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What is structured text, discrete data or more granular text?
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Structured text is often referred to as discrete data and results in data with a higher granularity.
In SW v4, and other free text record systems, the medication field is one big glob of letters and numbers. All that could be shared with another information system is this total glob of letters in a field called “Medications.” In this glob, “Amoxil” and “mxoliA” appear the same to the computer. It is not even possible for the computer to know how many medications are present or what medicines. While it was possible to create prescriptions that are pretty to the clinician, it was all but worthless for anything else, including electronic prescribing. We overcame this problem with the drug interactions module in v4 by attaching a visible, unique identifier to each med. It is not apparent to most clinicians that a computer can’t separate the individual items of the prescriptions. A clinician can instantly differentiate a Sig portion from a Refill portion, but a computer can’t recognize one from the other within freely-typed text.
In SW v5/2008, each medication can contain up to 15 separate items of information (for each med) that can be shared with other systems including pharmacies. Each medication is uniquely identified so that the exact med and the number of meds can be shared with other information systems. So, meds in v5/2008 can have 13 times more structure or granularity than those in v4.This level of information makes all sorts of functionalities possible. It provides a level of discreet information that can support such things as alerts when refills would be due, and all nature of links to bring up relevant information to assist with patient management in the future.
In order to link different programs/systems, it is important to not only have discreet information in a specifically identified location, but the data elements themselves must be associated with a unique identifier in the background. In SOAPware, for example, Amoxil, Amoxicillin, and Wymox all have a unique identifier of d00088 that is hidden within specific, structured ST items. This is the reason why users will want to download and use pre-built ST items rather than creating new ones whenever possible. Structured ST items are not recognized until they are associated with one or more unique identifiers (i.e. codes). SOAPware’s findings are mostly in the form of structured ST items that are being associated with multiple coding systems including ICD, CPT, SNOMED-CT, ICPC, ICD-10, UMLS and others. This encompasses a unique and unprecedented degree of ability to uniquely identify findings and terms. Take the SOAPware medication field to illustrate.
Free-text Prescription (e.g. v4) = Granularity of -1
SOAPware v5/2008 Prescription = Granularity of -15 = 15 times more structured data
| # | Prescription Granules |
| 1 | Medication Name |
| 2 | Strength |
| 3 | Sig |
| 4 | Dose |
| 5 | Frequency |
| 6 | Route |
| 7 | Modifier |
| 8 | Instructions |
| 9 | Quantity |
| 10 | Refills |
| 11 | Substitution |
| 12 | Indication |
| 13 | Start Date |
| 14 | End Date |
| 15 | Comments |
So, v5/2008 medications are no less than 15 times more robust and 15 times more likely to be able to link/share/report to other systems.
The degree of granularity = level of structure = information power = value of the documentation.
The level of granularity within v5/2008 is unlimited, but we have to start somewhere, so a starter framework has been developed. What is described below, in this document, and all the current documentation is only the starting, suggested framework. Taking the legacy or classic SOAP note fields, the table below offers a Comparison of the relative granularity of free-text systems (e.g. v4) and SOAPware v5/2008 (starting framework).
|
| Free-Text Systems (e.g. v4) | v5/2008 (starting framework) |
| Subjective | 1x granularity | 24x = 24 items and 24x more power |
| Objective | 2x granularity | 25x = >50 items or 25x more power |
| Assessment | 1x granularity | 6x = 12 items = 6x granularity (each Dx) |
| Plan | 1x granularity | 7x = 7 items and 7x more power |
| Medication | 1x granularity | 13x = 13 items and 13x more power |
Only the whole glob of letters and numbers in each of the SOAP fields can be discretely identified in most systems. There was some “pattern matching” in v4 in order to enable EM coding. However, this really did not make it possible to differentiate the HPI from the ROS. In other words, it was not possible to tell what was HPI or what was ROS as far as exchanging information between systems. There was no means to even share even the chief complaint. This limited the readability of most documentation to a subset of humans who have medical training. The world is changing and more is being expected from medical documentation. It must be sharable and readable by information systems as well as specially trained humans.
