Less than 10 percent of the data collected in a typical patient note is actually required to be structured in order to meet meaningful use, according to a study by WebChartMD, a software development company specializing in clinical documentation workflow applications.
The study analyzed 100 de-identified orthopedic and cardiovascular patient notes obtained from MTSamples.com, a collection of transcribed medical transcription sample reports. While a larger body of documents needs to be analyzed to confirm study findings, the key take-away is that as much as 91-93 percent of data typically captured within electronic health records (EHRs) in a structured format (e.g. point-and-click templates and drop-down boxes) could instead be captured as unstructured data (e.g. dictation and transcription, or free-text entry) and still meet meaningful use requirements. More, specifically, according to the study, only 7 percent of data (9 percent if lab data is present) in a patient note needs to be structured to meet meaningful use requirements.
Data required to be structured for meaningful use includes:
- demographics (preferred language, sex, race/ethnicity, date of birth)
- vital signs (height, weight, blood pressure, BMI)
- smoking status
- problem list
- medication list
- medication allergies
- lab tests/values
- minimum of one family history entry
"This study is especially relevant for physicians frustrated by the negative impact EHRs can have on their patient interactions and their productivity," Mark Christensen, WebChartMD's CEO, said in a statement. "Physicians are often asked to capture more data in a structured format than meaningful use requires."