HCA 417 Electronic Health Record Electronic Health Record Nomenclatures

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ELECTRONIC HEALTH RECORDS Understanding and Using Computerized Medical Records

CHAPTER LESSON

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Functional EHR Systems

CHAPTER TWO ONE

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

EHR Data Formats

• Three Forms of Data Formats – Digital images: Retrieved and displayed by

computer, but a human required to interpret meaning of content.  Diagnostic images  Scanned documents

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

EHR Data Formats

• Three Forms of Data Formats (cont.): – Text files: Word processing files of transcribed

exam notes and text reports. – Discrete data: Stored information that can be

instantly searched, retrieved, combined or reported in different ways.  Fielded data  Coded data

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Limitations of Certain Types of Data

• Digital image: If bulk of the EHR is scanned paper documents, only one or two of the IOM criteria are satisfied.

• Text data: Seldom used for generating alerts, trend analysis, decision support, or other real-time EHR functions, because search capability is slow and results often ambiguous.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Limitations of Certain Types of Data

• Fielded data: Unless the field data is codified, the meaning of the data can be ambiguous.

• Coded data: If codes are not standard it will be difficult to exchange medical record data between different EHR systems or facilities.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Limitations of Certain Types of Data

• Standard EHR Coding Systems – EHR coding systems are called

nomenclatures. – They are designed to codify details and

nuance of patient–clinician encounter. – They need to have more codes to describe

details of exam; more granular. – Prominent nomenclatures for EHR records

are SNOMED-CT®, MEDCIN®, and LOINC®.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Prominent EHR Code Sets

• Reference terminologies: Extremely granular code sets.

• EHR nomenclatures use the concept of findings (codified observations) that are medically meaningful to clinician.

• Findings are often linked to other findings.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Prominent EHR Code Sets

• Linked or indexed findings in an EHR nomenclature enable clinicians to quickly locate related: – Symptoms – Elements of the physical exam – Assessments – Treatments when documenting visit

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Prominent EHR Code Sets

• EHR users tend to locate findings by description, not by code.

• EHR nomenclatures often include internal cross references to other standard code sets.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

SNOMED-CT

• Systematized Nomenclature of Medicine; CT for Clinical Terms. – Contains over 364,400 healthcare concepts,

organized into 18 hierarchical categories. – Approximately 1,450,000 semantic

relationships  Is-A relationships connect concepts within a single

hierarchy.  Attribute relationships connect concepts from two

different hierarchies.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

MEDCIN

• MEDCIN is a medical nomenclature and knowledge base developed by Medicomp Systems, Inc. – Designed for point-of-care use by clinician. – Includes cross-references to map MEDCIN to

SNOMED-CT (ICD-9-CM, CPT-4, LOINC, CCC, and RxNorm drug codes).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

MEDCIN

• Consists of 277,000 clinical concepts (findings) in six categories: – Symptoms – History – Physical Examination – Tests – Diagnoses – Therapy

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

MEDCIN

• MEDCIN knowledge base includes 600,000 synonyms for findings.

• MEDCIN nomenclature has knowledge base with diagnostic index of more than 68 million links between clinically related findings. – Enables an EHR system based on MEDCIN

to quickly find other clinical findings.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Comparing EHR Code Sets

Figure 2-1: SNOMED-CT links for the term “Asthma.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Comparing EHR Code Sets

Figure 2-2: MEDCIN links for the term “Asthma.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Comparing EHR Code Sets

Figure 2-2 (cont.): MEDCIN links for the term “Asthma.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Point-of-Care Documentation

• Nomenclatures designed for point-of-care are key to successful adoption of an EHR by clinicians.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

LOINC

• LOINC: Logical Observation Identifiers Names and Codes. – Created and maintained by Regenstrief

Institute. – Standardizes codes for laboratory test orders

and results. – LOINC terminology three portions: laboratory,

clinical (nonlaboratory), HIPAA.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

UMLS

• UMLS: Unified Medical Language System®. – Maintained by National Library of Medicine

(NLM). – Resource of software tools and data created

from many medical nomenclatures. – Described as a “meta-thesaurus.” – Can be used to retrieve and integrate

biomedical information and provide cross- references among selected vocabularies.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• 12 standards for coded nursing languages are recognized by American Nurses Association.

• Clinical Care Classification System (CCC) – Used to document patient care. – Developed from government-funded research. – Provides standardized coding concepts for

nursing diagnoses, outcomes, nursing interventions, and actions.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• NANDA-I: North American Nursing Diagnosis Association International. – System of classification of 206 Nursing

Diagnosis. – Facilitates nursing communications and

guides process of professional nursing practice for assessing and treating the nursing diagnosis.

– NANDA-I taxonomy supports development of EHR.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• NIC: Nursing Interventions Classification. – Code set designed for documenting nursing

interventions in any clinical setting. – Consists of numeric codes for 514

interventions. – Seven domains: Basic Physiological,

Complex Physiological, Behavioral, Safety, Family, Health System, Community.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• NOC: Nursing Outcomes Classification. – Comprehensive list of nursing outcomes. – Used to document effect of nursing

interventions on patient progress. – Structure of 330 numerically coded outcomes. – Codes correspond to seven domains

identified in NIC. – NIC and NOC codes developed in the

University of Iowa, College of Nursing, and are owned by Elsevier Science.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• ICNP: International Classification for Nursing Practice. – Result of project by International Council of

Nurses to create organizing structure into which other nursing terminologies can be mapped.