Subjective:
| Free-Text Systems (e.g. v4) | v5/2008 (starting framework) |
| 1x granularity Subjective:
| 24x = 24 items and 24x more power Subjective: CHIEF COMPLAINT: HPI: SYMPTOMS/RELATED: LOCATION: QUALITY/COURSE: INTENSITY/SEVERITY: DURATION: ONSET/TIMING: CONTEXT/WHEN: MODIFIERS/TREATMENTS:
ROS: GEN- Constitutional: GEN - Endocrine: GEN - Hematologic-Lymphatic: GEN - Allergic-Immunologic: HENT: EYES: LUNGS/Respiratory: HEART/Cardiovascular: ABD/Gastrointestinal: GENT/Genitourinary: Musculoskeletal (BJE): NEURO/Neurological: PSYCH/Psychiatric:
|
Objective
| Free-Text Systems (e.g. v4) | v5/2008 (starting framework) |
| 2x granularity
1-Objective 2-Vital signs
| 25x = >50 items or 25x more power Vital signs GENERAL: General appearance can be described as LYMPHATIC: Neck node findings include Axillary node exam reveals Groin-Inguinal nodes demonstrate Lymph node exams (not axillary/neck/groin) reveal HEAD, EARS, NOSE AND THROAT: Ears-Nose (external) Inspection: Hearing assessment shows Nose exam, internally, reveals. Oropharynx Teeth, Gingiva, and Lip Exams: Otoscopic Exam:. NECK: Neck tissue exam demonstrates Thyroid exam reveals LUNGS and RESPIRATORY: Chest palpation reveals Chest Percussion demonstrates Lung auscultation elicits Respiratory effort described as HEART (Cardiovascular): Heart palpation reveals Heart auscultation discovers Abdominal aorta exam reveals Carotid artery findings include Femoral arteries reveal. Pedal pulses demonstrate Edema-Varicosity Exam: ABDOMEN (Gastrointestinal): Mass/Tenderness Exam: Liver/Spleen: Hernia checking discovers Anus and perineum inspection shows Guaiac testing demonstrates MUSCULOSKELETAL (BJE): Gait and station demonstrate Digit and Nails: Inspection-Palpation: Muscles: Joint stability checking finds Range of Motion: NEUROLOGICAL: Cranial Nerves: Reflexes: Sensation: PSYCHIATRIC: Insight and judgment appear Memory testing discovers Orientation is Mood and affect are described as SKIN: Skin Inspection:. Skin Palpation:. +++++
Scrotum inspection shows Penis exam shows Prostate digital exam reveals BREASTS: Breast inspection demonstrates Breast palpation reveals FEMALE-GENITOURINARY: External genitalia show Urethra findings include Bladder palpation reveals Cervical inspection detects Uterus bimanual exam demonstrates Adnexa palpation discovers
|
Assessment
| Free-Text Systems (e.g. v4) | v5/2008 (starting framework) |
| 1x granularity Assessment
In v4, there was some limited ability to share ICD codes. In v5/2008, up to 11 additional sub-items of information can be shared for each diagnosis. Many of these sub-items are necessary to implement quality improvement programs, disease registries and P4P. | 6x = 12 items = 6x more granular (each Dx) Assessment: Description Lay Term ICD# Responsible MD Onset Resolved Orders
|
Plan:
| Free-Text Systems (e.g. v4) | v5/2008 (starting framework) |
| 1x granularity Plan:
Again, v4 did some pattern matching to accomplish EM coding, but this was not individual, discrete information that meant anything to any system other than SOAPware. The initial sub-items here are the ones necessary for EM coding. Soon, a number of additional sub-items will be added to support order entry so orders can be shared between systems. This was not possible in v4 and with other free text based systems. | 7x = 7 items and 7x more power Plan: Lab/Tests: X-rays: Studies (other than lab or x-ray): Old Records Requested: Discuss with physician: Summary updated:
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