Getting diagnostic results into the chart
A report filed as a scanned image satisfies a documentation requirement and answers no question you can ask across a panel.
Three levels, in order of usefulness
- Document delivery. The report arrives as a PDF and is filed. Visible to a clinician reading that chart, invisible to everything else. Fast to set up, and where most practices stop.
- Discrete result capture. A short fixed set of values is entered as structured observations. Now they can be trended, graphed and queried.
- Interface-level exchange. Results flow in as structured messages with no manual entry. Highest effort, and the only level that scales to a whole panel.
Why level two is the right first target
Level one is not enough, because the entire clinical argument for repeat measurement rests on comparison, and a PDF cannot be compared with anything by a computer. Level three is the correct destination and is a project with its own timeline and its own budget conversation. Level two captures most of the value for a fraction of the effort, and it can be started this week.
A minimum field set
- Ankle-brachial index, left and right.
- Toe-brachial index, left and right.
- Sudomotor conductance, hands and feet.
- Heart rate variability summary index.
- Orthostatic blood pressure change.
- Resting energy expenditure.
- Lean body mass and fat mass.
- Cognitive screening score.
- Conditions of measurement — fasting state, caffeine, nicotine, time of day, medication timing.
That last one is the field most often omitted and the one that makes every other field comparable. Without it a trend is a guess.
Three rules that keep the data usable
- Choose the fields once and never change them. A field quietly redefined destroys the trend it was created for.
- Have the person who performed the study enter the values, at the time of the study. If it falls to the reviewing clinician it happens inconsistently.
- Keep the narrative report as well. Discrete values do not carry waveform morphology or the interpreting clinician’s reasoning.
The quality-reporting connection
Several of these values feed the clinical domains that quality programs consume — body mass index and follow-up, blood pressure, diabetes care, falls risk and cognitive assessment. Data captured discretely is auditable and comparable year over year in a way that an attestation is not. MIPS and quality reporting.
Related reading
Medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, medical director of Measura. Last reviewed .