Ehrdt 16 ppt

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Ehrdt 16 ppt

  1. 1. Above is the same text-based chart note shown in my last post. In print format, this particular chart note isthree pages in length. In my last post, we considered the low data density of the note, both at thismagnification . . .1 2 3Chart Note 10/15/2008
  2. 2. . . . and at full scale, viewed on the EHR monitor.PATIENT: Maria SmithDATE OF BIRTH: 08/14/1929DATE OF EXAM: 10/15/2008Chief Complaint and HPIComplaint 1: This 79 year old female presents for a 6 month follow-up for glaucoma in her right eye. She reports nochange in her vision. She has been using Alphagan-P drops on a regular basis 2x/day in the right eye without anyproblems. She is planning to move to Florida permanently.HistoryHistorian: Jenny AvarroPast Ocular History Eye Year DxOcular DiseaseNuclear Sclerosis OSTrichiasis OUNuclear Sclerosis OSGlaucoma suspect ODKeratitis Sicca OUPseudoexfoliation ODOcular MedicationsBrand Name Dose Sig Start Date Stop DateAlphagan-P 0.15% 04/17/2003
  3. 3. Consequently, when viewed on the EHR monitor, the user has to scroll or page down about six time to see theentire note. . .Past Systemic History Year DxSystemic DiseaseDM type 2 w/o comp.Ocular ProceduresSx Procedure Eye Date Gl End Date SurgeonCataract Surgery OD 2002Systemic MedicationsBrand Name Dose Sig Start Date Stop DateMetformin 04/17/2003AllergiesAllergen/Ingredient Brand ReactionTimolol breathing problemsPenicillinsFamily HistoryYes / No Disease Detail Family Member Name AgeGlaucoma MotherReview of SystemsConstitutional: The patient denied fatigue.Ears/Nose/Throat/Neck: The patient denied vertigo, hearing loss, nasal discharge and sinus congestion.
  4. 4. . . . as shown here. Hence, the user has to retain information in working memory as opposed to being ableto retrieve it with a glance from the same screen.
  5. 5. In addition to having low data density, there is second reason these text-based EHR documents tend to beinefficient -- they often have a low data-ink ratio -- the amount of ink used to display data divided by the totalamount of ink used in the graphic or display.Family HistoryYes / No Disease Detail Family Member Name AgeGlaucoma MotherReview of SystemsConstitutional: The patient denied fatigue.Ears/Nose/Throat/Neck: The patient denied vertigo, hearing loss, nasal discharge and sinus congestion.Cardiovascular: The patient denied arrhythmia, chest pain/pressure, edema, exercise intolerance, orthopnea andpalpitations.Respiratory: The patient denied dry cough, asthma, pleuritic pain, productive cough, dyspnea and wheezing.Gastrointestinal: The patient denied hemorrhoids, hepatitis, abdominal pain, constipation, diarrhea, gastroesophagealreflux, melena, nausea and vomiting.Genitourinary/Nephrology: The patient denied dysuria, nocturia and urinary incontinence.Musculoskeletal: The patient denied stiffness, swelling, muscle weakness and myalgias.Dermatologic: The patient denied rash and scar.Neurologic: The patient denied radicular pain, dizziness, headache, neck pain and syncope.Psychiatric: The patient denied anxiety and depression.Endocrine: The patient denied goiter, hyperglycemia and hypoglycemia.Hematologic/Lymphatic: The patient denied abnormal ecchymoses, petechiae, abnormal bleeding and bruising, anemiaand lymph node enlargement/mass.Allergy/Immunology: The patient denied wheezing or food allergy.OD Dva 20/25ccOS Dva 20/40 cc 20/25 ph
