EMERSE User Guide

A Temporary Patient List is a list that a user can make that, by its nature, cannot be saved. That is, it can be used for a single session but is erased when the user logs out. Such a list is useful in cases where a patient, or set of patients, needs to be reviewed but there is no need to save the list of patients for another time. A "review preparatory to research" should utilize this Temporary Patient List since such a list should not be saved during this type of research review phase.

A Temporary Patient List is meant to be fast and simple, and has a limited set of features. By contrast, a Saved Patient List (see next section) provides more features. For example, with a Temporary Patient List it is not possible to share the list with other users, nor is it possible to annotate the list with Comments or Tags, both of which are only possible with a Saved Patient List.

A Saved Patient List is a list that a user can make and save between sessions. There is no limit to the number of Saved Patient Lists that a user can have, and each list can contain between 1 and 100,000 patients. Because these lists are saved, each list should be given a name and a description, available under the Name/Description Tab. A Saved Patient List is very similar to a Temporary Patient List but there are several notable advantages when using the Saved Patient List.

Patients identified through an All Patient search can be moved to a Temporary Patient List for more detailed searching and viewing of their notes. Once an All Patient search is completed, simply click on the button called Move patients to Temporary Patient List. This will transfer the set of patients identified from an All Patient search to a Temporary Patient List, which is not saved between sessions. Once that move occurs, the list of patients will be shown. To then change that Temporary Patient List to a Saved Patient List, simply click on the button called Convert to Saved Patient List.

In addition to moving patients to a list from an All Patient search, patients can also be added to a list (either an existing list or a new list). This process is the same regardless of whether you are using a Temporary Patient List or a Saved Patient List. Entering patients is done via the Add/Upload Patients tab for the patient lists. To enter new patients, you can type each MRN one-by-one into the MRN text entry box, or you can paste an entire set of MRNs at once. For example, it is possible to copy and paste an entire column of MRNs from an Excel spreadsheet and paste them into the MRN text entry box to create a patient list. You can also upload a set of MRNs from a plain text file, with one MRN on each line. If there are already patients in a patient list, adding new MRNs will append them to the existing list, up to the maximum number allowed.

Any time an MRN is entered, that MRN is checked against the complete set of patients within EMERSE. If an MRN is not found, a warning to the user will be provided. Similarly, if a duplicate MRN is entered for a list, the duplicates will be removed automatically and the user will be alerted.

The Merge Patients feature allows for two Saved Patient Lists to be compared to each other with respect to the patients contained within each list. This feature can be accessed via the Merge Patient Lists button which can be found above the table displaying the Saved Patient Lists.

Merge Patients allows for two lists to be merged together but also provides additional functionality that can be useful for separating out only those patients of interest that may be found among two lists. This feature essentially builds a Venn diagram showing the overlap of patients between any two Saved Patient Lists. You can then select any part of the diagram you are interested in simply by clicking on the appropriate section of the diagram. Once your selection is finalized, click on the Save New List button and you will then have a new Saved Patient List based on your selection. Note that when lists are merged, duplicates will be removed automatically.

It may be useful to use Merge Patient Lists when you want to compare patients found through two different mechanisms or searches. For example, suppose you find a set of patients who had "back pain" and a separate set of patients who had "acupuncture". Using the Merge feature you can find the set of all patients who had both concepts mentioned in their notes at least once, even if the mentions were in completely separate notes or sections of the EHR.

Or, suppose you have a set of patients with a diagnosis of "amyotrophic lateral sclerosis" (List 1) and now you want to exclude any patients with a mention of "packs per year" (List 2). You can make two separate lists, one based on each search. Then using the Merge feature, you can select out the list of patients from List 1 that did not also appear in List 2.

To search for a multi-word phrase that contains one or more spaces, simply put that phrase in double quotes. This will force EMERSE to search for those words together, in that specific order, as opposed to separately, in any order, and in any place in the document. For example, if you search for motor vehicle accident without the quotes, you will end up finiding the terms motor, vehicle, and accident separately. However, if you put the phrase in double quotes ("motor vehicle accident") you will find only the specific phrase motor vehicle accident.

