Welcome to the third weak informatics talk.Our topic for today is about: Coded data entry Vs. Free text data entry.My name is Amr Jamal, and I’m so glad to be your host for today.This talk is a collaborative effort of Kevin Kavanaugh Tom Yaeger , and me.
First, let us start with definitions. Coded data or (Structured data): is defined as documentation of discrete data selected from controlled vocabulary such as ICD-10 , SNOWMED, or any other terminology standards.On the other hand, Free text: is defined as Alphanumeric data that are unstructured, typically in narrative form. Wither entered directly by the user in a text form, or converted from voice by a dictation system.
Here we can see an example of coded or structureddata entered in the Chronic Problem list
Here in this second example, we can see both types of data entry.When we look to the “reasons for admission” part, we will notice that the user has to choose from structured predefined choices “Coded Data”.While in the History and Examination notes bellow, the user has to enter a free text narration.So, which method is better? That what we will discuss in the few coming slides.
The quality of healthcare delivery is directly related to the quality of the data contained in the clinical records. Inaccurate or poor data can increase inefficiencies and lead to patient safety issues and increased cost. Sharing data across institutions can enhance quality initiatives, improved performance and clinical research; however, if the data is poor, these goals can be hindered. Furthermore, even a single error or misrepresentation in the clinical record can be magnified as data passes back and forth between different institutions and health care entities. Accordingly, the benefits of EHR have the potential to be lost or attenuated depending on the reliability of the data.Data must be structured and coded to enable optimal information capture. Clinical data is at best very difficult to extract when in text form and may be functionally inaccessible. Extracting such data can be prone to error. There are the additional costs of transcription to consider as well.
Much of the real and perceived benefits of the EHR are enabled by coded clinical data. Real time alerts are significant method to improve patient care and reduce the likelihood of errors in medication administration and other interventions. Clinical decision support tools are difficult to implement without structured data. Best documentation practices require searchable terms and components. The ability to do multi-media reporting including images and files other than text is enhanced with structured data. Multiple output formats such as differing reports for providers, patients and payers cannot easily be done with primarily text containing substrates.
Perhaps the most compelling reason for coded data entry are the preliminary Meaningful Use Criteria released by CMS. While the final regulations are not yet in place, it is likely to be similar to what has been announced. In order for providers to capture the incentives and avoid penalties, these measures need to be incorporated and used in the individual EHRs. Computerized provider order entry, under the proposed rules, will need to be in place for 80% of the orders in the ambulatory setting and 10% in hospitals. Clinical decision support is predicated on existing CPOE capability. Neither of these utilities can be fully implemented without entry of data in a structured format.Medication and allergy lists including drug-drug, drug-allergy, drug- formulary checks are required for meaningful use. At least 75 percent of all permissible prescriptions written by the providers are to be transmitted electronically using a certified EHR. This functionality is not available with text only.The ability to communicate with the patient electronically is needed. This communication includes the ability to generate patient reminders, give patients appropriate access to their health records and generate clinical summaries when requested. Without coded data entered in the EHR, such extractions are not readily available.The capability to exchange key clinical information (for example, problem list, medication list, allergies, and diagnostic test results), among providers of care and patient authorized entities electronically is a proposed meaningful use requirement. Documentation in text form would hinder and render very difficult compliance with this utility.The ability to electronically provide a summary care record for each transition of care and referral is another criteria. Extracting the appropriate information in a succinct form will necessitate coded data.
Quality reporting begins with a generation of lists of patients with specific conditions. This functionality is also mandated by the ONC. Data found only in text format is poorly accessible and may not meet the needs required.
Certainly one of the most important (if not the most important) aspects of the clinical record for good patient care is the problem list. Typically, it is the part of the medical record where the real issues regarding the patient’s care is found. It is frequently recorded as free text. In this modality, the structure is variable. There is a limited ability to search or code these data. While structured data entry can constrain the ability of the provider to communicate the issues in a robust manner, such entry can enhance the continuity of the record.
And, in any case, the Office of the National Coordinator for Health Information Technology (ONC) meaningful use criteria mandate that the problem list has to be in structured data format. It must be based on ICD-9-CM or SNOWMED CT. It must be provided to patients at their request, as well.
