style standards to improve data quality and interoperability
TRANSCRIPT
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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
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Laura Bryan, MS, MT(ASCP), CHDS, AHDI-F
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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Susan Dooley, MHA, CMT, AHDI-F
Has no real or apparent conflicts of interest to report.
Conflict of Interest
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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
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• 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
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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
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• 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
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• Improve written communication
• Reduce ambiguity
• Eliminate confusion
• Promote uniformity within and across documents
Purpose of Style Guides
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• 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
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• Units of measure
• Pharmaceutical regimens
• Cancer protocols
• Laboratory results
• Chemical elements
• Genetics
• Disease classifications
• Abbreviations, medical slang and lingo
Relevant Style Standards
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• Building and formatting templates
• Copy and paste policies
• Documentation best practices
• Normals and standard text
• Gender pronouns
Facility Best Practices
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• 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
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“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
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• Clear and unambiguous written
communication
• Patient safety
• Improved usability and readability
• Promotes consistency and accuracy
Value to Clinicians and Patients
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• 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
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Compilation of relevant styles by numerous SDOs• AMA• WHO• AJCC (classification and staging of
cancer)• ISMP ("Do Not Use" abbreviations)
A Single Source Reference
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• 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
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● 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
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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
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• “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
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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
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https://github.com/jddamore/ccda-samples/blob/master/z-infographic/medications.jpg
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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
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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
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“Dangerous” use of trailing decimal (ISMP)
Example
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Example Nonstandard use of decimals
Inconsistent use of units of measure (cm, g, Celsius vs feet, lb, and Fahrenheit)
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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
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● 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
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• Positive results indicated using bold, which could be lost in an interface
Example
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Poor template construction with incorrect verbs confuses intended meaning
Example
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• 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
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• Adopt documentation standards
• Use a single-source reference
• Employ certified documentation specialists
Recommendations
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• Please complete your online presentation evaluation.
• Thank you for your attention!
Q&A
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Laura Bryan, MS, CHDS
Susan Dooley, MHA, CMT
www.AHDIonline.org
800-982-2182
Contact Information
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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