Some medical acronyms are identical to common English words, including NO (nitric oxide), ALL (acute lymphblasic leukemia) and RICE (rest, ice, compression, elevation). Because EMERSE, by default, searches for all terms in a case-insensitive manner, you can end up with a lot of false positives for these otherwise commons words. To help reduce the number of false positives, you can specify a term to be case-sensitive by adding a carat (^) symbol in front of the term. For example, to search for a case-sensitive capitalized ALL, enter ^ALL as the search term, with the carat symbol (^) directly in front of the term. This well help reduce false positives by not returning the common word all as a hit.

You can mix case-insensitive terms and case sensitive terms as long as they are separate terms. For example, the query terms…​

…​will find documents with chemotherapy (case-insensitive), diagnosed on (case-insensitive), and ALL (case- sensitive)

However, if you have a multi-word phrase in double quotes, you cannot have just a single word in that phrase be case-sensitive. The case-sensitive symbol must go in front of the entire phrase, and the entire phrase would be case sensitive. For example, the query term…​

…​would match: diagnosed with ALL but would not match Diagnosed with ALL or the phrase diagnosed with all since the case does not exactly match the query which specifies that diagnosed and with should be lower-case and ALL should be all upper-case.

And, as described above, the following query is not permitted since a single word in a multi-word phrase can’t be case-sensitive. It is essentially an all or nothing choice where the entire phrase is case-sensitive, or the entire phrase is case-insensitive. The following query is not allowed and will not work:

Thus, for searches that require terms to be case-sensitive, in general it is best to just have a single term be case-sensitive and not an entire phrase.

Wildcards help with finding concepts where you may not be able to specify the exact details/phrasing/spelling of the terms.

For example, sometimes you may want to look for a term where the ending of the word may be variable. Suppose you want to look for terms related to hypertension. If you just search for hypertension you may miss other variations. Using the wildcard symbol, the asterisk (*), you can overcome this problem. Simply type in something like hyperten* and you will be able to match terms such as hypertension, hypertensive, hypertensives, etc. This would also match potential misspellings such as hypertenion.

In addition to adding a wildcard to the end of a word, you can also add it to the middle of a word. If you search for hyper*ia you will match terms such as hypercapnia, hypernatremia, and others. In this example, the search term with the embedded wildcard will look for words that start with hyper and end with ia.

Finally, you can place the wildcard (*) in between two words, in which case EMERSE will look for those two words within 5 words of each other, in any order. For example, "pain * leg" will match pain shooting down her right leg as well as leg with severe pain.

There are few caveats with using wildcards:

EMERSE supports a concept of excluding terms with a search. This is similar to the idea of "negation" but works a bit differently. Essentially, this is a way of ignoring certain phrases so that you can find the terms of interest in the appropriate context, and remove potentially positives.

For example, if you are searching for complication or complications in the context of a surgical complication, you may want to simply look through operative notes for the terms complication or complications. However, you don’t want to find negated forms of this such as no complications or without complications (this would be traditional "negation"). Additionally, you may not want to find the terms in other contexts that are not necessarily negated but are still the wrong context (e.g., complications from diabetes).

To ignore/exclude these phrases using Quick Terms, simply include a minus sign in front of the quoted phrase to exclude. For example:

When the terms are displayed to the user in the Navigation Panel, the excluded terms will be shown with strikethrough text, to emphasize that they are being excluded from the search. For example:

It is worth pointing out that an Exclude Terms phrase will only be effective if the excluded phrase contains a term that you are interested in looking for. This feature does not exclude documents that contain the term, it only excludes that phrase when highlighting the term of interest in other contexts found within the document. (You can exclude documents with certain words and phrases using the Boolean NOT operator with an Advanced Terms search).

EMERSE will check the spelling of terms entered. With Quick Terms this checking occurs after pressing the search button (which is either Highlight Documents for a Patient List or Find Patients with an All Patient Search). After running the search, you can view any potentially misspelled words by going back to the Quick Terms entry page. If anything is found to be misspelled it will be shown under the Terms text entry box in bold, preceded by "Did you mean". For example, if you enter your terms as word misspeling you will see:

To correct the spelling you can simply click on the spelling suggestion and the misspelled words will be replaced with the corrected version. Of course, sometimes you may want to search for misspellings, in which case just leave those spelling errors as-is.

The Quick Terms section keeps a short Term History, containing the last 40-50 searches conducted. This can be access by clicking on the Term History button and the clicking on the desired row in the table. Clicking on the row will fill the Quick Terms entry box with the prior set of search terms, but the search will not occur right way. This is so you can edit the terms further if desired.

