Adapting Terms to the Screen: Entering Orders and ICD10 Codes in EHRs

JAN HORSKY, PHD

BRIGHAM & WOMEN’S HOSPITAL, BOSTON

Interface terminology Clinicians need to enter orders and document care.

They interact with interface-specific terms.

Administrative codes ICD-10 CM, CPT Clinical codes LOINC, RxNorm Reference terminologies SNOMED CT Interface terminologies ICO, MEDCIN, HLI

Mapped to administrative and clinical terminologies

Concepts Crohn’s disease

Reference Term Crohn’s disease

Interface Terms Crohn’s disease Regional enteritis

Interface Terminology Architecture Relationships Preferred term, narrower term, same as, Is A

Interface Attributes Preferred display, patient-facing

Bronnert, June; Masarie, Chip; Naeymi-Rad, Frank; Rose, Eric; Aldin, Greg. "Problem-Centered Care Delivery: How Interface Terminology Makes Standardized Health Information Possible." Journal of AHIMA 83, no.7 (July 2012): 30-35.

Searches and lookups • Interface terminologies use familiar medical terms

• Search time reduced and precision increased • Term-to-code mapping complicated by granularity • Maintenance and updates are difficult

• Search engines match input strings to terms • Allow multi-word searches, partial strings • Rank results on their relevance to the search string • Output displayed on the screen for lookup/selection

Search strategies Speed – abbreviate, use partial strings ◦ Type “amo 250” ◦ Display “Amoxicilin 250 mg” and variations (capsule, tablet)

Redo or refine search ◦ Change search string ◦ Synonyms, acronyms, eponyms, abbreviations, characters

Constrain or expand the search space (scope) ◦ Change database where searches execute ◦ Narrow results – filter, sort content on screen

1. Type hdl No results

2. Type lipids No results

3. Type chol 2 results referral, culture

hdl Search

Steps and strategy:

Medications Order sets Laboratory Favorites Clinic Database

lipids chol

Ambulatory referral to MGH Lipid Associates (Cholesterol) Referral

E. Coli O157:H7 culture (BWH, BWF only) (Vibrio Cholerastool culture Microbiology

1. Type hdl No results

2. Type lipids No results

3. Type chol 2 results referral, culture

4. Expand search to Clinic chol 27 results - labs, referrals, medications, imaging, microbiology,…

Search

Steps and strategy:

Medications Order sets Laboratory Favorites Clinic Database

chol

Ambulatory referral to MGH Lipid Associates (Cholesterol) Referral

E. Coli O157:H7 culture (BWH, BWF only) (Vibrio Cholerastool culture Microbiology

Acetylcholinesterase, RBC (Cholinesterase, RBC) Laboratory

Ambulatory referral to MGH Lipid Associates Referral

Cholesterol (fluid-not CSF) Laboratory

Cholesterol, total Laboratory

CT Drainage gallbladder (cholecystostomy) Imaging

Cholangiogram via existing catheter Imaging

Cholangioplasty Imaging

Lipid panel (Cholesterol) Laboratory

MRI Cholangiopancreatography (MRCP) Imaging

US Drainage gallbladder (cholecystostomy) Imaging

VAP cholesterol Laboratory

Vibrio culture (vibrio cholerastool culture) Microbiology

Alendronate Sodium-Cholecalciferol (Vitamin D3) Medication

Cholecalciferol (Vitamin D3) 1000 unit tablet Medication

Cholecalciferol (Vitamin D3) 2000 unit capsule Medication

Cholecalciferol (Vitamin D3) 2000 unit tablet Medication

Cholecalciferol (Vitamin D3) 400 unit tablet Medication

Cholecalciferol (Vitamin D3) 400 unit/ml oral drc Medication

Cholecalciferol (Vitamin D3) 5000 unit capsule Medication

Lipid panel (Cholesterol) Laboratory

chol hdl Search

Steps and strategy:

Medications Order sets Laboratory Favorites Clinic Database

5. Refine search chol hdl 1 result

chol hdl Search

Steps and strategy:

Medications Order sets Laboratory Favorites Clinic Database

5. Refine search chol hdl 1 result

6. Expand search to Database 3 results

Cholesterol (aka lipid panel) Laboratory

HDL cholesterol subclass Laboratory

POCT HDL cholesterol POCT

chol hdl Search

Steps and strategy:

Medications Order sets Laboratory Favorites Clinic Database

5. Refine search chol hdl 1 result

6. Expand search to Database 3 results

7. Change term hdl cholesterol same results

8. Change term lipids 5 results

9. Change term high den lip 2 results

Cholesterol (aka lipid panel) Laboratory

HDL cholesterol subclass Laboratory

POCT HDL cholesterol POCT

hdl cholesterol lipids

Plasma serum blood lipid panel Laboratory

Lipids (aka Fat emulsion 10%) Medication

Lipids (aka Fat emulsion 20%) Medication

Lipids (aka Fat emulsion 25%) Medication

OM-3 150 MG-DHA 52.5 MG-EPA Medication

High density lipoproteine (aka HDL Cholesterol) Laboratory

High density lipoproteine (aka HDL Cholesterol) Laboratory

high den lip

Target result LAB416 High Density Lipoprotein (aka HDL Cholesterol)

Observed search strategies Try different search strings ◦ hdl ◦ lipids ◦ chol ◦ high den lip

Refine and combine strings ◦ hdl chol ◦ hdl cholesterol

Change search space ◦ Favorites list ◦ Institution list ◦ Global search

Point-and-click lookup support ICD-10 CM terms have multiple attributes

• Symptoms, complications, laterality,…

Searches often result in long lookup tables

Selection and display support interventions (widgets) help to create final ICD-10 term for documentation

Strategy: ◦ Branching logic in question-and answer form ◦ Contextually defined content ◦ Not in strictly alphabetical order – more common terms on top of lists ◦ Options change dynamically when you revise and retrace previous steps.

Strategy: ◦ Very long lookup table: 50+ entries, more to load (alphabetical) ◦ Use widget (bottom) to filter and refine list

◦ Designed as a hierarchy, filters (buttons) refine (dim) terms in sections below

◦ Poor concept for a large number of terms ◦ Horizontally arranged alphanumeric strings are difficult to lookup and read

Search and result presentation Interface terminology affects how information is managed.

Search engine determines speed and relevance of results.

Structure and layout of search results is critically important for workflow and finding the correct target term fast.

Trial-and-error behavior is typical for highly complex terminology with inadequate interface support, training

Clinicians are forced to find workarounds (satisficing, use of free text, etc.) when the interaface is lacking in cognitive support and usability.

Adapting Terms to the Screen:�Entering Orders and ICD10 Codes in EHRsInterface terminologySlide Number 3Searches and lookups Search strategiesSlide Number 6Slide Number 7Slide Number 8Slide Number 9Slide Number 10Observed search strategiesPoint-and-click lookup supportSlide Number 13Slide Number 14Slide Number 15Slide Number 16Search and result presentation