Data Manual
User’s Guide
North York Family Health Team
Prepared by:
Kimberly Wintemute
Marjan Moeinedin
Michelle Greiver
Date of document: August 29, 2013- V3
Contents
EMR version .................................................................................................................................................. 1
Objective ....................................................................................................................................................... 1
Background ................................................................................................................................................... 1
Risk Factors ................................................................................................................................................... 2
Improving data for Tobacco use: Tobacco categories ............................................................................. 2
Nightingale EMR.................................................................................................................................... 2
Chronic Diseases ........................................................................................................................................... 6
Improving data for Chronic Diseases: Coding .......................................................................................... 6
Standard codes for chronic conditions ................................................................................................. 7
Nightingale EMR.................................................................................................................................... 8
Practice Solutions EMR ....................................................................................................................... 10
Encounters .................................................................................................................................................. 13
Standards for data entry: stamps and templates .................................................................................. 13
Nightingale EMR.................................................................................................................................. 14
Practice Solutions (PSS) EMR .............................................................................................................. 18
Standards for data entry: recording vitals ............................................................................................. 20
Nightingale EMR.................................................................................................................................. 20
Practice Solutions EMR ....................................................................................................................... 21
Interprofessional Encounter Headers ......................................................................................................... 23
Improving Interprofessional Encounter Designations (Nightingale EMR only at this time) ................... 23
Nightingale EMR.................................................................................................................................. 23
Disclaimer.................................................................................................................................................... 25
References .................................................................................................................................................. 25
ii
EMR version
This process is provided for the Nightingale EMR, version 9.2 and the Practice Solutions EMR, version 5.2
Objective
The objective of this document is to document and provide guidance on consistent data entry processes
for the Nightingale EMR and the Practice Solutions EMR.
Background
Consistent and standardized clinical data play a key role in measuring and monitoring the
quality of healthcare delivery. Data quality matters: “you cannot improve what you cannot
measure”.1 The transition to Electronic Medical Records (EMRs) has led to expectations that
electronic data be collected as part of routine practice so that these data are available for
quality improvement activities, research and chronic disease management. 2-12 The quality of
the information we collect and use depends on the quality and integrity of the data we enter in
the charts. However, there are problems with the quality and consistency of our data.
In a recent research project conducted at the North York Family Health Team (NYFHT) 13, we
determined that we could systematically improve the quality of our EMR data.
We expect that standardizing data entry will lead to more accurate measurement of the care
we provide, and therefore to a better ability to monitor and improve the quality of our services.
Ultimately, our goal is to improve outcomes for our patients.
This document provides guidance on entering consistent, high quality data in the charts that
are shared across multiple health professionals in our Team. Better data for better care is
everyone’s responsibility.
Data Manual, User’s Guide 1|Page
Risk Factors
Improving data for Tobacco use: Tobacco categories
Why this is important
There are several ways to enter tobacco information for our patients: ex-smoker,
X smoker, smokes 1ppd, quit smoking etc.
The wide variety of entries used makes it very difficult to look at a whole practice and to see who the
current smokers are, or who the ex-smokers are. This is important if you want to identify all current
smokers (example, alerts in charts, invitations to quit smoking program etc), or ex-smokers (are they at
risk for COPD?)
Adding categories to “Tobacco” makes it possible to identify these patients, and can be used in
addition to the free text in Comments.
Here is how to do it:
Nightingale EMR
1- From the patient chart, select the CPP from the top menu, and then click on Social History
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2- Click on the ‘New Social History’ button highlighted in the following screen.
3- In the “Add Social History Info” screen select Tobacco form the dropdown list
4- From the ‘Item’ dropdown list, select one of the 3 available options that are applicable to the patient.
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5- If the patient is Ex-Smoker, it is important to uncheck the “Non-Smoker” check box.
If you don’t uncheck this, “Non-smoker” will show up in the CPP when you save it, instead of “exsmoker”.
