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Data Set Worksheet

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Data Set Worksheet

In 150 to 350 words, define and describe structured data sets. Use at least one outside source in your response.

Structured data sets are information or data that is organized in a uniform manner so that a computer can identify it and process it. Structured data is commonly used for things like templates, drop down lists, medical vocabularies (LOINC or SNOMED CT), and boxes that can be checked (Futrell, 2013). Information that is organized in structured data sets can be easily located and enables the full capability of an EHR with things like trend analysis and decision support. A doctor’s office uses structured data sets by using templates that record a patient’s information like demographics, vitals, etc. Data that is coded and organized allows for interoperability (Futrell, 2013). Having information in structured data sets means that information can be shared between different systems and even different providers. Having all of the patient’s information in structured data sets is important when point of care is delivered. If a physician has all of a patient’s information, I believe that they can reach a more accurate diagnosis and plan of treatment.

Using the following table, identify and list at least five benefits and five challenges of structured data sets. Explain each benefit or challenge in 50 to 100 words.

|Benefits |Challenges |
|One benefit is that the quality of care for patients will be |Even with structured data sets, there will still be human error. The |
|improved. With the standardization in an EHR by using data sets, |ability to quickly document information by checking a box might lead |
|things like alerts and reminders can be used to alert a clinician if |to careless mistakes. Also, with EHR’s having the capability to copy |
|a patient is prescribed a medication that could cause adverse |and paste, the wrong information could be copied and pasted into the |
|effects. Also, reminders can be automatically generated to send |wrong section. If a copying and pasting error happens, harm could |
|emails, texts, or phone calls to a patient. These features will help |come to a patient. |
|keep patients involved in their care. | |
|Having data in structured formats allows for the transfer of |Clinical vocabularies are not consistent across the board. One of the|
|information between providers. The integration of all EHR systems |terms from MEDCIN may describe leg pain where SNOMED-CT may have |
|means that information can transfer from one to another seamlessly. |separate finding for “leg” and a separate finding for “pain.” More |
|That means if you were going to see a specialist your medical records|has to be done to make the transfer of information and terminology |
|can easily accessed the day of your appointment. If your medical |seamless from system to system to more accurately describe a |
|record consisted of free handwriting, the information would not |patient’s condition. |
|transfer over because it is not codified and cannot be processed. If | |
|there were important information about medications that were left | |
|out, this could cause harm to the patient. | |
|Structured data sets encourage evidence-based medicine. When |A lack of coding standards could also become a challenge. For |
|information is coded in an EHR the information can be gathered to |example, if a patient is given medication that they have a reaction |
|look for trends. For example, if a patient has diabetes, the |to, that information may be included in the physician’s handwritten |
|information from their monitor can be linked to their EHR, and the |notes and not in the section for allergic reactions. If the |
|doctor can tell how well the patient’s condition is being monitored. |information were recorded in the wrong section, a patient could be |
| |prescribed the medication again. |
|Another benefit is that structured data sets organize all the |Another challenge is that some physicians may not want to use |
|information and save clinicians time. The information is put into the|standard data sets; they like writing free hand. Implementing |
|correct field and can be accessed just as easily. Doctors no longer |standard data sets will also likely change the workflow in the |
|have to search through multiple screens of information; they can just|office, and some may not want to make that type of change. Training |
|simply search for the particular field. Structured data sets allow |will have to take place and employees will have to learn the new |
|doctors to spend more time focusing on the patient. |system, this will take time and cost money. |
|Structured data sets also improve productivity by allowing clinicians|Another challenge is information technology interoperability not |
|to enter patient information quickly. When this process is |having one set standard. Different systems use different data sets |
|streamlined, it will help generate more revenue. The ability to enter|and when this happens it affects interoperability. By not using |
|patient information quickly and accurately will allow a doctor’s |standard code sets, this limits the coordination of care. |
|office to see more patients. By simplifying the process of inputting |Implementing the utilization of an EHR is not enough. Information has|
|information, the doctor can spend less time doing paperwork and spend|to be structured into data sets to utilize all of the benefits that |
|more time with the patient. |an EHR can provide like health maintenance and decision support. Only|
| |when the information is entered in structured data sets can it be |
| |processed and become useful. |

Reference

Futrell, K. (2013, October). Structured Data: Essential for Healthcare Analytics & Interoperability. Retrieved from Orchard Software: http://www.orchardsoft.com/files/white_paper_structured_data.pdf

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