Electronic Health Records


Clinical documentation in the EHR

By nheyden@xtelligentmedia.com

“I wish the doctor had spent as much time with me as she did with her PC”

Many years ago, an excited friend who worked for one of the electronic health record (EHR) vendors at that time — it was really more of a billing and patient tracking and management system than an EHR — was desperate to show me some of their latest applications.  In particular, a new module they had developed to capture clinical data.

My friend pulled out his laptop (see here for visual), fired up the application, selected a patient and proceeded to enter blood pressure (BP).  Some 20-plus clicks later, he had entered a BP of 120/80. While he was excited, I was dumbfounded. When it comes to patient care, doctors didn’t have time for 20 clicks to record BP years ago and they definitely don’t have that luxury in today’s demanding medical environment.

I was reminded of this memory in May as it was National High Blood Pressure Education Month.  As part of this annual celebration, participants were asked to create a two-minute video showcasing how they leverage health IT or consumer e-Health tools to manage high blood pressure.  For future insight on the contest, the winning videos can be viewed here.

Key to this challenge was the role technology is playing in allowing patients to take a more active role in the care process, by regularly gathering and sharing personal health data with their physician.  While patients are gaining ground in capturing their own health data, the question remains — are clinicians also making advancements in the way they capture patient data so that they can focus on care v. data-entry?

Today, the burden of walking a fine line between capturing patient data without sacrificing care weighs heavy on clinical staff.  I made this point a number of years ago – Doctor Please Look at Me not Your EMR.  This notion came from a personal experience at our local practice and as my then 10 year-old succinctly put it at the time, “I wish the doctor had spent as much time with me as she did with her PC.”

Still, our ability to preserve patient safety is partially dependent upon capturing the complete patient story and making this information easily accessible via the EHR.  In order to get the best of both worlds, many clinicians are adopting innovative ways to interact with technology — such as speech recognition — in order to simplify clinical documentation; capture both structured and unstructured patient data; and keep patient care priority number one.

There are good reasons that dictation as a means of capturing clinical documentation has been so successful for such a long time — it’s easy to do and above all, it saves time and allows clinicians to focus on patient care.  But the gap between the narrative text created and the clinical data we need to manage our patients widens with each report created.  Today, Natural Language Processing tools (also known as Clinical Language Understanding or CLU in the medical field) are bridging this divide; allowing clinicians to use their preferred method to capture the patient’s clinical information in narrative form and extracting out the discreet data that is essential for EHR systems that need the data to drive decision support tools and workflow processes.

Looking back on my friend’s “advanced” EHR clinical data capture model, it’s inspiring to see how far we’ve come.  Looking forward, it’s exciting to think about how clinical language understanding and other artificial intelligence tools will transform clinical documentation, and more importantly, patient care.

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