The importance of structured data elements in EHRs

By Tom Murray and Laura Berberian

Electronic health records (EHRs) that use structured data elements are documenting patient information using controlled vocabulary rather than narrative text. The historic lack of structured data and standardization in the healthcare industry today causes problems when sharing EHR content between providers. Currently, the healthcare industry is far from the desired state where patients have one complete, accurate EHR from which the quality of their individual health care can be monitored and maintained.

In many cases, critical data elements, such as problem lists, medications, and allergies, are inconsistent between EHR systems. These data elements' coding often differ from one health system to another using the same EHR. In other instances, it's a case of uncontrolled vocabulary usage drawn from a variety of clinical definition sources such as drug databases like First Data; SNOMED (Systematic Nomenclature of Medicine), a hierarchical medical classification system; or IDC-9 and currently IDC-10 (International Statistical Classification of Diseases and Related Health Problems, 9th and 10th Revision), a coding of diseases, signs and symptoms, and abnormal findings as classified by the World Health Organization (WHO).

Additionally, the general physician and hospital population have hastily "automated" the paper process and in doing so, have compromised creating standards and charting using structured data. The end result is what exists today: patient medical records comprised of "data dumps" from different systems, the seemingly insurmountable task of meeting meaningful use requirements set forth by the American Recovery and Reinvestment Act of 2009, and major obstacles in sharing healthcare information seamlessly between the entities within HIEs.

Challenges

Many health care initiative programs requiring structured data -- meaningful use, accountable care organizations, HIEs, and patient consumerism -- all require a robust level of reporting to measure the quality of clinical data and provide clinical decision support tools to physicians and hospitals.

Cultural barriers to adopting standards and the use of structured data do exist. While structured data is required to aggregate, report and transmit the collection of data at the point of care, it is often perceived by physicians to inhibit their ability to practice medicine and document in a fashion they feel is most effective. The adoption of EHRs systems that allow physicians flexible documentation via dictation/transcription, free text, macros, or voice recognition technology, have flourished.

Physician productivity has decreased while frustration associated with using EHRs increased as much of the burden to capture structured clinical data has fallen to the physician at the point of care, immediately following a patient visit, or at the end of the day.

The maturity of the technology solutions and standardization across platforms presents further barriers to adopting structured data standards. Coding schemes and critical structured data fields are not standardized and utilize different coding databases, for example, medication. Transitioning to ICD-10 will further complicate efforts to adopt standards. 

Solutions

To reach the desired state of one complete and accurate electronic chart per patient, healthcare organizations need to change their approach to implementing EHRs and HIEs.

1.      Institute a clinical standards committee for policies and standard clinical protocols, and EHR standards. Establish a clinical advisory committee (CAC) -- a cross-functional, multi-disciplinary governing body, empowered to provide leadership down to the practice level -- to develop and maintain standards for clinical information within EHRs and HIEs.

2.      Identify the "deal breakers" for structured data entry. For physicians resistant to structured data capture, a hybrid approach needs to be developed that blends the ability to capture required structured data elements and provides physicians the flexibility to document in their own personal manner. This will increase physician adoption while meeting data reporting and data exchange needs. In addition, healthcare organizations should take proactive measures to educate physicians on the benefits of capturing structured data elements and maintain flexibility within an EHR to allow for personalization of progress notes and individual physician styles.

3.      Identify the workflows to facilitate data entry capture. Identifying workflows and implementing processes that will distribute the workload of collecting demographic data and clinical information (vitals, allergies, problem lists, and medication) among staff throughout the care process is critical to maintaining maximum physician productivity. Doing so streamlines data capture and provides physicians more time to review and sign-off on information and less time addressing documentation accuracy issues with structured data elements based on a quality program's requirements.

4.      Identify the technology platforms necessary for seamless integration. Understanding the components of the technology architecture necessary to accommodate the capture and integration of structured data is often assumed to be a part of how EHRs exist today. However, the comparison between EHR software companies, HIE software companies, integration environments, and semantic translation services for example, are dissimilar.  A solution today will most likely be a combination of several technologies to solve critical issues.

The healthcare industry still faces many challenges on the road to embracing structured data elements and the ultimate goal of one complete, accurate EHR per patient. Healthcare organizations continue to implement EHRs and HIEs, going back to optimize practices that haven't captured structured data, and change the approaches.  As these challenges are addressed, we can anticipate a major change over the next five years in the quality of data and the seamless exchange of patient data.

Tom Murray is Practice Lead, EHR Workflow at Concordant and Laura Berberian is a Clinical Consultant at Concordant, which provides healthcare IT consulting services, specializing in ambulatory EHR adoption and implementation.

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