- A new report published in the Journal of the American Medical Informatics Association (JAMIA) provides a means for improving EHR documentation of adverse drug reactions.
“Well-developed documentation standards for EHR systems exist in some areas, such as medications, but not in others, such as allergies,” wrote Goss et al.
As part of the study by Goss et al., researchers sought to reduce variation in adverse drug reaction-related EHR documentation by developing a value set healthcare organizations using a variety of EHR systems by different vendors could use for clinical documentation.
“Standard value sets for encoding adverse reactions offer a solution to this problem by providing a list of codes to improve consistent data capture, clinical documentation, and quality reporting,” stated researchers. “The National Quality Forum defines a value set as a common group of codes used to define a clinical concept drawn from standard terminologies.”
With the help of funding from the Agency for Healthcare Research and Quality (AHRQ), the team developed a comprehensive value set for documenting and encoding adverse drug reactions in the allergy module of an EHR system.
Researchers analyzed nearly 2.5 million adverse drug reactions from 2.7 million patient EHRs stored in the allergy module at Partners Healthcare. They used the medical text extraction, reasoning, and mapping system to process both structured and text-free adverse drug reaction entries and enter them into a systemized nomenclature of medicine list of clinical terms.
“Using the Medical Text Extraction, Reasoning, and Mapping System, we processed both structured and free-text reaction entries and mapped them to Systematized Nomenclature of Medicine – Clinical Terms,” explained researchers. “We calculated the frequencies of reaction concepts, including rare, severe, and hypersensitivity reactions.”
Researchers then compared concepts in the Partners Healthcare allergy module to those in the Federal Health Information Modeling and Standards value set and data from the University of Nebraska Medical Center to create an integrated value set.
“The goal was to create a value set that is consistent with those found in the patient record, integrated with the most current terminology updates and aligned with the current data models needed to support clinical decision support,” wrote researchers.
Ultimately, researchers identified 1,106 concepts for the final integrated value set. This value set included clinically important severe and hypersensitivity reactions.
“This work contributes a value set, harmonized with existing data, to improve the consistency and accuracy of reaction documentation in electronic health records, providing the necessary building blocks for more intelligent clinical decision support for allergies and adverse reactions,” they stated.
The final value set could be useful in supporting adverse drug reaction documentation at healthcare organizations in the future and improving allergy-related clinical decision support.
Improving health data standardization in EHR documentation and other areas of EHR use remains a top priority among providers, policymakers, and health IT developers.
The present lack of widespread health data standardization has been named one of the biggest obstacles to true interoperability in healthcare.
In an effort to improve standardization, AMIA recently submitted a letter to ONC urging the federal agency to update the 2015 Interoperability Roadmap, enhance health IT testing, and improve health IT and health data standards.
Reducing variation across health IT and data standards could help to streamline health data access and exchange and enable well-informed patient care delivery.