Electronic Medical Records – Building Encounter Forms Erika Orrick GE Healthcare

2 / WEUSE II Presentation / 2/9/2014 By computerizing health records, we can avoid dangerous medical mistakes, reduce costs, and improve care. President Bush, 2004 State of the Union

What are EMR systems and why is this significant?

4 / WEUSE II Presentation / 2/9/2014 What is an EMR system?

5 / WEUSE II Presentation / 2/9/2014 Encounter forms generate chart data

6 / WEUSE II Presentation / 2/9/2014 What is rapidly increasing adoption of EMR systems? One recent reform pushing adoption of EMR systems has been Medicares (and many private insurers) pay-for-performance initiatives. It is much easier to prepare needed reports using electronic systems. (e.g. HbA1C for diabetes) This reform is one thing pushing EMR systems into smaller, less tech-savvy clinics than they were previously found.

7 / WEUSE II Presentation / 2/9/2014 EMR systems also can enable data availability RHIOs (Regional Health Information Organizations) are forming to encourage patient data exchange. EMR systems allow easy patient contact for drug recalls, etc.

Why is this an end-user software engineering problem?

9 / WEUSE II Presentation / 2/9/2014 Encounter forms in clinical workflows Centricity ® EMR is shipped with a default set of encounter forms, but many providers/clinics are used to working in a certain way and want to customize the forms to match them. There are a several third party vendors who sell additional forms and customization services for our EMR product. Forms enable quick entry of information in a manner that will ensure accurate coding for insurance/Medicare filing.

10 / WEUSE II Presentation / 2/9/2014 Default output of an encounter form History of Present Illness Chief Complaint: chest pain Location: Substernal Quality: Burning Severity: moderate Duration: 3 days Timing: constant Radiation: none Exacerbating factors: eating Relieving factors: antacids Associated with: weekly staff meetings

11 / WEUSE II Presentation / 2/9/2014 Provider-preferred output of the form This patient presents with a 3 day history of substernal chest pain. He describes it as moderately burning in character. Michael also describes the pain as constant without radiation. The patient states that eating exacerbates the pain, and that antacid provides relief from the pain. Pain is often associated with weekly staff meetings.

12 / WEUSE II Presentation / 2/9/2014 MEL (Medical Expression Language) to generate natural language output {CFMT(DOCUMENT.TEMP_ _1_891658, "", "This patient presents with a ", "")}{ cond case DOCUMENT.TEMP_ _1_ == "minutes" return " minute" case DOCUMENT.TEMP_ _1_ == "hours" return " hour" case DOCUMENT.TEMP_ _1_ == "days" return " day" case DOCUMENT.TEMP_ _1_ == "months" return " month" else "" endcond}{CFMT(OBSNOW("HPI location"), "", " history of ", "", "")}{cfmt(OBSNOW("Chief Cmplnt"), "", " ", "", ". ")} This snippet of code produces only the first sentence of the previous paragraph: This patient presents with a 3 day history of substernal chest pain.

13 / WEUSE II Presentation / 2/9/2014 The current Encounter Form Editor

14 / WEUSE II Presentation / 2/9/2014 Single item edit detail in the EFE

15 / WEUSE II Presentation / 2/9/2014 Debugging: MEL Trace Starting MELTrace on 07/26/2005 2:19 PM for WSID execute>Attach Symbols Begin execute>Attach Symbols End >{/****VARIABLES FOR MEL BUILT-IN SYMBOLS USED IN FORM****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL >{/****VARIABLES FOR MEL BUILT-IN SYMBOLS USED IN FORM****/\par } execute>end results>NULL >{/****START OF FORM TRANSLATION BODY****/\par } execute>end results>NULL … …. execute>call VAL("6") results>6 execute>6 <= 5.50 results>FALSE execute>if FALSE results>FALSE execute>Document.TEMP_CCC_HPI_FORM_OPENED results>"OPENED" execute>"OPENED" == "" results>FALSE execute>Document.TEMP_CCC_A_P_FORM_OPENED results>"OPENED" execute>"OPENED" == "" results>FALSE execute>FALSE AND FALSE results>FALSE execute>Document.TEMP_CCC_PED_A_P_FORM_OPENED results>"OPENED" execute>"OPENED" == "" results>FALSE execute>FALSE AND FALSE results>FALSE … (and so on)

Problem Summary

17 / WEUSE II Presentation / 2/9/2014 How do allow end users to construct encounter forms more easily? How do we make this customization tool more accessible to less technical users? How do we encourage the use of standards so one clinic can have a consistent interface in spite of using forms constructed by GE Healthcare, by a third-party vendor, and in house?

18 / WEUSE II Presentation / 2/9/2014 Erika Orrick