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Chapter 8

Clinical Inputs and


Outputs

Chapter Topics
Concepts related to data input, output, and
representation in EHRs
Clinical reports and uses of templates
Data integrity considerations in an increasingly electronic
environment
E-prescribing and clinical results reporting
Public health objectives addressed in the Meaningful Use
EHR Incentive Programs

Objectives
Define and discuss structured and unstructured data.
Define data mining and its relationship to structured and
unstructured data.
Explain manual and automated methods of data collection.
Identify the elements of a history and physical examination.
Understand how to enter progress notes into an EHR, as well
as the role of assessments, orders, test results, and other
clinical documentation in the EHR system.
Define cloned notes and their related concerns.
Define e-prescribing and its benefits and challenges.
Modify an e-prescription and override a drug allergy
notification.
Understand clinical results reporting and discuss manual and
automated methods of results entry into the EHR.
Understand how EHR systems support public health
initiatives.
Create a Meaningful Use report via the EHR Navigator.
Report an immunization.

Data Collection
Clinical inputs are data related to a patients clinical status entered
into the EHR
Data entered into EHRs are classified as structured or unstructured
Structured data are stored in fixed field databases; examples include:
Items captured via drop down menus, radial buttons, or
checkboxes
Unstructured data are not stored in fixed fields; examples include:
Typewritten narrative reports and summaries
Clinical outputs are data extracted from records and compiled in
meaningful ways
Data mining entails searching for and examining data to organize it
into useful patterns

Data Collection
Data collection in an EHR occurs
through a variety of manual and
automated methods
Manual data collection occurs
when a staff member or
provider type enters data into a
record
Automated data collection
occurs when the EHR system
houses data from a previous
encounter that is automatically
copied forward into future
encounters
Quality review of data entry is
increasingly important

Data Collection
The history and physical exam (H&P) is the most common document
type and used in nearly all settings
The beginning of an H&P depicts the patients chief complaint; from
there, the H&P is comprised of data that is subjective and objective
Subjective data depicts personal opinions and statements whereas
objective data is based on clinical facts
The history portion is subjective and provided by the patient; history
is comprised of the following:
History of present illness
Past medical history
Allergies
Medications currently prescribed
Family and social histories

Data Collection
The physical exam entails
the provider conducting a
review of systems (ROS)
and documenting related
findings in the following
systems:
General
Vitals
HEENT
Respiratory
Cardiovascular
Abdominal
Gastrointestinal
Genitourinary
Musculoskeletal
Neurologic

Data Collection
Following the H&P, the provider then reviews pertinent laboratory
or diagnostic data, assesses the patients condition, and develops a
treatment plan
The H&P may be typed into the EHR by the provider or dictated for
production by a healthcare documentation specialist
H&Ps in a clinic may be brief due to the nature of care provided in a
clinic setting; conversely, H&Ps for inpatient hospital visits are often
lengthy
Templates may expedite clinical inputs and have the following
benefits:
Required fields are not overridden
Ensures consistency in data gathering
Allows for structured data entry where appropriate
Provides immediate data population
Reduces transcription expense
Facilitates easy access to data due to consistency

Data Collection
Specialized templates may also be useful for specialists or general
physicians for specific purposes
Figure 8.1 shows a specialized template for an eye exam:

Checkpoint: Your Turn

True or false: Data mining is most easily achieved with


unstructured data.
True
False

True or false: H&P documentation accounts for subjective


and objective data elements related to the patient.
True
False

Data Collection
Progress notes are documented to depict patient progress or lack
thereof related to established goals of a care plan
Customized templates may be helpful to facilitate progress note
documentation in EHRs
Progress note templates are customizable by specialty or
profession for example, templates may be built for nursing,
physical therapy, etc., as well as all medical specialties
Cloned progress notes are those copied in whole or part from
previous progress notes and updated with new information
Cloned progress notes may save time when documenting, but the
practice leaves room for error and medical decisions can be made
from incorrect information

Consider This:
Discussion

Data Collection
Cloned progress notes also complicate coding since
documentation may not accurately reflect care provided and
diagnoses established; inaccurate documentation leads to
inaccurate code assignment
Inaccurate code assignment can negatively influence
reimbursement
The Office of the Inspector General (OIG) is concerned with fraud
and abuse related to coding and billing
In 2012 and 2013, OIG included EHR documentation auditing as a
focal point to investigate if EHR documentation practices such as
cloned notes lead to fraud and abuse
It is anticipated that OIG will continue this focus as more EHRs are
implemented