Synonyms are a very powerful feature of EMERSE, and are described in detail in a separate section. To access the Synonyms within the Quick Terms section, simply click on any of the terms in the Navigation Panel. This will take you to a page within EMERSE that looks similar to how the Term Bundles are managed. Note that many of the Term Bundle features are not enabled with Quick Terms. Nevertheless, you can access Synonym suggestions from this page and add those Synonyms to your current set of search terms, and you can also remove terms from this page. While you can add Synonym suggestions from this page, you cannot add other new terms here (you can add new terms only in the main Quick Terms text entry box).

You can add many terms at once by pasting them into the Upload Terms text entry box. This can be accessed in the same way that Synonyms are accessed. That is, by clicking on any of the terms in the Navigation Panel. Then click on the Add/Upload Terms tab, and then the Upload Terms button. Inside the box that appears simply type or paste in the list of terms or phrases, one term or phrase per line. Then press the Upload button.

A set of search terms within a Quick Terms search can be saved as a Term Bundle, which will allow you to keep and re-use the set of search terms permanently, have more control over the colors assigned to each term, and share it with other users. To perform this conversion, click on any of the terms in the Navigation Panel, and then click on the View Terms tab, and then the Convert to Term Bundle button. You will be asked to provide a Name and Description and then that list of terms will be saved as a Favorite within your list of Term Bundles, which are described in detail below.

If you have trouble finding the right Bundles to use, you can try to use the Filter Bundles feature, which can be found in a small text box above the list of available Bundles. Just start typing what you are looking for and those matching what you type will remain and everything else will be hidden. Filtering looks across the Name, Description and Terms within the Bundle. Filtering does not look through the Owner of the bundle.

Adding terms can be done within the Manage Terms tab of a Term Bundle.

Unlike the Quick Terms (where all terms are entered together in a row within a text box), with a Bundle you enter terms or phrases one by one, with each term or phrase within it’s own colorful "bubble".

As you enter the term the system will assign it a color, but you can change the color to one of the 18 possible choices by clicking on the small color palette icon (three overlapping colored circles) and then selecting a different color. You can always change this color later by editing the Term.

Editing terms can be done within the Manage Terms tab of a Term Bundle. Terms can be edited if you are the owner of the Bundle. If you are not the owner you will not be able to make any changes. To edit an existing term, just click on the term inside of its "bubble" and an editing box should appear. This is also how you would change the color of a term, by choosing the color palette icon to change the color.

If you have a large list of terms that you’d like to add into a Bundle, instead of adding them in one-by-one you can add them all at once using the Upload Terms feature. Click on the Upload Terms button which can be found on the Mange Terms tab for a specific Bundle. Then just type or paste in any list of terms or phrases, one per line. EMERSE will assign the colors to the terms, which you can change later (see the "Editing Terms" section in this guide, above).

To remove a term from a Bundle, go to the Manage Terms tab, click on a term to edit it, and then click on the Remove button next to that term.

If you want to remove all terms from a Bundle at once, click on the Clear/Delete tab and then click on the Clear All Terms from Bundle button. This will remove all of the terms but preserve any sharing preferences that you may have used with the bundle.

To delete a Term Bundle, go to the Clear/Delete tab of the Bundle and then choose the Delete Bundle button. This will completely remove the Bundle, but be careful because there is no undo option once it has been deleted.

Spell checking of terms can also be done for terms entered in a Bundle. The main difference between spell checking for Term Bundles compared to Quick Terms is that spell checking will be done live, right below the term being entered. To fix the spelling, simply click on the suggested spelling and it will be entered into the term "bubble".

General details about how the Exclude Terms work can be found in the Quick Terms section of this guide.

Exclude Terms for Term Bundles are entered differently compared to how they are entered for Quick Terms. For a Bundle, there are two columns of terms that can be entered. The column on the left is for Terms to include, and the column on the right is for Terms to exclude. It is the column on the right where these Exclude Terms should be entered. Additionally, since that section already defines a term as being an Exclude Term a minus sign should not be placed in front of it.

