JAMIA: Handle EHR data exceptions with care
“Exception situations” can enable clinicians to get around limitations of structured data during clinical documentation in an EHR, but must be handled carefully to avoid errors, according to a case report published online June 14 in the Journal of the American Medical Informatics Association.
In the report, Kai Zheng, PhD, of the department of health management and policy at the University of Michigan School of Public Health in Ann Arbor, Mich., and colleagues investigated exception-handling procedures in an EHR for facilitating clinical documentation.
These “exit strategies,” or built-in software features that handle anticipated exceptions, can help clinicians temporarily address limitations imposed by structured data entry, “which may prevent them from documenting, for example, certain patient care data that could not be easily classified or codified using a given taxonomy or nomenclature,” Zheng and colleagues wrote.
Such exit strategies can reduce disruptions or delays and prevent misinterpretation of data in future patient care episodes or in research, but also could be misused to expedite entry of all types of patient care data, the authors wrote. “Optimal approaches to providing such exit strategies, however, are unknown.”
Researchers conducted an empirical study in an ambulatory primary care practice at the Western Pennsylvania Hospital (WPH), a large urban teaching hospital in Pittsburgh. The EHR system, jointly developed by WPH practitioners and the research team, was designed to help the practice manage its daily operations and provide clinicians with electronic documentation and computerized decision support capabilities.
The system was deployed in the study practice in June 2005. Research data collection began three months later and lasted 12 months. During this period, 34 residents, 10 attending physicians, and 10 nurses and physician assistants (PA) used the system in their day-to-day patient care activities, the authors stated.
During the study period, the exit strategies were used to document 6.9 percent of problems and diagnoses, 10.7 percent of medication prescriptions and 4.1 percent of Review of Systems and Physical Exam annotations.
“The tension between structured and narrative documentation has been well recognized. The exit strategies described in this paper may provide a solution to mitigating this tension by facilitating the capture of structured data while preserving certain information elements that cannot be adequately accommodated by structured forms."
For example, "in several instances, ‘Zero Code’ was used to document pertinent negatives (action performed while no findings resulted)—for example, ‘(the patient is) on no meds at this time.’ On paper, clinicians can add an annotation in any convenient spot to indicate pertinent negatives, while on a computerized structured data entry form, making such a note can be rather difficult unless the function is explicitly provided.”
“Further, a significant number of ‘Zero Codes’ entered through the ‘Problems’ form were used to express clinical uncertainty at the point of documentation.”
Zheng and colleagues’ analysis highlighted several issues of concern. “Although exit strategies enabled actions that would be otherwise difficult or impossible, many data entries recorded via these exception-handling procedures could have been ‘properly’ documented according to recommended practice, yet were not, and a significant proportion containing temporary or incomplete information were never subsequently amended,” they wrote.
The authors also acknowledged the limitations of the research. For example, the idiosyncrasies of the study clinic and its EHR might cause unique exit strategy usage that would not be generalizable to other settings. Also, “in this investigation, we only used computer-recorded data to infer reasons underlying the exit strategy usage, which limited our ability to understand the root causes of the exception situations that clinicians had to cope with,” Zheng and colleagues stated. “Future work is needed to study and address the sources of such exception situations, so that the need to handle them can be minimized.”
The study was supported in part by grants from the Health Resources and Services Administration and frm the National Center for Research Resources, a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research.
In the report, Kai Zheng, PhD, of the department of health management and policy at the University of Michigan School of Public Health in Ann Arbor, Mich., and colleagues investigated exception-handling procedures in an EHR for facilitating clinical documentation.
These “exit strategies,” or built-in software features that handle anticipated exceptions, can help clinicians temporarily address limitations imposed by structured data entry, “which may prevent them from documenting, for example, certain patient care data that could not be easily classified or codified using a given taxonomy or nomenclature,” Zheng and colleagues wrote.
Such exit strategies can reduce disruptions or delays and prevent misinterpretation of data in future patient care episodes or in research, but also could be misused to expedite entry of all types of patient care data, the authors wrote. “Optimal approaches to providing such exit strategies, however, are unknown.”
Researchers conducted an empirical study in an ambulatory primary care practice at the Western Pennsylvania Hospital (WPH), a large urban teaching hospital in Pittsburgh. The EHR system, jointly developed by WPH practitioners and the research team, was designed to help the practice manage its daily operations and provide clinicians with electronic documentation and computerized decision support capabilities.
The system was deployed in the study practice in June 2005. Research data collection began three months later and lasted 12 months. During this period, 34 residents, 10 attending physicians, and 10 nurses and physician assistants (PA) used the system in their day-to-day patient care activities, the authors stated.
During the study period, the exit strategies were used to document 6.9 percent of problems and diagnoses, 10.7 percent of medication prescriptions and 4.1 percent of Review of Systems and Physical Exam annotations.
“The tension between structured and narrative documentation has been well recognized. The exit strategies described in this paper may provide a solution to mitigating this tension by facilitating the capture of structured data while preserving certain information elements that cannot be adequately accommodated by structured forms."
For example, "in several instances, ‘Zero Code’ was used to document pertinent negatives (action performed while no findings resulted)—for example, ‘(the patient is) on no meds at this time.’ On paper, clinicians can add an annotation in any convenient spot to indicate pertinent negatives, while on a computerized structured data entry form, making such a note can be rather difficult unless the function is explicitly provided.”
“Further, a significant number of ‘Zero Codes’ entered through the ‘Problems’ form were used to express clinical uncertainty at the point of documentation.”
Zheng and colleagues’ analysis highlighted several issues of concern. “Although exit strategies enabled actions that would be otherwise difficult or impossible, many data entries recorded via these exception-handling procedures could have been ‘properly’ documented according to recommended practice, yet were not, and a significant proportion containing temporary or incomplete information were never subsequently amended,” they wrote.
The authors also acknowledged the limitations of the research. For example, the idiosyncrasies of the study clinic and its EHR might cause unique exit strategy usage that would not be generalizable to other settings. Also, “in this investigation, we only used computer-recorded data to infer reasons underlying the exit strategy usage, which limited our ability to understand the root causes of the exception situations that clinicians had to cope with,” Zheng and colleagues stated. “Future work is needed to study and address the sources of such exception situations, so that the need to handle them can be minimized.”
The study was supported in part by grants from the Health Resources and Services Administration and frm the National Center for Research Resources, a component of the National Institutes of Health (NIH) and NIH Roadmap for Medical Research.