TIU Note Titles Learning Objective • Examine the hierarchy for TIU Notes including classes, document classes, and titles. • Determine best practices for TIU note titles. • Examine Sample Note Titles • Map to Standard Note Titles 2 TIU Note Titles • TIU Progress Note Titles are created before users can write progress notes. • TIU operates from a structured Document Definition Hierarchy. • The hierarchy allows documents (Note Titles) to “inherit” characteristics (behavior) from higher levels. 3 Document Definition Hierarchy 4 Hierarchy Relationship • Business Rules for the note title documents follow the hierarchy relationship. • Best advice: Do not edit Business Rules! 5 Edit Document Definitions Menu 6 Inactivating a Note Title • NEVER DELETE a note title once it has been used! • EHR committee - Review your note titles. • Note titles that are no longer in use need to be INACTIVATED! • New title needs to be approved before its creation. 7 Note Titles Recommendations • Keep Note Title naming conventions simple. • Keep the number of Note Titles to a minimum (recommended: around 30). • Use caution when moving Note Titles that have been used by providers. • Do not put “Note” in the title of a Note. 8 Sample Note Titles • Keep titles simple and short: • Family Practice • Optometry • Nursing • Behavioral Health • Pharmacy • Community Health • Nutrition • Diabetes Program • Podiatry 9 Note Title Menu • EHR > BEH > TIU > HIS > TMM > DDM • DDM1 Edit Document Definitions • DDM2 Sort Document Definitions • DDM3 Create Document Definitions • DDM4 Create Objects • DDM5 List Object Descriptions • DDM6 Create TIU/Health Summary Objects 10 Why Map to VHA Enterprise Standard Document • Share meaningful titles across systems. • Create searchable, retrievable, comparable, and computable data. • Capture complete health information. 11 How were Note Title Standards Determined? • Researched existing Standard Development Organizations (SDO) for existing clinical document standards. (LOINC and HL7). • Extracted all TIU document titles from 128 databases [in the VA] (156,000). • Analyzed every term within the extracted Titles. • Categorized the title terms to follow LOINC and HL7 standards. 12 Local Title Examples; the Need for Standardization • AUDIO/REEVAL/HA CHECK (T)(CI) • CH-SARP NOTE • CIH/STAR II CONSULT • DME CLINIC (T) • IC/ID/V • SOCIAL WORK BOMH DISPOSITION NOTE (O) (T) • UR 67CD (T)(K) • BLDG 85 CAFFEINE CLASS • BED STY NURSING NOTE • BUDGET GROUP, PHASE I (CI) • DIVERSIONAL ACTIVITY - K • PATIENT HEALTH EDU POINT AND CLICK • RAP NOTE (K) • STARDOM EVALUATION 13 What TIU Data will be Standardized? • TIU Document Definition file 8925.1: • Name field .01 (note title name). • TIU Document file 8925: • Status Field .05: • Keeping current statuses. 14 LOINC Standards • LOINC document naming nomenclature contains five axes: • Subject Matter Domain – Characterizes the subject matter of a note. • Role - Characterizes the training or professional level of the author of the document, but does not breakdown to specialty or subspecialty. • Setting – Characterizes the general setting of the health care being provided. Setting is not equivalent to location, which typically has more locally defined meanings. • Service - Characterizes the kind of service or activity that was provided to/for the patient as described in the note. Common subclasses of service would be examinations, evaluations, and management. • Document Type - Characterizes the general structure of the document at a macro level. 15 Standard Title Terms A standard note title is created by combining terms for each axis into a composite title: Subject Matter Domain (SMD) Service Primary Care Counseling Cardiology Diagnostic Study Surgery Evaluation and Management Role Physician Document Type Nurse Note Attending Consult Setting Report Inpatient Outpatient Home Health Care 16 Order of Title Terms The order of combining terms within a Title is as follows: Subject Matter Domain : Role : Setting : Service : Document Type • Not all axes are required to create a valid document title; some axes may be blank. • For example, taking Cardiology from the SMD axis and Consult from the Document Type axis, the following title could be created: Cardiology: No Author/Role: No Setting: No Service: Consult. • Result: Cardiology Consult. 17 More Examples of Standard Titles • Report of Contact (Document Type only) • Physical Therapy Note (SMD, Document Type) • Primary Care Nursing Outpatient Note ( SMD, Role, Setting, Document Type) • Advance Directive (Document Type ) • Audiology Inpatient Diagnostic Study Report (SMD, Setting, Service, Document Type) 18 Important Facts • No delimited characters in standard titles with the exception of the ampersand (&). HL7 specifications use delimited characters for message transmission. • Examples of delimited characters: ; ~ ^ : | • Sites will maintain their local titles in the Text Integrated Utility Document Definition file 8925.1. • The VA sends these documents to the Health Data Repository – we do not yet but this will prepare for future exchange of data. 19 Mapping 20 Mapping to National Titles 1. Perform Active Title Cleanup: • Inactivate unused note titles (except National titles). 