style standards to improve data quality and interoperability

1

Style Standards to Improve Data Quality and Interoperability

Session 195, February 14, 2019

Laura Bryan, MS, MT(ASCP), CHDS, AHDI-F, Chair, Book of Style Development Team, AHDI

Susan Dooley, MHA, CMT, AHDI-F, National Leadership Board, AHDI

2

Laura Bryan, MS, MT(ASCP), CHDS, AHDI-F

Has no real or apparent conflicts of interest to report.

Conflict of Interest

3

Susan Dooley, MHA, CMT, AHDI-F

Has no real or apparent conflicts of interest to report.

Conflict of Interest

4

Style standards and best practices that support clinical care, data exchange, aggregation, integration, and normalization• Objectives• Introduction• Definition, purpose, and elements of style• Relevant SDOs• Value and benefits• Examples• Challenges• Recommendations• Q&A

Agenda

5

• Explain the benefits of applying style and format to information

exchange, data aggregation, natural language processing and

artificial intelligence

• Describe the purpose of style standards related to clinical and

technical information and identify standards developing

organizations that promulgate those standards

• Recognize the value of style standards to improve communication

among clinicians and to enhance patient safety

• Recognize the value of a single-source reference tool for writing

clinical and technical information

• Compare and contrast formatted vs non-formatted clinical data

Learning Objectives

6

Who we are and what we do• Association for Healthcare Documentation Integrity (HIMSS

Endorser)

• Professional association for documentation specialists

• Develop, promulgate, and apply standards for communicating

clinical and technical information

• First style manual published in early 80s

• Advocate for highest quality healthcare documentation

• Promote standards that enhance current and future outcomes

of EHR use

Introduction

7

• Establishes style to improve communication

• Promotes consistency within and across multiple documents

• Outlines best practice in usage and language composition,

visual composition, orthography and typography

• Promotes best practice in ethics (such as authorship, research

ethics, and disclosure) and compliance (technical and

regulatory)

Purpose of Style Guides

8

• Improve written communication

• Reduce ambiguity

• Eliminate confusion

• Promote uniformity within and across documents

Purpose of Style Guides

9

• Abbreviations, acronyms, initialisms

• Symbolization (eg, genes, protein products of genes)

• Character spacing (eg, medication regimens, chemical

terms, alphanumeric terms)

• Dates and times

• Use of punctuation marks in scientific nomenclature

– Colon, semicolon

– Diacritics, asterisks, ampersand, hash mark

Elements of Style

10

• Units of measure

• Pharmaceutical regimens

• Cancer protocols

• Laboratory results

• Chemical elements

• Genetics

• Disease classifications

• Abbreviations, medical slang and lingo

Relevant Style Standards

11

• Building and formatting templates

• Copy and paste policies

• Documentation best practices

• Normals and standard text

• Gender pronouns

Facility Best Practices

12

• Decreases normalization effort

• Provides guidance for those without expertise in medical science– Informaticists

– Engineers and programmers

– Implementers

• Improves– Data aggregation

– Analysis

– Exchange

Value to IT Industry

13

“We and others in the industry that process the output of EMR and documentation systems spend considerable effort improving style and format within documents. In many cases, the documentation templates or formats have been designed for easier entry but not for readability or interoperability."

Mark MorschVP of Technology, NLP Innovation

Optum360

Value to IT Industry

14

• Clear and unambiguous written

communication

• Patient safety

• Improved usability and readability

• Promotes consistency and accuracy

Value to Clinicians and Patients

15

• Improves information exchange, data

integration, and data aggregation

• Reduces data normalization tasks

• Improves results from NLP and emerging

technologies such as AI

• Reduces ambiguity or misinterpretation

Technical Benefits

16

Compilation of relevant styles by numerous SDOs• AMA• WHO• AJCC (classification and staging of

cancer)• ISMP ("Do Not Use" abbreviations)

A Single Source Reference

17

• Reduces research

• No need to recreate the wheel at each

facility

• Eliminates "guessing" or "googling"

• Easy-to-use guide for those unfamiliar

with biological and chemical

terminologies

Value of a Single-Source Reference

18

● When to spell out or write numbers

● How to write units of measure

● How to write prescriptions

● How to abbreviate clinical terms

● How to write chemical formulas, lab

results, needle sizes

Questions Resolved by Style Guide

19

P:

• Fluids per primary care, lactic acid 0.9, antibiotics on board, blood culture pending, procalcitonin 14.78, repeat.