– It has merged the two different taxonomies used for nursing diagnosis and nursing interventions into one classification.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• Omaha System: Standardized terminology recognized by American Nurses Association as a standard language system to support nursing practice. – One of the oldest systems for nursing

documentation. – Often used in community-based nursing.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• NMDS: Nursing Minimum Data Set. – Intended to standardize collection of essential

nursing data. – Can be used to capture nursing data for

comparison of patient outcomes.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• PNDS: Perioperative Nursing Data Set. – Codifies nursing diagnoses, interventions, and

outcomes. – Focused on special needs and level of detail

required to document perioperative nursing.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Nursing Code Sets

• PCDS: Patient Care Data Set. – Developed primarily not as a classification

system for clinical terms but as a data dictionary defining elements to be included in and abstracted from clinical information systems.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Digital Image Systems

• Digital image data subcategorized into diagnostic and scanned document images.

• Cataloging the image: computer program to associate various ID fields and keywords with scanned images.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• In this exercise you will experience how an imaging system works.

• You will need access to the Internet.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 1 – Start web browser program; follow steps listed

inside cover of textbook to select discipline; click on book cover that matches this Electronic Health Records textbook; log in.

– When welcome page is displayed, click on link “Activities and Exercises” or select “Activities” from drop-down list; click button labeled “Go.”

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 2 – Menu on right of screen will list various

activities and exercises. – Locate and click on link Exercise 5. – Information about exercise will be displayed. – Locate and click link “Click here to start the

Document/Image System program.” – Screen similar to Figure 2-3 will be displayed.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-3: Document/Image System window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Document/Image System Window: This program simulates many features typically found in an EHR document/image management system.

• Menu Bar: At top of screen, the words “File,” “Select,” “View,” “Setup,” and “Help” are menus of functions typically found in document image software.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 3 – Position mouse pointer over word “Select” in

Menu bar at top of screen and click mouse button once.

– A list of Select menu functions will appear (Figure 2-4).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-4: Document/Image System after clicking the Select menu.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 4 – Move mouse pointer vertically down list over

word “Patient.” – Click mouse to invoke Patient Selection

window (Figure 2-5).

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-5: Selecting Raj Patel from Patient Selection window.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 5 – Find patient named Raj Patel in Patient

Selection window. – Position mouse pointer over patient name and

double-click mouse. – Once patient is selected, patient's name, age,

and sex are displayed in title at top of window. – Compare your screen to Figure 2-6.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-6: Left pane displays catalog list of documents and images for Raj Patel.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Toolbar: Located at top of screen are a row of icon buttons. Purpose is to allow quick access to commonly used functions.

• Catalog Pane: Middle portion of screen divided into two window panes. – Left pane: list of cataloged documents display

once patient is selected. – Top of catalog pane: eight tabs used to limit

list to images by category.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 6 – Locate Toolbar in Document/Image System

window. – First icon labeled “Exit”; it will close simulation

program and return you to MyHealthprofessionskit page. Do not click it yet.

– Next two buttons are used to change display of items in Catalog pane from list to thumbnails.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 6 (cont.) – Position mouse pointer over “Thumbs” icon on

Toolbar (circled in Figure 2-7); click your mouse.

– Compare your screen to Figure 2-7.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-7: Catalog pane displaying thumbnails of images.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 6 (cont.) – Now position mouse pointer over “Catalog”

icon on Toolbar and click your mouse. – Your screen should resemble Figure 2-6.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-6: Left pane displays catalog list of documents and images for Raj Patel.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 7 – Locate tab labeled “Med/Srg Hist” above

Catalog pane; position mouse pointer over it and click your mouse.

– List should be shorter as it is limited to items cataloged in category of Medical/Surgical History.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 8 – Locate catalog item “Anesthesia Report” and

click on it. – Compare your screen to Figure 2-8.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

Figure 2-8: Catalog on Med/Srg tab, Anesthesia Report, displayed in Image Viewer pane.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Image Viewer Pane: Right pane of window will dynamically display corresponding image for a catalog entry that is clicked.

• Item Details: Just below Catalog pane is gray panel that displays information about selected catalog item.

• Image Tools: Just below Image Viewer pane are a row of icon buttons used to change displayed image.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 9 – Locate image tools buttons just below viewer

pane. – Anesthesia Report has two pages. – Locate and click on Next page button (circled

in red in Figure 2-8). – Button displays next page of multipage

document; numeral between two buttons is page number currently displayed.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 9 (cont.) – Your screen should display second page of

report and Image Tool should display numeral two.

– Previous page button is first icon in image tools. Locate it and click on it.

– Image tool area should now display numeral one; image viewer should display first page of report.

Electronic Health Records: Understanding and Using Computerized Medical Records, Second Edition Richard Gartee

Guided Exercise 5: Exploring a Document Imaging System

• Step 9 (cont.) – Next two icons resemble magnifying glasses. – One includes a plus sign—Zoom In tool; it

enlarges text in viewer. – Other magnifying glass has a minus sign—

Zoom Out tool; it reduces enlarged view to show more of the page in viewer.

– Locate and click on Zoom In icon to see how this works.

Slide Number 1
EHR Data Formats
EHR Data Formats
Limitations of Certain Types of Data
Limitations of Certain Types of Data
Limitations of Certain Types of Data
Prominent EHR Code Sets
Prominent EHR Code Sets
Prominent EHR Code Sets
SNOMED-CT
MEDCIN
MEDCIN
MEDCIN
Comparing EHR Code Sets
Comparing EHR Code Sets
Comparing EHR Code Sets
Point-of-Care Documentation
LOINC
UMLS
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Nursing Code Sets
Digital Image Systems
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System
Guided Exercise 5: Exploring a Document Imaging System