6- Click Save at the bottom of the page.
7- Once you save, the following, is what will appear in the CPP. This will allow you to audit your data in
the EMR, and put alerts for all “Current Smokers” in the future if required.
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Practice Solutions EMR
1- From the patient’s chart, in the CPP, click on the “Risk” at the side (circled in the following screen).
2- Once clicked on the CPP “Risk” section, the following screen will appear. Select Tobacco tab and click
on “Add Tobacco Risk” shown below
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3- Put in “Never smoked”, “current smoker” or “Ex-smoker” using the radio buttons
The details like number of pack/years etc. can be optionally added into the details section.
4- When done, click “Save All Changes” on the bottom right.
Chronic Diseases
Improving data for Chronic Diseases: Coding
Why this is important
A first step to improve the management of our patients with chronic diseases is to make sure that they
are identified correctly and consistently. For example, if we want to know how we are doing with BP
control in diabetics, we have to know who the diabetics are. In order to do this, we need to use
consistent codes.
We have found that using diagnostic codes leads to consistency of data in a more effective and efficient
manner than agreeing upon text. For instance, it is much faster to get all clinicians’ agreement upon
diagnostic code 401 for hypertension than to get them to agree on a unified terminology (some want to
use various terms such as Hypertension, HTN, High BP, incr BP, etc.). In addition, terms in text format
are prone to spelling errors, even when clinicians do agree on one. Another advantage of using
diagnostic codes is when new clinical members join the team, they do not need to be informed of any
agreed upon nomenclature; they just need to learn how to insert the diagnostic code.
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For example, for diabetes, all diabetic patients should have a code of 250 entered in their CPP and EMR
encounters when diabetes is recorded. A frequent problem is when Impaired Fasting Glucose (IFG) or
Gestational Diabetes is incorrectly coded as 250. This results in appearing these records inadvertently on
Diabetics searches, which makes it very difficult to identify who is or is not diabetic.
Standard codes for chronic conditions
The followings are diagnostic codes that NYFHT clinicians have agreed upon:
Diabetes
250
Hypertension
401
COPD
496
Asthma
493
Depression
311
Osteoarthritis
715
Heart Failure
428
NOTE: If you see a patient who is not diabetic, avoid using code 250 in Encounter notes, billing or CPP.
Instead, use 249 or 259 for IFG. If you have “rule out diabetes”, please do not use 250 until you have
actually diagnosed the patient, then you can certainly use the code. Do not bill 250 for “rule out
diabetes”.
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Here is how to do it:
Nightingale EMR
1- From the patient chart, select CPP from the top menu, select an active provider from the list, and
then click on the “Problem List” link (see the following screen)
2- In Problem List, use the ICD and/or descrption box to enter the problem.
NOTE: Avoid using the “Problem” area to enter the diagnosis as this area is free text and any values
entered in this area WILL NOT be tracked by the clinical reports generated within the EMR.
Data Manual, User’s Guide 8|Page
If you know the diagnosis code, enter it in the “ICD” box
If the code is not known, type the diagnosis in the “Description” box, the ICD code will appear. If known,
include the date of onset; the most important value to enter is the Year.
To add the diagnosis to an Encounter, click the “CPP” box (shown in the following screen)
NOTE: Do not check the CPP box if the chronic disease is already in CPP, or today’s date will override
date of diagnosis in CPP!
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Practice Solutions EMR
1- In CPP, look in “Prob” (problem list) if the diagnosis text appears in black, that means the ICD code has
been entered but if the text appears in blue color that means the ICD code has not been entered and
needs to be added.
2- To code the diagnosis, double click on a blue diagnosis (e.g. Diabetes), the following screen will
appear. Include patient age or the start date (if known) by putting a check mark in the associated box
(see the following screen). This information is very helpful as it tracks how long the patient has had
diabetes.
