Session ID: 
195

Style Standards to Improve Data Quality and Interoperability

8:30am - 9:30am Thursday, February 14
Orlando - Orange County Convention Center
W230A

Description

This session will discuss the value and benefits of documentation standards as described by the American Medical Association and other standards developing organizations such as WHO and the American Joint Committee on Cancer. Examples of relevant standards include units of measure; pharmaceutical regimens; cancer protocols; laboratory studies; genetics; disease classifications; and the use of abbreviations, medical slang and lingo. The consistent use of style in the healthcare record promotes clear communication; contributes to patient safety; and improves information exchange, data integration and data aggregation. Applying standards of style to EHR templates, drop-down text, and data dictionaries reduces the need for data normalization, potentially improving results from NLP and emerging technologies such as AI. The Association for Healthcare Documentation Integrity has compiled relevant standards into a single reference to aid in the programming and implementation of EHRs.

Learning Objectives: 

  • Explain the benefits of applying style and format to information exchange, data aggregation, natural language processing and artificial intelligence
  • Recognize the value of style standards to improve communication among clinicians and to enhance patient safety
  • Describe the purpose of style standards related to clinical and technical information and identify standards developing organizations that promulgate those standards
  • Recognize the value of a single-source reference tool for writing clinical and technical information
  • Compare and contrast formatted vs. non-formatted clinical data

Speaker(s): 

Chair, Book of Style for Medical Transcription, 4th Edition, Working Group,
Association for Healthcare Documentation Integrity
National Leadership Board,
Association for Healthcare Documentation Integrity

Audience: 

Clinical Informaticists
Data Scientist
Information Management Professional

Level: 

Intermediate