If you are not the owner of a Term Bundle but wish to make edits, you can make your own copy and become the "owner" of this new Bundle. To access this feature, click on the View Terms tab of the Bundle and then click on the Copy Term Bundle button. This new Bundle will then be yours to modify and control, but it is important to know that any changes to the original Bundle will no longer be reflected in your new Bundles, as they have essentially been split off from one another. You can also make a copy of your own Bundle if you want to make some changes but leave the original one intact.

Similar to Patient Lists, Term Bundles can be shared with other users. In fact, to encourage sharing, any new Term Bundle is automatically made publicly available to everyone unless you specifically choose for it to not be, with the exception of Bundles that are copied. To access this Sharing feature click on the Sharing tab. You can make the Bundle private to only you, share it with others on your team (by entering their EMERSE usernames), or make it available to everyone who uses EMERSE.

Boolean searches use the operators AND, OR, and NOT. They must be capitalized or they will be considered as regular terms. NOT in this context means that a document should not be identified/returned if it contains that term. For example:

The query above would identify documents that have the words chest and xray in the same document (anywhere in the document), but if the word abdomen was also in the document it would not be considered a hit even if the first two words (chest and xray) were there.

You can also group booleans together using parentheses, for example:

This query will return documents that have the terms chest, pneumonia and headache all together in the same document in any order, or documents that have kidneys, reflux, and back pain all together in the same document in any order.

Two basic types of wildcards are supported (? and *). Wildcards can only be applied to single words, and cannot be applied to phrases.

? is used to match a single character. For example:

Would match words like beam, beat, bear, bean, bead, etc.

* is used to match zero or more characters:

Would match terms like hypertension and hypertensive, as well as just hyperten.

A fuzzy search allows you to search for terms that are similar to the term of interest. This can be way to look for possible misspellings. A fuzzy search can only be applied to a single word at a time. To use a fuzzy search you append the term of interest with a tilde (~) followed by a number between 0 and 2. These numbers represent the number of potential character substitutions that would have to occur to match the new term.

For example:

Would match beats as well as the word breast, since both of those terms can be created from the word beast by changing just one character. (Note that the original term beast would also be highlighted in this example).

A proximity search looks for two words within a certain maximum distance from one another, regardless of their order. Separate the two words by a space and wrap them in double quotes, then add a tilde (~) followed by a number representing the maximum distance in words that they can be separated.

For example:

Would match phrases like …​a CT scan showed a mass in his left…​

as well as …​a 12x12x8 cm mass in her L upper lung found on CT…​.

and even simply mass CT

A Regular Expression is powerful way to match text using complex patterns. Regular Expressions are commonly used by computer programmers, and it is expected that only those with a certain level of technical expertise would ever use this feature. The syntax for creating Regular Expressions can be complex and difficult to understand, and can vary between programming languages. To create a Regular Expression with EMERSE follow the guidelines for Java regular expressions.

Regular Expressions within EMERSE can be created for single words/tokens only (not multi-word phrases). Nevertheless, there may not be much advantage to using this featured compared to simple wildcard matching. Wrap the regular expression within a forward slash at the beginning and end to tell the query parse that it is a regular expression. For example,

Would match 100mg, 150mg, 400mg, 650mg, etc.

By default EMERSE will use the case-insensitive index when identifying a regular expression. That means even if you specify a mix of uppercase or lowercase letters, they will all be treated as lowercase for the search. It is possible to specify that the regular expression search is Case-sensitive. Details on how to do this can be found in the section on Case Sensitive Searches, below.

By default, all searches using the Advanced Terms feature are case-insensitive. However, it is possible to specify that a term be Case-sensitive using the Advanced Terms feature. This is done by using the case-sensitive index instead. Add RPT_TEXT_NOIC: in front of the term and that term will be searched in a case-sensitive manner that exactly matches the case of the term entered. For example,

Would match ALL but not All or all

You can also use Regular Expressions (see above) with Case-sensitive searches. For example,

Would find either EcG or EkG but not ECG, EKG, ecg, ekg, etc., since the Regular Expression specifies that the first and last letters are upper-case and the middle character is lower-case.

One more example using the the Boolean feature along with a Case-Sensitive search:

This search looks for the case-sensitive SAM as well as the case-insensitive term mitral in the same document. SAM is an acronym for 'systolic anterior motion' which can refer to the mitral valve. The query also excludes documents that contain the case-sensitive Sam which could refer to someone’s name, and excludes the case-insensitive "sam-e" which can be the name of a supplement some people may be taking.