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3- Click the “Add” button located at the bottom of the screen
4- In the following screen search for the code by typing the problem in the search box. Select the code
and click on the “Choose” button at the bottom of the screen or double click on the code to enter the
code (if you know the code, you can enter it at the top, for example 715 for OA).
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5- Click on the “Add to List” button at the far right bottom corner of the screen.
6- Sometimes you get warnings like the one in the following screen, indicating that the new diagnosis
entered may affect other areas of the patient’s care.
7- Review the warnings; in case any of the warnings require a modification in the patient’s care, click on
“Manage” to manage the interaction and then click on the “Add Health Problems” on the bottom right
corner of the screen (see the following screen).
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Encounters
Standards for data entry: stamps and templates
Why this is important
Standardized data entry includes all clinical offices and central programs. Entering data in a standard
manner increases the rate of data captured through reports and improves our ability to measure patient
care more accurately across the entire FHT. We use stamps and templates to standardize data within
our two EMR systems. Currently, the NYFHT uses Evidence-based stamps/templates for several
conditions, including diabetes, depression, and Congestive Heart Failure (CHF); these stamps/templates
allow the EMR to produce appropriate reminders to improve care.
Additional stamps/templates are being developed as needed for various patient visits and programs.
Using these evidence-based and standardized templates/stamps is strongly recommended instead of
using free text to record chronic disease visits.
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Here is how to do it:
Nightingale EMR
How to load a template for diabetes:
1- Load an “Encounter” page by clicking on “Encounter” from top menu, then click on “New” to open an
encounter.
2- When in an encounter screen, load the Diabetes template by clicking on “Load Template” (see the
following screen).
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3- From the “View” dropdown list, select “Enterprise Templates”
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4- Choose your template by picking its checkbox, and then click “Load”. The Chronic Disease
Management templates have “CDM” after their name.
5- Fill in the appropriate information in the template.
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Overdue Procedures:
From the top menu click on “HM” button to find out what procedures are overdue and need to be
addressed during the patient visit.
CDM Flowsheet
The CDM flowsheet can be accessed from the top as well:
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Practice Solutions (PSS) EMR
NOTE: In PSS, Templates are called Stamps.
For Diabetes:
Inserting Stamp in Practice Solutions Suite (PSS)
1. In PSS Choose Patient
2. Open a new progress note: click on Data from menu and then New Progress Note or use keyboard
shortcut (Mac users: Command + N)
(PC users: control + N).
3. To insert a STAMP, use keyboard shortcut (Mac users: command + I ) (PC users: Control + I).
4- In the STAMP screen, select the appropriate Stamp (e.g. DM visit) from the list
5- Double click on the selected stamp to enter it in the progress note.
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NOTE: if you know the name of your stamp, type in the first few letters of the STAMP name in the
progress notes (e.g. DE), then use keyboard shortcut (Mac users: command + I ) ( PC users: control
+I ) to open a selective list as shown below.
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Standards for data entry: recording vitals
Why this is important
Entering vitals properly in your EMR system ensures that the data can be tracked across multiple visits.
The data can then be added to flow sheets, and monitored for the FHT.
NOTE: Vitals should not be recorded in free text format.
Here is how to do it:
Nightingale EMR
Loading Vitals in an Encounter by default:
1- In “Dashboard”, go to “My Settings” tab,
2- From “Clinical Template” dropdown list, select “Vital signs”
3- The “Vital signs” template will automatically load when you start an encounter.
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2- In the encounter, open Vitals template by clicking on the blue link for “vital signs”.
3- Enter vitals in the appropriate fields. Make sure that you choose correct units; the default is cm and
kilograms.
Practice Solutions EMR
How to insert a STAMP for vital signs:
1. In PSS choose patient record
2. Open a new progress note by clicking on the “New Progress Note” from “Data” on the top menu. You
can also open a new progress note by using keyboard shortcut (Mac users: Command + N) (PC users:
control + N).
3. To insert the “Vitals” Stamp, use keyboard shortcut (Mac users: command + I) or
(PC users: control + I).