Consider This:
Discussion

e-Prescribing
e-Prescribing is a feature of
EHRs which allows providers
to enter a prescription order
and transmit it electronically
to pharmacies
Meaningful Use requires that
EHRs have e-prescribing
capability and is used in 40%
of permissible prescriptions
written by eligible providers
Benefits of e-prescribing
include:
Improved accuracy and
efficiency
Decreased potential for
medication errors
Timely billing

e-Prescribing
e-Prescribing technology includes alert functionalities
notifying providers of things such as drug-to-drug
interactions, drug-to-food interactions, and patient
medication allergies
Studies have cited a 12% to 15% decrease in medication
errors by use of e-prescribing
This technology also supports providers in weighing risks
and benefits in a more informed manner when
determining the most appropriate drug for their patient

e-Prescribing
Figure 8.2 provides an example of an e-prescription

e-Prescribing
Some challenges exist with e-prescribing
One challenge pertains to the prescribing of Schedule II controlled
substances; the Controlled Substances Act of 1970 requires that
these pharmaceuticals are dispensed only with hard-copy or
printed prescriptions
Providers may only e-prescribe Schedule II controlled substances if
they are located in a state where the state board of pharmacy has
approved e-prescribing technology for Schedule II controlled
substances
Interoperability between EHRs and pharmacy information systems
may also pose challenges to e-prescribing
In instances of lacking interoperability, e-prescribing cannot be
used

Checkpoint: Your Turn

True or false: Lack of interoperability is a barrier to eprescribing.


True
False

Which of the following depicts industry concerns related to


cloned notes?
Patient safety issues may arise when cloned notes are not
updated
Cloned notes may not accurately depict clinical care
provided
Cloned notes may negatively affect the accuracy of
coding
All of the above are concerns about cloned notes

Consider This:
Discussion

Clinical Results
Reporting
Clinical results reporting is an EHR function allowing providers to
view laboratory and other diagnostic test results immediately
Functionality of clinical results reporting meets one of the National
Patient Safety Goals (NPSGs) set forth by The Joint Commission (TJC)
Specifically the NPSGs indicate that critical results of diagnostic tests
must be made available in a timely manner
A focus on timely availability of critical results is anticipated for
many years
Each organization is responsible for defining critical results to include
specifications related to values; specifications are clearly defined in
policy and procedure as well as medical staff bylaws

Clinical Results
Reporting
EHR systems allow for automated clinical results reporting
Prior to EHRs, providers relied on phone and fax communication of
results
Reliance on phone and fax notification of results poses challenges
In paper based environments, phone and fax transmission of
clinical results depends on a provider being physically available at
the time the results are received

Clinical Results
Reporting
Automated clinical results are viewable from anywhere via
secure computer or mobile device
Many EHR systems send text or email notification to providers
when clinical results become available
Creating interfaces between outside laboratories and diagnostic
facilities to the EHR system supports an automated method for
results to reach the HER
Without interfaces, results are printed or faxed and uploaded
into the EHR via a manual method

Meaningful Use

Stage 1 of meaningful use


includes three objectives related
to public health reporting
These objectives require EHR
systems to possess capabilities
to submit the following electronic
data to public health agencies:

Immunization registries
Reportable laboratory
results
Syndromic surveillance

Meaningful Use
Collecting immunization data
enhances provider ability to
remind patients of upcoming
immunizations and consolidate
immunization records from
multiple providers
Immunization registries also
allow for anonymous/confidential
reporting of immunization data
to state public health agencies

Meaningful Use
The Council of State and Territorial Epidemiologists determines a
list of reportable conditions reported nationally from state public
health agencies to the Centers for Disease Control and Prevention
(CDC)
These nationally reportable conditions include:
Anthrax, measles, rubella, polio, small pox, and botulism
EHR systems are beneficial in this type of data reporting because
they support:
Timelier reporting
Data entry error reduction
More complete data reporting

Meaningful Use
Syndromic surveillance allows for the production of real-time
health and health-related data to identify health status
within communities
This surveillance is particularly useful to public health
agencies for the purposes of:
Awareness of public health trends
Identification of needed emergency responses
Identification of potential or actual disease outbreaks
When this data is shared with public health agencies those
agencies can share the data via the Public Health
Information Network operated by the CDC for data sharing
across organizations and jurisdictions

Checkpoint: Your Turn

True or false: Clinical results reporting helps achieve


compliance with one of The Joint Commissions National
Patient Safety Goals.
True
False

True or false: Improvements to public health data capture


and reporting are not addressed in meaningful use.
True
False

Chapter Summary
Clinical data inputs and outputs are fundamental to actualizing
an EHR as an interactive data repository
Automated and manual entries of data facilitate data capture
Demographic and clinical documentation comprise data
elements represented in EHRs
Data collection practices such as cloned notes is an area of
concern
Interfaces between EHRs and laboratories and pharmacies
enhance clinical results reporting and prescribing respectively
Meaningful use stage 1 includes objectives related to public
health reporting from EHR systems

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