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