4- In the “Stamp Chooser” screen, select the “Vitals” Stamp from the list and double click on the stamp
or click on the “Please select a stamp or keyword” button at the bottom to enter it in the progress note.
5- Complete the Vital signs in the “Progress Notes”.
6- To cancel and exit the “Stamp Chooser” screen, click on the “Cancel” button
NOTE: To enter the BMI value, put the cursor in front of the BMI and use keyboard shortcut (PC users:
Control + I) or (Mac users: Command + I), this will calculate the BMI provided that you entered the
Weight and Height values earlier.
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Interprofessional Encounter Headers
Improving Interprofessional Encounter Designations (Nightingale EMR only at
this time)
Why this is important
It is difficult at times to identify if an encounter was InterProfessional in the EMR and that is if an AHP
with a physicians visited the patient in a same encounter.
This is important for measuring the impact that the Inter-professional care has on patient outcomes,
Adding IP Headers to Encounters makes it possible to identify these patients. This option can also be
used for trainees including medical students, and residents
Here is how to do it:
Nightingale EMR
1- When you start an encounter, click on the “Visit Type” drop down list. Pick the designation that is
appropriate for you.
2- To view the list of signed off encounters go to “Patient” module, from the top menu, go to
“Encounter”, “Signed off” option, you can easily identify the encounter that was done by an AHP (see
the following screens).
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Disclaimer
The information and reference material including text, graphics, images and information contained in
this manual are intended solely for educational purposes and for the general information of the reader.
Every effort has been made to provide information that is accurate and complete; however, we cannot
guarantee its applicability in specific clinical situations or with individual patients.
This information is provided on an “as is” basis and is not intended to dictate what constitutes
reasonable, appropriate or best care for any given health issue. Physicians and others should exercise
their independent judgment concerning patient care and treatment, based on the special circumstances
of each case and setting.
References
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pharmacoepidemiology. Br J Clin Pharmacol 1998;45(5):419-25.
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approach from the Intego database. Fam Pract 2005;22(4):442-7.
5. Biermans MC, Spreeuwenberg P, Verheij RA, de Bakker DH, de Vries Robbe PF, Zielhuis GA. Striking
trends in the incidence of health problems in The Netherlands (2002-05). Findings from a new
strategy for surveillance in general practice. Eur J Public Health 2009;19(3):290-6.
6. Hueston WJ, Mainous III AG, Ornstein S, Pan Q, Jenkins R. Antibiotics for Upper Respiratory Tract
Infections: Follow-up Utilization and Antibiotic Use. Arch Fam Med 1999;8(5):426-30.
7. Hall J, Tomlin A, Martin I, Tilyard M. A general practice minimum data set for New Zealand. N Z Med J
2002;115(1163):U200.
8. Stocks NP, McElroy H, Sayer GP, Duszynski K. Acute bronchitis in Australian general practice. A
prescription too far? Aust Fam Physician 2004;33(1-2):91-3.
9. Lagasse R, Desmet M, Jamoulle M, Correa G, Roland M, Hoyois P, et al. European situation of routine
medical data collection and their utilization for health monitoring: Euro-Med-Data final report.
Brussels: Universite Libre de Bruxelles, 2001.
10. Smeeth L, Thomas SL, Hall AJ, Hubbard R, Farrington P, Vallance P. Risk of Myocardial Infarction and
Stroke after Acute Infection or Vaccination. N Engl J Med 2004;351(25):2611-18.
11. Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E. Dopamine Agonists and the Risk of CardiacValve Regurgitation. N Engl J Med 2007;356(1):29-38.
12. Have paper records passed their expiry date? CMAJ 2005;173(7):725.
13. Greiver M, Barnsley J, Aliarzadeh B, Krueger P, Moineddin R, Butt DA, et al. Using a data entry clerk
to improve data quality in primary care electronic medical records: a pilot study. Inform Prim
Care 2011;19(4):241-50.
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