Using structured text and templates to capture health status outcomes in the electronic health record

Because of the difficulty of implementing clinical outcomes-focused quality improvement (QI) projects, most organizations' efforts and comparative quality report cards have centered on structure and process indicators or on outcomes captured in administrative data systems. Ultimately, however, health care is intended to improve health. Health status is now frequently included in the set of quality of care information requested by purchasers of health care, accrediting and governmental agencies, and consumer groups. Subsequently, users of electronic health record (EHR) systems are demanding that the EHR support the collection and comparative analysis of health status information over time and by clinical population and provider.

As opposed to the current practice in most organizations of collecting health status data via an annual mail survey, the approach discussed in this article utilizes standardized coding and classification (SCC) systems and standardized surveys to capture health status information in the EHR during the routine course of care delivery through the use of templates built on structured text. This method is illustrated with examples from the WAVE EHR. The EHR-based structured text and template approach facilitates the incorporation of health status measurement into the documentation of the patient-provider encounter, builds on recognized SCC systems and standardized surveys, and enables information retrieval for a variety of analyses, including those focused on QI.

Health status outcomes are an essential component of an information set focused on health care quality. To routinely capture and analyze health status variables, SCC systems and standardized health status surveys are necessary.