  6. 6. Consider the information in the Review of Systems section above. While it looks comprehensive, it is boilerplatetext that is often included in chart notes to support coding and billing at a higher lever of service. All the findingsare negative. There is no way of knowing whether all the above questions were actually asked. Furthermore, thereis no way to distinguish a true pertinent negative from the boilerplate negatives. So in fact, the data-ink ratio inthis example is close to zero.Family HistoryYes / No Disease Detail Family Member Name AgeGlaucoma MotherReview of SystemsConstitutional: The patient denied fatigue.Ears/Nose/Throat/Neck: The patient denied vertigo, hearing loss, nasal discharge and sinus congestion.Cardiovascular: The patient denied arrhythmia, chest pain/pressure, edema, exercise intolerance, orthopnea andpalpitations.Respiratory: The patient denied dry cough, asthma, pleuritic pain, productive cough, dyspnea and wheezing.Gastrointestinal: The patient denied hemorrhoids, hepatitis, abdominal pain, constipation, diarrhea, gastroesophagealreflux, melena, nausea and vomiting.Genitourinary/Nephrology: The patient denied dysuria, nocturia and urinary incontinence.Musculoskeletal: The patient denied stiffness, swelling, muscle weakness and myalgias.Dermatologic: The patient denied rash and scar.Neurologic: The patient denied radicular pain, dizziness, headache, neck pain and syncope.Psychiatric: The patient denied anxiety and depression.Endocrine: The patient denied goiter, hyperglycemia and hypoglycemia.Hematologic/Lymphatic: The patient denied abnormal ecchymoses, petechiae, abnormal bleeding and bruising, anemiaand lymph node enlargement/mass.Allergy/Immunology: The patient denied wheezing or food allergy.OD Dva 20/25ccOS Dva 20/40 cc 20/25 ph
  7. 7. The same information could have been conveyed, with a much higher data-ink ratio, as shown here.Family HistoryYes / No Disease Detail Family Member Name AgeGlaucoma MotherReview of SystemsNegative in detailOD Dva 20/25ccOS Dva 20/40 cc 20/25 ph
  8. 8. Similarly, consider this portion of the exam: it looks comprehensive, but when you actually read it, yourealize that most of the information consists of boilerplate normal values. In fact, the only real data on thisscreen is . . .ConfrontationOD: confrontation fields full to finger countingOS: confrontation fields full to finger countingMotilityOD: EOM is fullOS: EOM is fullAdnexaOD: no rashes or rosaceaOS: no rashes or rosaceaEyelidsOD: no ptosis, retraction, or lid lesionsOS: no ptosis, retraction, or lid lesionsConjunctiva:OD: white and quietOS: white and quietCornea:OD: normal endothelial, epithelial, stroma and tear filmOS: normal endothelial, epithelial, stroma and tear filmAnterior Chamber:OD: PXFOS: no cell or flareIris:OD: iris normalOS: iris normalLens:OD: PCIOLOS: 1+ NS and cortical changes
  9. 9. . . . the information highlighted in yellow. So in this screen as well, the data-ink ratio is exceedingly low.In some encounter notes, one could make a good case that the data-ink ratio is actually a negativenumber because the default values don’t reflect the actual findings.ConfrontationOD: confrontation fields full to finger countingOS: confrontation fields full to finger countingMotilityOD: EOM is fullOS: EOM is fullAdnexaOD: no rashes or rosaceaOS: no rashes or rosaceaEyelidsOD: no ptosis, retraction, or lid lesionsOS: no ptosis, retraction, or lid lesionsConjunctiva:OD: white and quietOS: white and quietCornea:OD: normal endothelial, epithelial, stroma and tear filmOS: normal endothelial, epithelial, stroma and tear filmAnterior Chamber:OD: PXFOS: no cell or flareIris:OD: iris normalOS: iris normalLens:OD: PCIOLOS: 1+ NS and cortical changes
  10. 10. If both the data density and the data-ink ratio of this text-based note were increased, instead of having todisplay the data for this patient encounter in six screen views . . .
  11. 11. . . . all the relevant data could be presented in a single screen, as shown above. It should be noted that some EHRsdo a much better job than others of creating text-based chart notes of both high data density and high data-ink ratio.
  12. 12. These differences in visual presentation make an enormous difference in how much cognitive effortgoes into making sense of a patient encounter. Unfortunately, for many EHR vendors, increasing thedata density and data-ink ratio of their text-based chart notes is not a high priority.(last slide)

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