1. Functional EHR Systems
CHAPTER
TWO
ONE
Functional EHR Systems

2. EHR Data Formats Three Forms of Data Formats
Digital images: Retrieved and displayed by computer, but a human required to interpret meaning of content.
Diagnostic images
Scanned documents

3. 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.
Fielded data
Coded data

4. 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.

5. Limitations of Certain Types of Data
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.

6. Limitations of Certain Types of Data
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®.

7. 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.

8. Prominent EHR Code Sets
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

9. Prominent EHR Code Sets
EHR users tend to locate findings by description, not by code.
EHR nomenclatures often include internal cross references to other standard code sets.

10. 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
Is-A relationships connect concepts within a single hierarchy.
Attribute relationships connect concepts from two different hierarchies.

11. 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).

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

13. 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.

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

15. Comparing EHR Code Sets
Figure 2-2: MEDCIN links for the term “Asthma.”

16. Comparing EHR Code Sets
Figure 2-2 (cont.): MEDCIN links for the term “Asthma.”

17. Point-of-Care Documentation
Nomenclatures designed for point-of-care are key to successful adoption of an EHR by clinicians.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. Guided Exercise 5: Exploring a Document Imaging System
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.”

32. Guided Exercise 5: Exploring a Document Imaging System
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.

33. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-3: Document/Image System window.

34. Guided Exercise 5: Exploring a Document Imaging System
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.

35. Guided Exercise 5: Exploring a Document Imaging System
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).

36. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-4: Document/Image System after clicking the Select menu.

37. Guided Exercise 5: Exploring a Document Imaging System
Step 4
Move mouse pointer vertically down list over word “Patient.”
Click mouse to invoke Patient Selection window (Figure 2-5).

38. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-5: Selecting Raj Patel from Patient Selection window.

39. Guided Exercise 5: Exploring a Document Imaging System
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.

40. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-6: Left pane displays catalog list of documents and images for Raj Patel.

41. Guided Exercise 5: Exploring a Document Imaging System
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.

42. Guided Exercise 5: Exploring a Document Imaging System
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.

43. Guided Exercise 5: Exploring a Document Imaging System
Step 6 (cont.)
Position mouse pointer over “Thumbs” icon on Toolbar (circled in Figure 2-7); click your mouse.
Compare your screen to Figure 2-7.

44. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-7: Catalog pane displaying thumbnails of images.

45. Guided Exercise 5: Exploring a Document Imaging System
Step 6 (cont.)
Now position mouse pointer over “Catalog” icon on Toolbar and click your mouse.
Your screen should resemble Figure 2-6.

46. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-6: Left pane displays catalog list of documents and images for Raj Patel.

47. Guided Exercise 5: Exploring a Document Imaging System
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.

48. Guided Exercise 5: Exploring a Document Imaging System
Step 8
Locate catalog item “Anesthesia Report” and click on it.
Compare your screen to Figure 2-8.

49. Guided Exercise 5: Exploring a Document Imaging System
Figure 2-8: Catalog on Med/Srg tab, Anesthesia Report, displayed in Image Viewer pane.

50. Guided Exercise 5: Exploring a Document Imaging System
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.

51. Guided Exercise 5: Exploring a Document Imaging System
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.

52. Guided Exercise 5: Exploring a Document Imaging System
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.

53. Guided Exercise 5: Exploring a Document Imaging System
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.