ELECTRONIC HEALTH RECORDS Understanding and Using Computeriz.docx

ELECTRONIC HEALTH RECORDS
Understanding and Using Computerized Medical Records
CHAPTER
LESSON
Copyright ©2012 by Pearson Education, Inc.
All rights reserved.
Electronic Health Records: Understanding and Using
Computerized Medical Records, Second Edition
Richard Gartee
Functional EHR
Systems
CHAPTER TWO
ONE
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.
agnostic images
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.
data
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.
Richard Gartee
• 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.

Richard Gartee
• 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®.
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.
Richard Gartee
• 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
Richard Gartee

• EHR users tend to locate findings by
description, not by code.
• EHR nomenclatures often include internal
cross references to other standard code
sets.
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
-A relationships connect concepts within a single
hierarchy.
different hierarchies.

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

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.
Richard Gartee
Comparing EHR Code Sets
Figure 2-1: SNOMED-CT links for the term “Asthma.”

Richard Gartee
Figure 2-2: MEDCIN links for the term “Asthma.”
Richard Gartee
Figure 2-2 (cont.): MEDCIN links for the term “Asthma.”
Richard Gartee
Point-of-Care Documentation

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

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.
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.
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.
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.
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.

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.
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.

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.
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.

Richard Gartee
• 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.”
Richard Gartee
• 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.
Richard Gartee
Figure 2-3: Document/Image System window.
Richard Gartee
• 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.
Richard Gartee
• 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).
Richard Gartee

Figure 2-4: Document/Image System after clicking the Select
menu.
Richard Gartee
• Step 4
– Move mouse pointer vertically down list over
word “Patient.”
– Click mouse to invoke Patient Selection
window (Figure 2-5).
Richard Gartee

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

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

Richard Gartee
• 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.
Richard Gartee
• Step 6 (cont.)

– Position mouse pointer over “Thumbs” icon on
Toolbar (circled in Figure 2-7); click your
mouse.
Richard Gartee
Figure 2-7: Catalog pane displaying thumbnails of images.
Richard Gartee
• Step 6 (cont.)
– Now position mouse pointer over “Catalog”

icon on Toolbar and click your mouse.
– Your screen should resemble Figure 2-6.
Richard Gartee
Figure 2-6: Left pane displays catalog list of documents and
images for Raj Patel.
Richard Gartee
• 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.
Richard Gartee
• Step 8
– Locate catalog item “Anesthesia Report” and
click on it.
Richard Gartee
Figure 2-8: Catalog on Med/Srg tab, Anesthesia Report,
displayed in Image

Viewer pane.
Richard Gartee
• 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.
Richard Gartee

• 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.
Richard Gartee
• 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.
Richard Gartee
• 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 1EHR Data FormatsEHR Data FormatsLimitations
of Certain Types of DataLimitations of Certain Types of
DataLimitations of Certain Types of DataProminent EHR Code
SetsProminent EHR Code SetsProminent EHR Code
SetsSNOMED-CTMEDCINMEDCINMEDCINComparing EHR
Code SetsComparing EHR Code SetsComparing EHR Code

SetsPoint-of-Care DocumentationLOINCUMLSNursing Code
SetsNursing Code SetsNursing Code SetsNursing Code
SetsNursing Code SetsNursing Code SetsNursing Code
SetsNursing Code SetsNursing Code SetsDigital Image
SystemsGuided Exercise 5: Exploring a Document Imaging
SystemGuided Exercise 5: Exploring a Document Imaging
System

ELECTRONIC HEALTH RECORDS Understanding and Using Computeriz.docx

Recommended

Recommended

More Related Content

Similar to ELECTRONIC HEALTH RECORDS Understanding and Using Computeriz.docx

Similar to ELECTRONIC HEALTH RECORDS Understanding and Using Computeriz.docx (20)

More from jack60216

More from jack60216 (20)

Recently uploaded

Recently uploaded (20)

ELECTRONIC HEALTH RECORDS Understanding and Using Computeriz.docx