Unit 4: EHR Formats and Data Flashcards
Digital Images
Digital X-rays, CT scans, pathology, and annotated drawings
Text files
Word processing files, and transcribed exam notes
Discrete Data
Fielded or coded data (structured data)
Fielded data
each piece of information is stored in an assigned position called a field
Coded data
Fielded data that also contains computer codes (for data mining and retrieval)
needs to adhere to a national standard for optimal interoperability
Data capture
process of recording healthcare-related data in a health record system or clinical database
“garbage in, garbage out”
Ability of the EHR to function properly is dependent upon the quality and accuracy of data capture
Direct data entry
keyboard, mouse, manual, etc.
Hot spot
help message that is triggered when you hover your cursor over a data field
Unstructured data fields
allow for free-text entry.
Ex: description of a procedure performed r a patients description of their medical history
Free-text complicates data retrieval, so structured data is preferred
Structured data fields
guide the user during data entry and limit what can be entered in the field
Radio buttons, drop-down boxes, check boxes, etc.
Drop down menus
offer pre-selected options so data entry is consistent between users and saves time so you don’t have to type out your selection
Check box
allows multiple boxes to be checked
Radio button
When only one of several option is allowed to be chosen
Ex: gender
Numeric field
numbers that can be mathematically manipulated:
Age, weight, height
But not dates
Date fields
allows valid, not correct, dates
Time field
entry of valid times, preventing 26 hours in a day or 70 minutes in an hour, does not ensure the entered time is correct
Auto-numbering
health record numbers are assigned to patients in numerical order
Template based data entry
Cross between free text and structured
ex in a physical exam the field would direct the physician to enter review of symptoms, history of present illness, physical exam, impression, plan, and other required elements
The template helps to ensure that the required categories of data are captured
Speech recognition
Technology that translates audio to text
The text may require editing since software isn’t perfect
Data analytics
the science of examining raw data with the purpose of drawing conclusions about that information, which can then be used to make business decisions concerning services to provide and how to improve patient care
Data analytics categories
descriptive, predictive, and prescriptive
Descriptive data analytics
addresses the past to establish what has already occurred
Predictive data analytics
addresses the future to predict what will likely occur
Prescriptive data analytics
what to do with the information you have learned
Data integrity
The extent to which health care data is complete, accurate, consistent, and timely
About the data itself
Data quality
reliability and effectiveness of data for its intended uses in operations, decision making, and planning
All about data use
Required Fields
a preset field in which data must be entered before the information system will allow the user to proceed
Some fields may allow user override
Required fields are the main reason EHRs are preferred over paper to avoid missing relevant data or information
Edit checks
Pre-programmed definitions of each data field set up within the application
Sometimes called flags
Checks for illogical data such as a patients gender not matching a gender specific procedure (ask about trans patients?)
ex: prevent a user from entering a body temp of 254C
blood pressure as 543/87 flag as illogical
Data quality management
the business processes that ensure the integrity pf an organization’s data during collection, application, warehousing, and analysis
collection refers to how data is gathered
application is the reason for data gathering
Warehousing refers to data storage
Analysis refers to converting data to information
Data Cleansing
process of checking internal consistency and duplication as well as identifying outliers and missing data
check for errors such as duplicate patients
Documentation integrity errors
when a revision is made to a report and it is not clear which is the most current version
Patient identification
If patient A’s info is mistakenly documented in patient B’s record, potentially resulting in serious health problems
Authorship
Data entry attributed to the individuals who recorded it. Important for tracking origin of mistakes and errors, legal purposes, also use of electronic signatures
Dictation errors without editing
errors not edited out, incorrect words or medications
Copying and pasting
Copy and paste speeds up data entry, but can accidentally be pasted into the wrong health record or not be correctly updated during a new visit for the correct patient
Amendments to the health record
Files should be locked to changes and have to be unlocked to make amendments to prevent carryover info from incorrect patients
Erroneous info should not be deleted but rather indicated and corrected with an indication as to who made the correction and when to keep a more complete record of mistakes for quality tracking and improvements
Alternate versions of documents are the best way to do this, but must clearly indicate which is the most recent/up to date
Previous versions can be important in court cases
Copy and paste concerns
nullified entry entire record can be suspect health care practitioners may not notice extra or missing information if copying large amounts of text misrepresentation of a case patient harm fraudulent reimbursement claims
There must be checks and balances on copy paste, data integrity is ultimately more important that data entry speed
