Knowledge Activity: The Power of the EHR

Learning objectives
1. Identify the differences between coded and non-coded data entry.
2. Identify the differences between structured and unstructured data entry.
3. Evaluate the clinical implications of structured versus unstructured data entry
in the EHR.
4. Relate the use of coded data to meeting the objectives of the Meaningful Use
effort for implementation of electronic health records.
5. Apply current knowledge of electronic health records and appropriate,
accurate documentation.

Student instructions
1. If you have questions about this activity, please contact your instructor for
assistance.
2. You will review the chart of Gwen Cummings to complete this activity. Your
instructor has provided you with a link to the The Power of the EHR activity.
Click on 2: Launch EHR to review the patient chart and begin this activity.
3. Refer to the patient chart and any suggested resources to complete this
activity.
4. Document your answers directly on this activity document as you complete the
activity. When you are finished, you will save this activity document to your
device and upload this activity document with your answers to your Learning
Management System (LMS).

Glossary
Adverse event: Any undesirable experience associated with the use of a medical
product or pharmaceutical in a patient.

Clinical quality measures (CQMs): Tools that help measure and track the quality of
health care services provided by eligible professionals, eligible hospitals and critical
access hospitals (CAHs) within the health care system.

Coded Data: Quantitative data entered into specific fields in the EHR via a
computerized form which enables the search, retrieval and/or data mining of the
gathered information. Examples: ICD diagnostic codes, CPT procedural codes, the
order number for a medication and the numbered barcode associated with it.

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Non-coded data: Data entered in a field where the EHR cannot recognize the entry.
This is very similar to unstructured data. Non-coded data will not trigger prompts or
show up in searches of linked terms. Examples: Comment boxes, where there is no
use of drop-down lists or check boxes.

Data Mining: Compiling and reporting of data from coded fields within the EHR for
accurate biosurveillance, public health reporting, quality improvement and
performance measurement.

Meaningful Use: Meaningful use describes the use of health information technology
(HIT) that leads to improvements in healthcare and furthers the goals of information
exchange among health care professionals. To become Meaningful Users, health
professionals need to demonstrate they're using certified EHR technology in ways that
can be measured in quantity and in quality, such as the recording and tracking of key
patient health factors to enable the planning and delivery of timely and effective
care.

Structured data: Information entered in a structured or pre-determined field within a

record, file or note. This information, or data, is understood by other functions in the
EHR, because it is built with a universal set of protocols.

Unstructured data: Information that is entered in an unstructured format, such as a

nurse’s narrative note or the free text in a comments box. It is considered free form
and does not follow any sort of organizational pattern, similar to entering information
into a word document. The EHR is not able to easily read and interpret information
that is free form.

The activity
Student name: ____Julie Khmelchenko________________

The key to unlock the powerful potential of the EHR is the careful and consistent
entry of data into retrievable areas, or fields, also referred to as structured or coded
data fields. Properly entered electronic health data enables search, retrieval and
comparison across patient populations over time in a process called data mining. This
carefully extracted data can be used for meaningful research to improve individual
patient care, patient safety and best practices in healthcare delivery.

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However, the EHR is only useful if the data entered by the user is correct and placed
in the most appropriate data fields. This is what makes the EHR “meaningful” in its
function and capabilities. When data is entered correctly it has the potential to lower
healthcare costs, improve patient safety and decrease healthcare errors. Keeping that
in mind, not every piece of information must go into a structured or coded field.
There is still a need for the unstructured comment boxes and narrative notes. The
unstructured areas “fill in the blanks” and enable the interdisciplinary use and
coordination of care that is important in healthcare.

Coded and non-coded data fields


When developed for data extraction, any data entered in a coded field can easily be
searched, retrieved, aggregated and summarized for easy interpretation in a
standardized report. Most often coded data will be a medical diagnosis (a problem),
procedure codes, exam codes, or demographic data. Other elements in the EHR that
are also considered coded data include lab results, orders, allergies, and medication
orders.