2. Print a list of Active Note Titles (BEH – TIU – HIS – LAD). 3. Review of VHA Enterprise Standard Titles: File VHA ENTERPRISE NOTE TITLES (44 page document in your class materials). 4. Review and identify which standard titles your local titles may be mapped to: • Direct map. 5. Add Synonyms (optional). 6. Use mapping tools to map remaining titles. 21 Step 1: Active Title Cleanup Report/Utility 22 Active Title Cleanup Report (1) • Delivers the Active Title Cleanup Report and automated cleanup utility to assist the Data Standardization’s efforts and standardize Document Titles: • Cleanup report should be run and inactive notes processed prior to using mapping options. • National Note titles such as Crisis Note, Advance Directive, and Patient Record flag note titles should not be inactivated. 23 Active Title Cleanup Report (2) • When running report: • Users may be on system. • Run at a time that does not conflict with system back up. • Processing times will vary. • The report displays: • All currently active titles. • The number of instances each title was used in the previous 365 days. • The last day each title was used. • The last AUTHOR/DICTATOR of each entry. 24 Active Title Cleanup Report (3) • INACTIVE titles will only appear on the report if that title has been used in the previous 365 days. • ACTIVE titles that have a document type field that points to a document (in 8925.1) of type DOCUMENT CLASS or CLASS will have a *[DOCUMENT CLASS]* or *[CLASS]* tag appended to the title respectively. • ACTIVE titles that contain a 0 (zero) or NULL document type field will be displayed as UNKNOWN *[missing]* on the report and the document IENs for these titles will be listed at the end of the report. 25 Active Title Cleanup Report (4) • ACTIVE titles with a count of 0 (zero) will be selected for automatic inactivation only after user intervention during the report process. No changes will be made to file #8925.1 without consent from the user. • Specific titles may be selected that will NOT be inactivated even if their usage count for the last year is 0. 26 Active Title Cleanup Report (5) • Run the utility twice: • The first time, select NO when prompted to inactivate note titles. This allows you to review your system. • The second time, inactivate selectively. 27 Review the Report (1) BEH>TIU>HIS>TMM>CLN Inactivate the unused Document Titles at this time? NO// NO DEVICE: HOME// The sample shown below was on a test database and is not indicative of the results at any actual site. Review Screen Elapsed Time: 0 minute(s) 1 second(s) # of Used Titles : 8 # of Unused Titles : 76 # of Invalid Titles : 0 ---------- # of Total Titles : 84 # of Docs : 29 # of Docs Incorrect .01 Field : 0 # of Docs Zero/Null .01 Field : 0 ---------- # of Total Docs Searched : 29 Current User: USER,DEMO Current Date: Jan 04, 2013@11:52:38 Date range searched: Jan 05, 2012 - Jan 04, 2013 28 Review the Report (2) 29 Review the Report (3) 30 Active Title Cleanup Report (6) • Review the list. Select the titles you wish to inactivate. • Remember: Do not inactivate National Note titles or Patient Record Flag note titles. 31 Active Title Cleanup Report (7) National Document Classes ADDENDUM ADDICTION SEVERITY INDEX ADVANCE DIRECTIVE ADVERSE REACTION/ALLERGY ANESTHESIA REPORTS C & P EXAMINATION REPORTS CLINICAL WARNING CRISIS NOTE DISCHARGE SUMMARIES HISTORICAL PROCEDURES LR ANATOMIC PATHOLOGY NURSE INTEROPERATIVE REPORTS PATIENT RECORD FLAG CAT I PATIENT RECORD FLAG CAT II PROCEDURE REPORT (NON-O.R.) OPERATION REPORTS REQUEST FOR CORRECTION/AMENDMENT OF PHI SCI OUTCOMES 32 Active Title Cleanup Report (8) National Document Titles National Document Titles ADDENDUM HISTORICAL PACEMAKER IMPLANTATION PROCEDURE ADVANCE DIRECTIVE HISTORICAL PRE/POST SURGERY RISK NOTE ADVERSE REACTION/ALLERGY HISTORICAL PULMONARY FUNCTION TEST PROCEDURE ANESTHESIA REPORT HISTORICAL RHEUMATOLOGY PROCEDURE ANNOTATION *** LR AUTOPSY REPORT APPROVED REQUEST FOR CORRECTION/AMENDMENT OF PHI LR CYTOPATHOLOGY REPORT ASI-ADDICTION SEVERITY INDEX LR ELECTRON MICROSCOPY REPORT CLINICAL WARNING LR SURGICAL PATHOLOGY REPORT DENIED REQUEST FOR CORRECTION/AMENDMENT OF PHI NURSE INTERPRETATIVE REPORT DISCLOSURE OF ADVERSE EVENT NOTE OPERATION REPORTS CRISIS NOTE PATIENT RECORD FLAG CATEGORY I DISCHARGE SUMMARY PATIENT RECORD FLAG CATEGORY I - HIGH RISK FOR SUICIDE