Clinical Documentation is at the Core of Healthcare Reform

by Dr Nick
Everyone agrees we need codified structured data for problem lists, medication, allergies and labs…….or do they?

John Halmka wrote a piece for HealthcareIT News earlier this month titled “Rethinking Clinical Documentation” in which he asks

what is the role of unstructured clinical documentation text

In many instances there has been an attempt to drive unstructured text out of the electronic medical record and while there is a challenge for computers and technology to understand unstructured text – we humans actually prefer the narrative for absorbing information. As John points out referring to the New England Journal of Medicine article in March this year “Can Electronic Clinical Documentation Help Prevent Diagnostic Errors” (full text here) the authors note:

Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties

I could not agree more and and have referred to the loss of knowledge and the nuanced information in the narrative resulting in the dumbing down of clinical notes and the Henry VIII’s cause of death debate (we still debate this 463 years after he dies) and indeed in recent presentations on the ability to keep the narrative and structured data in harmony in my presentation at AHIMA: “Clinical Narrative and Structured Data in the EHR: Venus and Mars Live in Harmony with CDA4CDT“. The Healthstory project allows for the two worlds to coexist happily providing the value John describes in his article for the clinicians while delivering the structured data essential for the clinical systems today. As John says in his blog

I agree. Notes should be included as part of clinical summaries. However, we should do all we can to improve the quality of notes

He is right the quality of these notes need to improve and while I look forward to hearing more about the Daily Patient Wiki (which has similarities to the “Facebook Medical Record“) I suspect that we need to pay attention to the process of capture of information. While the keyboard, mouse and other tools are useful, they remain inefficient for many. Contrary to popular belief the QWERTY keyboard was not designed to slow typists down rather to prevent jams when typing at speed, but it is not the most efficient layout placing only one vowel on the home row. Solving this challenge remains the major barrier to adoption of clinical systems.

Clinicians will use whatever method is most efficient for them at the time they need it with different methods suiting at different times. We will see Minority Report concepts of visual interaction, traditional but improved screen, keyboard and mouse systems and even touch screen applications. I am willing to bet we will see an application for clinical data capture on the iPad before too long. But the predominant means of data capture today is using voice. Tools that facilitate the capture of voice and the conversion of this into useful clinical knowledge will remain a large component of any successful implementation and will bridge the adoption barriers that plague clinical system implementations.

Do you agree – where is your facility or practice on data capture and the inclusion of the narrative note?

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