Metadata are additional pieces of data about a document that can potentially be used to help with searching. Examples of metadata might be the source of the document (e.g. the main EHR, radiology, pathology, etc), the type of test (e.g., MRI report, CT report, plain film report, etc), the clinical service (e.g., nephrology, cardiology, rheumatology, etc) and others. While it is possible to search based on metadata, the specific types of metadata and names of the possible elements will vary from one installation/site to another and will depend completely on how the system was configured locally, what data have been loaded, etc. Therefore, if you are interested in this option you will likely need to contact your local EMERSE administrators to get more information. Below is simply an example of the type of query that could be run if specific metadata elements were captured and stored within EMERSE:

The query above will search for the phrase motor vehicle accident and it will limit the search to a locally named source that is called EHR and a locally named department called ADULT EMERGENCY. As mentioned above, the specific names of sources, departments, and other metdata will be unique to each installation, so it is not possible to provide specific details on what options will be available at each site.

Searches can be limited by date ranges using the Advanced Terms feature. Currently, due to technical constraints for how EMERSE was designed, this date feature can only be used when searching across All Patients using the Find Patients function. It will not work when searching across a Patient List with the Highlight Documents function. At some point the system may be re-designed to allow these Advanced Terms date ranges to be used everywhere.

It is worth pointing out that there may be no real need to use a date range within an Advanced Search query, since a date range can already be applied to any search (even searches using Advanced Terms) by using the Dates button available in the Navigation Panel, in the upper left corner of the screen. However, if using dates in the query is desirable, they should be in the standard Solr date syntax, which can be somewhat complex to use. It is also worth pointing out that if you set a specific date range using the Dates button in the Navigation Panel AND you also set a custom date in your Advanced Terms query, an error will occur and 0 patients will be returned. In other words, if you want to use the date options within an Advanced Terms query, you need to leave the standard EMERSE date fields blank.

A basic example of how a date range can be included in a search is below. This query will search for the term trabeculotomy and it will limit the search to the date range January 20, 2015 through May 20, 2015.

The following query is similar to the one above, but shows how some basic date math can be used. In this query the same date is used for both the initial and final dates (2015-01-20), but the second instance of the date is followed by +4MONTHS which essentially adds 4 months to the date, and thus is equivalent to the previously shown query that includes the date range of January 20, 2015 through May 20, 2015.

A few more examples, using the special NOW option are below.

Search for trabeculotomy between January 20, 2015 and the current date:

Search for trabeculotomy between 12 months prior to the current date and the current date:

Search for trabeculotomy between 30 days prior to the current date and the current date:

Search for trabeculotomy between 60 days prior to the current date and 30 days prior to the current date:

When in the Find Patients mode, EMERSE will provide results including:

If you are satisfied with the search results, you can then explore the list of patients in more detail, or save the list for later use by clicking on the button Move patients to Temporary Patient List. Note that to actually save the list for later use you would then need to click on the Convert to Saved Patient List button after converting it to a Temporary Patient List. Once the patients have been moved to a Temporary Patient List, you can also search through their documents using the Highlight Documents button, because at this point you have switched from the Find Patients mode to the Highlight Documents mode by selecting a subset of patients in the system to look through.

Using the Find Patients mode, with either Quick Terms or a Term Bundle:

Using the Find Patients mode, with Advanced Terms:

Because of how searches are conducted, and how patients are identified, in the Find Patients mode, it is best to use a Term Bundle when using multiple terms, and to ensure that true synonyms for a concept are highlighted in the same color. Using Quick Terms may result in no patients being found when multiple terms are being used since Quick Terms assigns different colors to each term and, as a result, the system would be looking for patients that have all of the distinct terms in a single document. With a Term Bundle you have full control over the colors that the terms are highlighted in, so it is much easier to form a more complex/broad query with multiple terms.

Additionally, be careful about adding too many terms, especially if a term is a different color from the others, since it means that the additional term must also be in the document for the document to be retrieved. Adding an extraneous term that isn’t very important for identifying the right patient population has the potential to result in no patients being found. For example, if the following query is used, the query will only find patients that have at least one document with all three of those terms in the same document:

Thus, it is better to use only those terms that are absolutely necessary to find the right patients, or to use a Term Bundle and set the color of the terms more strategically, such as:

In this case, the above query will look for documents that contain heart AND either chest pain or chest tightness, but chest pain and chest tightness do not have to both be present, only one of them.

