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Capturing Structured, Pulmonary Disease-Specific Data Elements in Electronic Health RecordsCapturing Structured Data Elements

Peter E. Gabriel, MD, MSE; Cynthia Gronkiewicz, APN, MS; Edward J. Diamond, MD, MBA, FCCP; Kim D. French, MHSA, CAPPM; John Christodouleas, MD, MPH
Author and Funding Information

From the Perelman School of Medicine at the University of Pennsylvania (Drs Gabriel and Christodouleas) and Suburban Lung Associates (Mss Gronkiewicz and French and Dr Diamond).

CORRESPONDENCE TO: Peter E. Gabriel, MD, MSE, Penn Medicine Department of Radiation Oncology, 3400 Civic Center Blvd, TRC 4 W, Philadelphia, PA 19104; e-mail: peter.gabriel@uphs.upenn.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):1152-1160. doi:10.1378/chest.14-1471
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Electronic health records (EHRs) have the potential to improve health-care quality by allowing providers to make better decisions at the point of care based on electronically aggregated data and by facilitating clinical research. These goals are easier to achieve when key, disease-specific clinical information is documented as structured data elements (SDEs) that computers can understand and process, rather than as free-text/natural-language narrative. This article reviews the benefits of capturing disease-specific SDEs. It highlights several design and implementation considerations, including the impact on efficiency and expressivity of clinical documentation and the importance of adhering to data standards when available. Pulmonary disease-specific examples of collection instruments are provided from two commonly used commercial EHRs. Future developments that can leverage SDEs to improve clinical quality and research are discussed.

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