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Creating Data Entry Templates
- 1. Configuring Electronic Health Records Creating Data Entry Templates This material (Comp 11 Unit 5) was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.
- 2. Data Capture • Scanning – Hand written documents – Hard copy documents • Downloading – Other computer systems – Will depend on compatibility • Interfacing – Feed data directly from other devices – Blood pressure monitors • Manual data entry/transcribing 2
- 3. Data Entry Templates • Control quality – Data type – Range – Limit to lists – Forced entries/Required fields • Efficiency – Can make data entry quicker and easier. – Provide default values 3
- 4. Labs and Exercises • Hands-on experience with building templates and including them on the EHR’s list of data entry templates to select. • Provided by working through 3 corresponding labs and exercises. • To begin labs and exercises go to these files: – comp11_unit5_lab_exercise1 – comp11_unit5_lab_exercise2 – comp11_unit5_lab_exercise3 4
- 5. Creating Data Entry Templates References References AHIMA. Quality data and documentation for EHRs in physician practice. J Am Health Inform Assoc. 2008 Aug; 79 (8): 43-48. Amatayakul MK. Electronic health records: A practical guide for professionals and organizations 4th ed. Chicago IL: AHIMA; 2009. Carter JH. Electronic health records: A guide for clinicians and administrators. 2nd ed. Philadelphia: ACP Press; 2008. Eichenwald Maki S, Petterson B. Using the electronic health record. Canada: Delmar Cengage Learning; 2008. Hebda T, Czar P. Handbook of informatics for nurses & healthcare professionals. 4th ed. New Jersey: Pearson; 2009. Lehman HP, Abbot PA, Roderer NK, Rothschild A, Mandell SF, Ferrer JA, et al, editors. Aspects of electronic health record systems. U.S.A: Springer; 2006 5
- 6. Configuring Electronic Health Records Creating Data Entry Templates This material was developed by Oregon Health & Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0001. 6
Editor's Notes
- Welcome to Configuring Electronic Health Records: Creating Data Entry Templates. This component, Configuring Electronic Health Records, provides a practical experience with a laboratory component (utilizing the VistA for Education program) that will address approaches to assessing, selecting, and configuring Electronic Health Records (EHRs) to meet the specific needs of customers and end-users.
- There are several methods through which data is captured by, or enters into, the electronic health record (EHR). For instance, hand written documents or other hard copy documents can be scanned into the system. Since it is difficult for a system to read and interpret handwriting, the use of these documents will likely be limited to storage and retrieval and will not be used for supporting automated analysis and reporting. Information may also be downloaded (or read) directly from other computer information systems depending upon the compatibility of the two systems. This is where health information exchange standards will play a critical role. A variation of this form of data capture is the interfacing or feeding of data directly from other data capture devices, such as blood pressure monitors or electrocardiographs. Much of the data, however, will be manually entered into the system from existing textual documents, by a person directly recording observations, or by a person transcribing audio files. In these instances, the use of data entry templates are important tools in ensuring the quality of the data captured and improving the efficiency of data collection.
- GIGO, an acronym commonly quoted in information circles, stands for Garbage In - Garbage Out. This expresses the concept that the quality of information that an information system can provide is highly dependent upon the quality of the data that is entered into the system. Data entry templates can manage the quality of data captured in a variety of ways. One method is to limit the data type so that, for example, character data cannot be entered where numerical is required or by limiting a response to a Yes/No or True/False or Male/Female choice. Data entry templates can also build in acceptable ranges of values to avoid erroneous entries. An example of this would be requiring blood pressure, or other physiological measurements to be within a realistic range of values. Another tool available to data entry templates is what is called a pick list, which restrict users to making a selection from a list of values such as available lab tests. This ensures that this data is entered consistently and accurately, leaving no room for misinterpretation. Finally, data entry templates can require that certain key fields must be completed before the form can be submitted, thus minimizing the omission of critical information. These examples demonstrate the important role of data entry templates in the creation of quality health information. As well as supporting the collection of quality data, data entry templates also improve the efficiency of data capture in a variety of ways. Templates that are well designed and uniformly implemented provide a structured format for the user that is familiar and easy for them to use. Templates can speed data entry by providing suggested static default values. The user entering the data can simply accept the default value and avoid a considerable amount of additional work. The greater the probability of the default value being the correct value, the greater the efficiency gains. For example, when installing an EHR system for an organization in Denver, Colorado, choosing Denver as the default city and CO as the default state would be a good choice. For the same EHR system installed in Seattle, Washington, configuring the system so that Seattle is the default city and WA the default state will likely create greater efficiency. Finally, the EHR system can suggest dynamic default values that are based upon existing information stored in the field being matched to the letters or numbers that the user begins entering. At any point the user can accept the suggested default or continue to enter the value.
- The next step is to begin working on the labs and corresponding exercises that will focus on creating a document title to attach to template document for access in a computerized patient record system (CPRS) chart, shared templates, personal templates and template fields. We will see how document templates make entering and editing documentation for diabetic patients quicker and easier. The CPRS chart template editor in the VistA EHR simulation program is used to create and manage document templates and access is limited to specific users such as Clinical Application Coordinators (CAC), or Clinical Coordinators. In the lab, the document template will be created and then linked to the document title. This will provide quick access for users to access the desired template by selecting a descriptive title which will automatically open the correct template, ready for data to be entered. Shared templates are available to all users, but users can also create personal templates in which text can be copied and pasted, structured data capture fields added, existing patient information inserted, or a shared template inserted. However, users will not be able to make changes to a shared template that is inserted into a personal template. Now it is time to learn to create templates in the EHR by engaging in hands-on practice through the three corresponding labs and exercises. These labs and exercises are best completed in the order indicated. It may be useful to work through these activities more than once in order to develop the skills necessary to navigate and work with templates in the EHR. The CPRS chart template editor in the VistA EHR simulation program is used to create and manage document templates and access is limited to specific users such as Clinical Application Coordinators (CAC), or Clinical Coordinators. In the lab, the document template will be created and then linked to the document title. This will provide quick access for users to access the desired template by selecting a descriptive title which will automatically open the correct template, ready for data to be entered. Shared templates are available to all users, but users can also create personal templates in which text can be copied and pasted, structured data capture fields added, existing patient information inserted, or a shared template inserted. However, users will not be able to make changes to a shared template that is inserted into a personal template. Now it is time to learn to create templates in the EHR through the three corresponding labs and exercises. These labs and exercises are best completed in the order indicated. It may be useful to work through these activities more than once in order to develop the skills necessary to navigate and work with templates in the EHR. This concludes Creating Data Entry Templates which, in conjunction with the labs and exercises developed the ability to access and use the template editor in the VistA EHR simulation system, explored and used the various types of field templates available to promote data quality, and improve the efficiency of data collection. Designed, created, and viewed both a shared and a personal template for data entry. And, discovered how data entry fields and templates can support efficient and effective health information management and improve health information quality to support quality care and improved patient safety.
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