In the following screen shot, the ICD-10 code, I73.9, is designated to identify
“Peripheral vascular disease, unspecified.” If performing a data search of the EHR for
any patient chart that has the code of I73.9 in the Problem list, this chart would be
included in the list. The EHR search can retrieve structured numbers and letters, in
this case the ICD-10 code, much easier than it can sort through words and phrases.

Whereas in the next example, there is no code assigned to this free-text entry of
“Peripheral Vascular Disease.” These two examples may look similar, but they are very
different in their ability to be coded.

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In this order, the medication Metformin hydrochloride has a Barcode ID number
assigned to it. This Barcode ID is the structured number and letter format that the
EHR is able to search for to produce a standardized report.

In the following order, the Order Item and Order Details are all entered in a free-text
format. Therefore, aggregating the data in this type of order would not be easy.

Structured and unstructured data fields


When looking at structured and unstructured data fields in Go, the entry of vital signs
and using documentation notes will be discussed.

In this first example of structured data entry fields, notice that the “blank” boxes
(the free-text boxes) to enter a Value and a Description, are the non-structured
fields. The Qualifiers (Location, method, position) are structured data fields because
of the drop-down menu function. Open Gwen Cummings’s chart and click on the Vitals
tab to take a closer look at these data fields. Explore by typing in the boxes and
selecting from the drop-down menus.

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Notes contain several ways to document what is happening with the patient or what
has been assessed with the patient. This note example shows structured data entry by
using drop-down lists. The selections cannot be modified.

This next note is an example of structured and unstructured data. The meta
information, the header of the note (date, author, location), is structured. This is
automatically populated with each note when it is created – making it structured. The
data entry fields of the note, the Chief Complaint and the History of Present Illness,
are free-text entry, which make them unstructured.

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 Improving patient safety and outcomes


The EHR has many components that are used to improve patient safety and decrease
healthcare costs. Recent studies have revealed the following (healthit.gov):

EHRs may improve risk management by:

• Providing clinical alerts and reminders to healthcare providers
• Improving aggregation, analysis, and communication of patient information
• Making it easier to consider all aspects of a patient's condition
• Supporting diagnostic and therapeutic decision making
• Gathering all relevant information (lab results, etc.) in one place
• Support for therapeutic decisions
• Enabling evidence-based decisions at point of care
• Preventing adverse events with built in safeguards
• Enhancing research and monitoring for improvements in clinical quality

Look at the needs of groups of patients who:

• Suffer from a specific condition
• Are eligible for specific preventive measures
• Are currently taking specific medications

EHRs can improve the quality of patient care:

• Improved quality of care screenings
o Breast cancer
o Diabetes

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 o Chlamydia
o Colorectal cancer
• Increase in services
o Blood pressure control for patients with hypertension
o Breast cancer screenings
o Recording of body mass index and blood testing for patients with
diabetes

When thinking of alerts and warnings in an EHR, most think first of a patient’s
allergies to medications. When a provider is presented with an alert and made aware
of a patient’s medication allergy, prescribing a medication or treatment that is
contraindicated will prevent an adverse event.

Other improved patient safety measures that take place when the full capabilities of
an EHR are utilized, are related to:
• Environmental allergies
• Latex allergies
• Food allergies or intolerances
• Risks: fall, aspiration, bleeding, suicide, wandering
• Incomplete orders
• Duplication of medication orders

For members of the healthcare team, often the most utilized information in the chart
is what can be looked at quickly, such as tables and graphs. Whether you are looking
at a patient’s hospital stay for the last 24 hours, or a patient’s medical office record
for the last year, having clinical data in an easy-to-view format has its benefits.

Interdisciplinary use with the EHR

For patients with a 3 to 5-day hospital stay, a study revealed that an average of 30.8
clinicians access the electronic chart, including 10.2 nurses, 1.4 attending physicians,
2.3 residents, and 5.4 physician assistants (Vawdrey et al, 2011).

