability Resources) APIs.

The types of data most commonly exchanged for clinical care include medication lists, allergies, medical devices, problem lists, immunization status, device generated data, providers, pending orders, and other relevant clinical information. The receiving provider organization must be able to reconcile any differences between data in its EHR, and data received from an external provider.

Data Reconciliation Challenges

Common challenges include discrepancies between current problems (diagnoses), medication lists, and immunization status. Diagnoses entered into the problem list may not be in agreement with existing problems. They may require clinical knowledge, research and judgment to resolve issues when incoming data tells a different story. For example, a primary care provider evaluates a patient for episodes of loss of consciousness and renders a diagnosis of epilepsy. The patient is subsequently evaluated by a neurologist who determines that the patient does not have epilepsy. The origin of the patient’s episodes, secondarily confirmed by a cardiologist, is vasovagal syncope (i.e., loss of consciousness caused by a sudden drop in heart rate and blood pressure).

However, the primary care provider, neurologist and cardiologist are using different EHR systems with different underlying coding. Until reconciliation occurs, the diagnosis of epilepsy remains on the problem list of the primary care provider’s EHR.  Once the new diagnosis is received via C-CDA or another mechanism, the clinician performing reconciliation must determine whether the diagnosis of epilepsy should be removed from the patient record. This may require reviewing additional medical records.

Medication Reconciliation Challenges

Medication lists also require frequent reconciliation. Prescriptions sent electronically to pharmacies by clinicians are generally captured by pharmacy networks. However, providers often start, stop, or adjust the frequency and timing of medications within the EHR. These changes may not be reflected in pharmacy network data. Patients may also discontinue medications due to adverse reactions, cost, or other concerns, and this information may not be captured in either system.

Discrepancies may be compounded when a patient’s medication list is transmitted to another provider organization. Clinicians must compare medication information in the receiving EHR with data transmitted from external sources. In practice, medication reconciliation typically occurs during patient encounters, where the patient or caregiver serves as the primary source of information. In a high percentage of cases, clinicians have no source of information other than the patient during encounters. The reliability of patient generated information varies from accurate to unreliable, depending on the individual’s level of healthcare knowledge.

Data reconciliation remains a labor intensive process that requires advanced clinical knowledge. It is one of the most significant patient safety challenges faced by healthcare organizations today.

Perceived Clinician Reliability of Patient Medical History Data Based on Information Source

Data Source	Reliability Rank (High to Low)
Fully reconciled data from the same EHR system	6
Facsimiles	5
Fully reconciled data from an external EHR system	4
Patient maintained personal health records	3
Unreconciled patient data (e.g., problem lists from HIE or C-CDA upload)	2
Patient generated health information (highly variable levels of accuracy)	1

Healthcare data reconciliation improves patient care by increasing the accuracy and reliability of clinical information. Current solutions embedded within EHRs often present data from multiple sources side-by-side. This allows clinicians to select which items to incorporate into the reconciled medical record. Data reconciliation remains a labor intensive process that requires advanced clinical knowledge. It is one of the most significant patient safety challenges faced by healthcare organizations in the electronic era. Gathering context is critical to the reconciliation process. Patients and providers benefit from a consistent, reliable solution to reconciling the latest patient updates. The healthcare data reconciliation process is an essential aspect of patient care that allows clinicians to improve patient safety and clinical outcomes.

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About Dr. Stearns