What you have heard is the seminal start of the topic. Now, we want to hear your voice, and look forward to see your comments about the following discussion questions:Will work flow disruptions and time inefficiencies preclude most providers from accepting the need for coded data entry?Is the clinical narrative too important for quality patient care to even attempt to supplant with coded data?In the narrative of the history, how would you strike a balance between descriptive free text and coded data?Since it is not practical to code every single data in the EHR, in what bases we can select what data code?
Coded data entryBetter or worse than Free text?
Coded data entryBetter or worse than Free text?<br />Amr Jamal Kevin Kavanaugh Tom Yaeger<br />
Definitions<br />Coded data:<br />Documentation of discrete data from controlled vocabulary<br />Free text:<br />Alphanumeric data that are unstructured, typically in narrative form<br />
Benefits of EMR’s<br />Quality reports<br /> maintenance of lists, such as problem list, and medication list<br />Real time alerts and reminders.<br />Ability to aggregate patients for research<br />Collect information from other sources<br />Integration with billing and scheduling systems<br />
Barriers to adoption of the EHR<br />Cost<br />Cost of the system<br />Productivity concerns<br />Usability<br />
The case for free text<br />Coded data ok for lists<br />Issues with coded data<br />A narrative captures more robust information<br />Supports quality patient care<br />Faster for common situations<br />Supports adoption<br />
Narratives tell a story. <br />A narrative tells a story<br />See the patient through a description<br />Complicated events are easier to describe in text<br />Undifferentiated problems<br />Interpretation. <br />“only a human can prioritize and determine what the chief complaint really is”<br />
Care of the individual - Quality<br />Every patient, every time<br />Hospital billing<br />
Speed<br />a person can generally speak 3 x faster than typing<br />Adoption<br />Tools are in their infancy. <br />Electronic Health Record Usability: Evaluation and Use Case Framework<br />
Issues with coded data<br />“pick from a list” allows wrong selection<br />Compliance concerns<br />Over documentation for care<br />cloning<br />
Advantages of Coded Data<br />Need for structured and coded information capture<br />Clinical data is lost or inaccessible as text<br />Costs of transcription<br />
CMS Meaningful Use Criteria<br />CPOE<br />CDS<br />E-prescribe, medication and allergy lists<br />Patient reminders, access and clinical summaries<br />Information exchange<br />Care summaries<br />
Quality reporting<br />Generating lists of patients by specific conditions<br />Mandated by ONC<br />Information required poorly accessible in text format<br />
Problem List<br />Critical to patient care<br />Frequently done in free text<br />Variable structure<br />Limited ability to search or code<br />
Problem list continued<br />Mandated structured data by ONC<br />Based on ICD-9-CM or SNOMED CT<br />Provide to patients at their request<br />
Questions for Discussion<br />Will work flow disruptions and time inefficiencies preclude most providers from accepting the need for coded data entry?<br />Is the clinical narrative too important for quality patient care to even attempt to supplant with coded data?<br />In the narrative of the history, how would you strike a balance between descriptive free text and coded data?<br />Since it is not practical to code every single data in the EHR, in what bases we can select what data code?<br />
References<br />Bachman, J.W., The patient-computer interview: a neglected tool that can aid the clinician. Mayo Clin Proc, 2003. 78(1): p. 67-78.<br />Bell, A.a.J. and T.A. Institute, Electronic Health Record Usability, Health, Editor. 2009: Rockville, Maryland. p. 60.<br />Callen, J.L., M. Alderton, and J. McIntosh, Evaluation of electronic discharge summaries: a comparison of documentation in electronic and handwritten discharge summaries. Int J Med Inform, 2008. 77(9): p. 613-20.<br />Clayton, P.D., et al., Physician use of electronic medical records: issues and successes with direct data entry and physician productivity. AMIA Annu Symp Proc, 2005: p. 141-5.<br />Cuvo, J.B., et al., Quality data and documentation for EHRs in physician practice. J AHIMA, 2008. 79(8): p. 43-8.<br />DesRoches, C.M., et al., Electronic health records in ambulatory care--a national survey of physicians. N Engl J Med, 2008. 359(1): p. 50-60.<br />Johnson SB, Bakken S, Dine D, Hyun S, Mendonca E, Morrison F, et al. An electronic health record based on structured narrative. J Am Med Inform Assoc. 2008 Jan-Feb;15(1):54-64. <br />Meaningful Use: http://edocket.access.gpo.gov/2010/E9-31217.htm<br />