Aims and objectives
The incorporationof a patient problem list (PPL) into an electronic health record (EHR) is required by the US Government's Meaningful Use Stage 1 and Stage 2 [1,
However,the creation of relevant PPLs is challengedby several factors : Lack of efficient coding tools Incorrect coding (figure 1) Under-coding (figure 2) Incorrect coding Failure to code Over-coding yielding an excessive list Failure to update with only active problems Since radiological observations and diagnoses often form...
Methods and materials
We developed a multimedia structured reporting system that works as follows: Record key images and voice descriptions of findings (figure 3) Tag images using natural language processing (NLP) with metadata (figure 4) that is referenced to SNOMED-CT terminology (figure 5) and organized as hierarchies (figure 6) Link related serial findings in timelines (figure 7) Assemble a multimedia report organized by anatomical groups and/or medical priorities (figure 8) Filter information as required to...
Multimedia structured reporting provides a means to generate standardized radiology reports as well as createa patient problem list.
All potential signs,
radiologic observations and diagnoses can be recorded throughout a patient’s lifetime,
but filtering image findings to exclude insignificant and inactive problems can be used to create a relevant patient problem list as illustrated in figures 9 and 10.
Many challenges exist today for the creation of relevant patient problem lists,
including under coding,
and failure to curate thelist.
The use of multimedia structured reporting with filtering of structured data based on SNOMED-CT coding,
medical priorities anddisease timeline analysis can be used to produce a pertinent patient problem list to enhance an electronic health record.
Disclosure: David J.
Vining is the founder and CEO of VisionSR,
which has licensed intellectual property from the Unversity of Texas MD Anderson Cancer Center related to the ViSion TM multimedia structured reporting technology. For more information,
please contact: David J.
MD Email: firstname.lastname@example.org or Email: email@example.com Website: www.visionsr.com Video demonstration:https://www.youtube.com/watch?v=Tc1UEQVqGC4
Step 5: Achieve Meaningful Use Stage 1.
https://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-measures/patient-problem-list Problem List Guidance in the EHR.American Health Information Management Association,
http://library.ahima.org/doc?oid=104997#.WlEilVUrJMk Holmes C.
The problem list beyond meaningful use.
Part I: The problems with problem lists.
JAHIMA 2011;82:30-33. Standardizing the Problem List in the Ambulatory Electronic Health Record to Improve...