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Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.
BACKGROUND - The U.S. government has licensed SNOMED CT to permit broad-based evaluation and use of the terminology. We evaluated the ability of SNOMED CT to represent terms used for interface objects (e.g., labels and captions) and concepts used for data and branching logic in a general medical evaluation template in use within the Department of Veterans Affairs.
METHODS - The general medical evaluation form definition, report definition, and script files were parsed and 1573 expressions were mapped into SNOMED CT. Compositional expressions required to represent 1171 concepts. Double independent reviews were conducted. Exact concept level matches were used to evaluate reference coverage. Exact term level matches were required for interface terms. Semantics were analyzed for a randomly selected subset of 20 terms.
RESULTS - Sensitivity of SNOMED CT as a reference terminology was 63.8% , ranging from 29.3% for history items to 92.4% for exam items. SNOMED CT's sensitivity as an "interface terminology" was 55.0%. 80% of the necessary linking semantics for the subset were present. Subgroup statistics are presented.
DISCUSSION - SNOMED CT is promising as a terminology for knowledge representation underlying a large general medical evaluation. Its performed less well as an interface terminology.
Previous investigators have defined clinical interface terminology as a systematic collection of health care-related phrases (terms) that supports clinicians' entry of patient-related information into computer programs, such as clinical "note capture" and decision support tools. Interface terminologies also can facilitate display of computer-stored patient information to clinician-users. Interface terminologies "interface" between clinicians' own unfettered, colloquial conceptualizations of patient descriptors and the more structured, coded internal data elements used by specific health care application programs. The intended uses of a terminology determine its conceptual underpinnings, structure, and content. As a result, the desiderata for interface terminologies differ from desiderata for health care-related terminologies used for storage (e.g., SNOMED-CT), information retrieval (e.g., MeSH), and classification (e.g., ICD9-CM). Necessary but not sufficient attributes for an interface terminology include adequate synonym coverage, presence of relevant assertional knowledge, and a balance between pre- and post-coordination. To place interface terminologies in context, this article reviews historical goals and challenges of clinical terminology development in general and then focuses on the unique features of interface terminologies.
BACKGROUND - Accurately documenting patient comorbidities and complications improves case-mix representation, coding accuracy, and risk-adjusted mortality estimates for benchmarking. We hypothesized that a progress note template containing comorbidities and complications would improve documentation and teach residents to correctly document comorbidities and complications.
STUDY DESIGN - Surgical residents and patients on three inpatient services were followed for a 1-year prospective cohort study. After a 6-month baseline period, a progress note template was developed and implemented for 6 months, and administrative data were retrieved. Residents were given three case examinations assessing documentation knowledge pre- and postintervention, and a satisfaction survey. Demographics, Charlson comorbidity score, ICD-9 codes, template-specific ICD-9 codes, All Patient Refined (APR)-DRG patient severity, DRG relative weight, predicted mortality (University Healthcare Consortium), pre- and postexam scores, and resident satisfaction were collected.
RESULTS - No difference in age, gender, race, or Charlson comorbidity score existed between pre- and postintervention patient groups. The length of stay decreased from 5.5 days to 4.8 days (p = 0.013). In the intervention group, total ICD-9 codes, template-specific ICD-9 codes, APR-DRG, DRG weight, and UHC predicted mortality had significant increases. Residents exposed to the progress note template improved their knowledge scores from 52% to 63% (p < 0.001), and 73% agreed that the progress note template was an improvement over handwritten notes. Residents not exposed to the progress note template did not improve their scores.
CONCLUSIONS - A progress note template improves documentation of comorbidities and complications, APR-DRG patient severity for benchmarking, and case-mix index, and increases patient-specific predicted mortality. The progress note template also improves surgical residents' documentation knowledge and satisfaction.
The purpose of this study was to describe and classify the barriers to breast self-examinations (BSE) and mammography in African American women. A total of 125 African American women were recruited from historically black colleges, churches and community organizations in Nashville, Tennessee. Their responses to a comprehensive open- and closed-ended questionnaire about barriers to BSE and mammography were coded using a hierarchical coding system and analyzed according to participants' stage of behavior change assignment. On the average, each woman reported 3.1 barriers to BSE (2.5 psychological and 0.6 environmental) and 2.5 barriers to mammography (1.5 psychological and 1.0 environmental). Barriers cited included fear of finding cancer, forgetting, lack of time, lack of knowledge, competing demands, costs, pain, emotional consequences, cultural attitudes towards medicine, uncertainty about benefits and laziness. For BSE, the number of psychological barriers exceeded environmental barriers, while for mammography, the number of psychological and environmental barriers was similar. For BSE, but not mammography, psychological barriers appeared most important for women in the precontemplation, contemplation and preparation stages of behavior change. Overcoming barriers to BSE and mammography could increase early detection rates in African American women. Interventions based on stage of change theory may be especially applicable.
BACKGROUND - There have been no studies of interventions to reduce test utilization in the coronary care unit.
OBJECTIVE - To determine whether a 3-part intervention in a coronary care unit could decrease utilization without affecting clinical outcomes.
METHODS - Practice guidelines for routine laboratory and chest radiographic testing were developed by a multidisciplinary team, using evidence-based recommendations when possible and expert opinion otherwise. These guidelines were incorporated into the computer admission orders for the coronary care unit at a large teaching hospital, and educational efforts were targeted at the house staff and nurses. Utilization during the 3-month intervention period was compared with utilization during the same 3 months in the prior year. The hospital's medical intensive care unit, which did not receive the specific intervention, provided control data.
RESULTS - During the intervention period, there were significant reductions in utilization of all chemistry tests (from 7% to 40%). Reductions in ordering of complete blood counts, arterial blood gas tests, and chest radiographs were not statistically significant. After controlling for trends in the control intensive care unit, however, the reductions in arterial blood gas tests (P =.04) and chest radiographs (P<.001) became significant. The reductions in potassium, glucose, calcium, magnesium, and phosphorus testing, but not other chemistries, remained significant. The estimated reduction in expenditures for "routine" blood tests and chest radiographs was 17% (P<.001). There were no significant changes in length of stay, readmission to intensive care, hospital mortality, or ventilator days.
CONCLUSION - The utilization management intervention was associated with significant reductions in test ordering without a measurable change in clinical outcomes.
The use of computer-based documentation tools confers many benefits to the delivery of evidence-based health care. We developed Clictate, a structured reporting environment that utilized standard Windows-based data entry constructs and natural language generation. Clictate has been in use for over 3 years by pediatric providers in an ambulatory setting. More than 50% of our providers use Clictate during the patient encounter. This report describes our results to date, and suggests future opportunities for research and development in the area of computer-based documentation.