When in the Highlight Documents mode, EMERSE will provide results including:

The Highlight Documents mode is simpler than the Find Patients mode. This is because all terms are treated as being separated by the OR operator, regardless of the color in which the terms are highlighted (unless otherwise specified using actual Boolean operators with the Advanced Terms). The general idea is that since the patients of interest have already been identified, the goal with Highlight Documents is to simply highlight any terms of interest anywhere in the documents to support a rapid, efficient chart review process. As a result, there is no harm in including additional terms even if they are not present anywhere in the documents, since their absensce will not affect the highlighting of the other terms.

In general, no specific search strategies are needed when searching in the Highlight Documents mode. Even so, it may still be advantageous to use a Term Bundle to group terms with similar meaning by the same color to aid in more rapid chart reviews. In other words, if you are searching for a list of narcotic medications and the resulting constipation that they might cause, it may be useful to set all of the narcotic medications to be green, all of the constipation terms to be orange, and all of the stool softeners/laxatives to be purple. Then, someone reviewing the charts would only have to recognize one of three colors to know what kind of concept was being highlighted.

This is described elsewhere, but it is extremely important to understand the differences between the two search modes, Find Patients and Highlight Documents. The way EMERSE works differs depending on which search mode is being used, and therefore this difference must be understood to ensure effective search results.

EMERSE can provide a lot of suggestions for additional terms through the Synoyms feature. Use this to expand your search to cover more possibilities for how something was worded or phrased in the notes. Also be careful because EMERSE is a very literal search engine. If you want to look for antibiotics and that is what you type in, the system will look for the word antibiotics only. If what you really meant was to find any instance of any antibiotic mentioned in the notes, then you will have to include all of the possible terms for these, and there may be hundreds of them (e.g., cephalexin, Keflex, Ancef, Ciprodex, amoxicillin, etc). The Synonyms feature can certainly help expand the breadth of the query terms, but it may not be complete.

While the Synonyms can be very useful and powerful, be careful about what Synonym suggestions you add. EMERSE has the potential to provide a very large list of options, but adding too many terms could slow things down without providing much benefit. And, for ambiguous terms, you might inadvertently include concepts you don’t even want. For example, if you are searching for synonyms of MI because you want to look for terms related to myocardial infarction, EMERSE will also suggest terms like Michigan since that is also a different meaning of MI.

Similar to trying multiple variations, be careful about how specific the query is. For example, if you enter "metastatic breast cancer", then the system will look for that specific phrase. It might be better to look for the phrase metastatic and the phrase "breast cancer" separately, so that you have a greater chance of finding other variations such as:

Note, however, that sometimes breaking up the query can lead to false positives if, for example there was text such as:

Another approach for 'separating' the terms is to use the Proximity Search feature within the Advanced Terms section. This will allow you to search for two terms within a specified number of words from each other. For example, suppose you were looking for "sublingual nitroglycerin". A logical alternative phrase would also be "nitroglycerin sublingually". But if the phrase in the clinical note is actually "nitroglycerin was given sublingually" then the simpler, shorter phrase would miss it. Including a Proximity Search parameter like "nitroglycerin sublingually"~5 would capture the longer phrase, since it will look for the words nitroglycerin and sublingually within 5 words of each other. Example:

Search Term: "nitroglycerin sublingually"

Search Term: "nitroglycerin sublingually"~5

But similar to the prior example with breast cancer and metastatic, there are risks of false positives when the terms are more separated. There will likely be a tradeoff between how far apart you may allow the terms to be, and how likely there may be a false positive as a result. With a proximity distance set too small, you may also miss some terms, resulting in false negatives. Example:

Search Term: "nitroglycerin sublingually"~5

A concept that you’re looking for may be implicitly described but not explicitly stated. An example of this would be looking for the concept of metastatic as it relates to breast cancer. If the phrase is…​

…​this implies that the cancer was metastatic even though the term metastatic or its variants (metastasized, mets, etc.) was not explicitly mentioned. EMERSE, being a simple tool, is not able to interpret that phrase as being an example of a metastatic breast cancer.

Another example:

This is an example of an asymptomatic rash, even though neither of those two words (neither asymptomatic nor rash) appears in the sentence above. This can happen often, so it is important to be careful of what might be missed when only searching for specific phrases or concepts.