When all encounters and interactions with the patient are documented accurately and
timely, this can improve continuity of care, patient safety, and interdisciplinary
approaches. There are many times that healthcare team members work
collaboratively despite never seeing one another face-to-face. The only way to
communicate to others caring for the same patient is often through the
documentation in the patient’s medical record.

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 Questions
1. What are the clinical alerts for Gwen? Aspiration Precautions, NKA, Fall Risk,
Full Code

2. What medication allergies does Gwen have? NKA ( Adverse Reaction/Allergy)

3. Dr. West has written orders in Gwen’s chart. Identify two healthcare
professionals who can view her record because there are orders requesting they
be involved in Gwen’s care. The Case Management and Psychiatry Consult

4. Gwen had three sets of vital signs documented in her chart. What was the
trend of her temperature from the time that she arrived in the emergency
room until 12 hours later? 98.4 F, 98.6 F and 99.4F

5. Gwen has an order for CIWA Scoring. What is CIWA scoring and why is it used?
Clinical Institute Withdrawal Assessment for Alcohol. It is a ten item scale
used in the assessment and management of alcohol withdrawal.

6. The nurse has completed a CIWA scoring on Gwen and calculated a score of 21.
What are the orders entered by Dr. West for a CIWA score of 21? Complete CIWA
Score every hour until the score < 8 and then reassess CIWA score every 4 hours
or PRN based on patient&#146;s condition. Score < 20: Lorazepam 1 mg IV as
needed every hour until score is < 8. Score >/= to 20: Lorazepam 2 mg IV as
needed every hour until score is < 8. Then Lorazepam 1 mg IV every 6 hours as
a scheduled dose.
7.

8. You are a member of the healthcare team coming to work the day after Gwen
has been admitted. You have been assigned to care for Gwen. She asks why a
case manager has to talk to her. Where would you go to find that information in
Gwen’s chart? What does her chart state? The information can be found in
“Order Tab.” The order came from Dr. West, which states, “The information
can be found in “Order Tab.” The order came from Dr. West, which states,
“Counseling while hospitalized, alcohol and drug rehab, discharge planning.” I
would have to explain to her exactly why I was assigned to her case, go over
some essential information regarding dangers of drinking, and give her
informative documents such as “Rethinking Drinking” which is research-based
information from the National Institute of Health U.S Department of Health and

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 Human Services. This document will help her understand the basics of
consuming alcohol and why she should seek help to quit.

9. Consider this example of how EHRs can improve the quality of patient care
(‘Improving patient safety and outcomes”). A healthcare facility wishes to find
out if a new, more expensive diabetes medication (Medication B) is lowering
the weight and Hgb A1C lab values for patients more than the traditional
medication (Medication A). What coded or structured data is necessary to look
for in the EHR in order to answer this question? 

One must use the order number for medication and the numbered barcode
associated with the medication. It would be beneficial to gather all relevant
information (lab results, etc.) in one place. Also, another useful tab could be
helpful such as pop-up alert which would notify medical personnel to document
any changes in the subject's weight with confirmation of which medication a
patient is taking. 

Submit your work

Document your answers directly on this activity document as you complete the
activity. When you are finished, save this activity document to your device and upload
this activity document with your answers to your Learning Management System (LMS).
If you have any questions about submitting your work to your LMS, please contact your
instructor.

References
Healthit.gov (2014) Benefits of EHRs: Improved Diagnostic and Patient Outcomes.
Retrieved from https://www.healthit.gov/providers-professionals/improved-
diagnostics-patient-outcomes
Vawdrey, D. K., Wilcox, L. G., Collins, S., Feiner, S., Mamykina, O., Stein, D. M.,
Stetson, P. D. (2011). Awareness of the Care Team in Electronic Health Records.
Applied Clinical Informatics, 2(4), 395–405. http://doi.org/10.4338/ACI-2011-05-
RA-0034

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