• Surgical workup with occasional WBC, 2+ GPCs, GNRs, GPRs, and rare yeast, awaiting final culture.

• Continue Diflucan and Zosyn.

• Blood culture preliminary negative x2 days, sputum pending.

• MRSA screen.

• CBC and BMP in the morning.

• Thank you for this consultation.

ExampleNonstandard abbreviations

20

• “History of gastric ulcer 2ry to NSAIDs.”

– 2ry

– 2/2

– 2˚

• Creatinine 1.04, initial troponin negative, BNP 1K

• qDay (daily)

• d/t (due to)

• Wx (workup)

Example

Nonstandard abbreviations

21

Medication regimens

• Full-dose aspirin and Crestor 10 mg at night. She has not been able to get anything orally, for which she has been receiving the aspirin 300 mg p.r.

Example

22

https://github.com/jddamore/ccda-samples/blob/master/z-infographic/medications.jpg

23

Tylenol 500 mg 1 tablet orally daily as needed for 10 days

ceftriaxone 100 g injection twice a day for 8 days

darbepoetin alfa 0.5 mg/mL inject 1 mL once a week

Example

24

Tylenol 500 mg 1 tablet orally daily as needed for 10 days

ceftriaxone 100 g injection twice a day for 8 days

darbepoetin alfa 0.5 mg/mL inject 1 mL once a week

Example

25

“Dangerous” use of trailing decimal (ISMP)

Example

26

Example Nonstandard use of decimals

Inconsistent use of units of measure (cm, g, Celsius vs feet, lb, and Fahrenheit)

27

Special characters that do not translate through data interfaces

Clinician dictated:

D: Per her last quantitative EEG, her peak alpha frequency was 9 Hz and at 15.58 UVSQ.”

mV2 (microvolts squared)

Greek letter “mu” interpreted as “u,”

T: Per her last quantitative EEG, her peak alpha frequency was 9 Hz and at 15.58 mcV sq.

Example

28

● Variations in testing results

● The FEV1-to-FVC ratio was 60%. It was 65% bronchodilators.

● The FEV1-to-FVC ratio was 60%. Post-bronchodilation, there was

minimal improvement to 65%.

● The FEV1-to-FVC ratio was 60%. There was no significant

improvement with bronchodilators.

● Per standard:

● FEV1/FVC 60%, post-bronchodilation 65%

Example

29

• Positive results indicated using bold, which could be lost in an interface

Example

30

Poor template construction with incorrect verbs confuses intended meaning

Example

31

• Industry awareness

• Industry education on the value and benefits

• Consistent implementation across platforms

• Educating users on correct style

• Coordinating easy data entry with readability and

interoperability

Challenges

32

• Adopt documentation standards

• Use a single-source reference

• Employ certified documentation specialists

Recommendations

33

• Please complete your online presentation evaluation.

• Thank you for your attention!

Q&A

34

Laura Bryan, MS, CHDS

Laura@mtwerks.com

Susan Dooley, MHA, CMT

susanddooley@gmail.com

www.AHDIonline.org

AHDI@AHDIonline.org

800-982-2182

Contact Information

35

Book of Style and Standards for Clinical Documentation 4th Edition (BOSS4CD)

by the Association for Healthcare Documentation Integrity

www.AHDIonline.org

Publishing Late Spring/Summer of 2019

Additional Information

Health Story Project Roundtable

March 4, 2019