There are hundreds of terms that are used in the clinical notes that are ambiguous—​that is, it is hard to know what a term represents without understanding the context in which it appears, and some terms/abbreviations may have been completely made up locally by a single clinician or a small group of clinicians.

For example, diffs might mean differentials, or differences, or difficulties or even be a part of an abbreviation for Clostridium difficiles (C diffs).

Other common ambiguous abbreviations include CA which can mean cancer, calcium, or California, and MG could mean milligrams, myasthenia gravis, or magnesium.

Even terms that one might think are straightforward might not be. For example, imagine you are interested in exploring milk consumption to assess dairy intake, so you search for milk. Be careful because there can be terms like almond milk, carob milk, soy milk, rice milk, and others which are clearly not the right kind of milk. This is why reviewing the results carefully is very important.

You may be tempted to use the most standard, common phrasing for a particular concept, but it is best to consider all of the ways in which something might be phrased. Clinicians will sometimes even make up new terms. For example, scaphotrapeziotrapezoidal may be the official spelling, but clinicians have also used terms such as scaphotrapeziumtrapezoid, scapho-trapezoid-trapezium, and scaphoid-trapezium-trapezoidal. Clinical note creators also add hyphens or spaces (these are equivalent in EMERSE) into words where they might not be expected, as can be seen in the above examples, or even simple words like ham burger or yester-day. The system-suggested Synonyms can help capture this variability lot, but they may not be enough to cover all of the possibilities forwhat is mentioned in the notes.

Remember that the people who create clinical notes often have a difficult time spelling medical words, they make errors when they type, automated transcription systems can "hear" the wrong word, etc. For example, beast mass and prostrate cancer are phrases that contain correctly spelled words, but they are not the right words. In fact, many such word substitutions of correctly spelled (but incorrectly used) words appear. Often these are homonyms, but not always. Think carefully about how someone (or a computer) might hear a word and insert the wrong word. If you’re looking for people with a hoarse voice, be sure to search for horse voice because it’s almost guaranteed that someone will have used the wrong word at least once.

Following is a table containing examples of such word substitutions that have been found int he medical record. It is by no means complete.

This has already been described in the section on Terms, but it is worth pointing out again. EMERSE ignores multiple characters such as ! ? . > < + - #. This means that some searches will not work. For example: BRCA1- will be interpreted by EMERSE as simply BRCA1, which means that although you can still search for BRCA1 you cannot distinguish between BRCA1- and BRCA1+. (If the phrase is "BRCA1 negative", or a similar variation, then EMERSE will be able to find the concept. Similarly, "150 pounds" when written as "150 #" or 150 # will simply be interpreted as 150 and a blood pressure written in the form of 120/90 will be interpreted the same as 120 90, meaning that you cannot use the slash symbol (/) as a way to look for a pattern that appears to be a blood pressure.

A search engine like EMERSE is great for finding concepts quickly, but it does not have any understanding of what it found, or the context in which a term was found. That is why it is important to carefully review the results for accuracy. Even in cases where you might think no error is possible, it just might be possible. The following is a real example of what was found in a clinical note:

Similarly, terms like ular could represent a misspelling of the word ulnar or part of a word that had an inadvertent space such as ventric ular or fib ular.

Another example:

As a general rule of thumb, if you have found what you were looking for, and have verified that it is truly the correct concept then consider that to be a success. If you haven’t found what you were looking for, the concept may not be there at all, or it may be that you just haven’t figure out the unusual, or incorrect, way in which a term or concept was phrased.

If possible, talk to someone who has clinical expertise in the area for which you are conducting your searches. They might be able to provide guidance about how certain concepts are likely to be phrased in the clinical notes.

Queries that are too long or specific will generally not work well. For example, if you are looking for a positive depression screen based on a PHQ-9 test, do not search for "positive depression screen based on a PHQ-9 test". Instead it might be better to search for PHQ-9 since that alone will help narrow down the results because it is already very specific. This could perhaps be combined with terms such as positive to help narrow down the results.

With more general terms you may need to add more terms to help narrow the results. For example, if you are looking for type 1 diabetes and you just search for the word diabetes you will end up with far too many irrelevant hits because you will most likely be finding diabetes related to type 2 diabetes since it is much more common.

In other words, you will need to come up with a rational strategy for how to construct your search queries with search terms, and this will usually be very customized to your specific task.

Indeed, there may be times when using longer and more specific phrases can be useful. An example of this might be to look for wording used in a specific note template or report template, which can be useful when trying to identify specific notes needed for data abstraction. In such a situation, the specific text surround a concept of interest may be needed to narrow down the results to the desired one. The example below identifies very specific language used in a test result reported by the Mayo Clinic Medical Laboratories. Searching for this very specific language, which does not appear to vary between reports, helps to identify the actual lab report and not the mention of HIV-1 elsewhere in the notes.

Sometimes it may not be an effective strategy to find your patients of interest with a single query. It may require several queries. For example, you may want to first identify your patient population using the Find Patients search mode just by searching for a rare disease. Once you have identified those potential patients, you can move them to a Patient List and then search them for more details (for medications, side effects, etc.) in a subsequent query using the Highlight Documents search mode.

Another example: Imagine you want to find a set of patients who have fibromyalgia and back pain but your query with the Find Patients mode returns almost none. This may be because with Find Patients the system is looking for documents that have the terms fibromyalgia and back pain in the same document. But what if the patients have these terms mentioned in different documents? One solution, among several, would be to first conduct a search for fibromyalgia using Find Patients and then saving the result as a Saved Patient List. Then conduct another, separate search for back pain using Find Patients, and saving this result as a Saved Patient List. Then, use the Merge Patients feature and select the patients that belong to both lists. The resulting set of patients would be ones that contain the terms fibromyalgia and back pain, but not necessarily within the same document. This smaller subset of patients could then be saved as a new list and searched further using the Highlight Documents feature.

EMERSE was designed to work with unstructured, free text data. These clinical documents can be extremely valuable for finding the needed information, much of which might not be present anywhere else in the medical record. However, there are times when using structured data makes sense. For example, if you want to find all patients with a hemoglobin less than 6, you can’t type that into EMERSE and expect to get any sensibile results. It would be better to use a separate system designed for structured data (e.g., DataDirect at the University of Michigan, or the widely used i2b2 Workbench). It may also make sense to use structured data such as ICD-9 or ICD-10 billing codes as a first pass attempt to narrow down a patient cohort, and then search that subset of patients within EMERSE to do additional verifications within the clinical notes.

A patient list generated from a different system can be imported into EMERSE, or one can simply copy and paste a column of medical record numbers from an Excel sheet containing a list of patients generated in a different system. EMERSE also provides the technical capabilities for importing a list directly from another software system, but this functionality will depend on how it has been locally installed, configured, and connected to other systems.

It is best to think of EMERSE as being one tool among many in a toolbox of useful software to support your work. It is unlikely that any single tool will enable you to complete your task, but using multiple tools together will help you efficiently get your work done.

While this may not often be possible, if you have any control over how data are initially entered into the electronic health record, you can use strategies to help identify the note or concept later when searching. One example is to use standardized phrases that can be used in search later on that will positively identify only the notes of interest. Also, using more standardized language helps with ensuring that no unusual variations in wording are missed with the search.

Give thought to how you might want to identify and abstract data later on. It may be useful, for example, to include a unique "note identifier" in a note template, so that searching for just that identifier will identify all of the notes of interest. You can use something distinctive like stntv25; it can even be simple phrases like Strep throat note template version 2.5, as long as it is unique to that set of notes.

Sometimes it helps to think 'outside the box' when conducting searches. For example, you may be interested in identifying patients based on structured ICD-10 codes. If your clinical notes contain such codes within the text of the document, they can be searched just like searching for any other word or phrase. If you’re interested in finding Ehlers-Danlos syndrome, which has an ICD-10 code of Q79.6, just search for that term and it will find any mention of that code in the notes. The main thing that you cannot do, as already mentioned above, is search for numeric data using comparitors such as greater than (>), less than (<) or equal to (=).

Or your access has been revoked. EMERSE contains patient data, so it is not the kind of system you can just log onto without someone providing an account. Talk to your system administrators if you think that is the issue.

If you can’t even see the login page (because the page is not found), this may be the reason you’re having trouble. In general, EMERSE will be available on a secured network available only to individuals on that internal, trusted network. There may be ways to get to this network from the outside using virtual private network (VPN) software. This is an issue to bring up to your local IT support teams.