SummaryIn 2013, electronic documentation of clinical care stands at a crossroads. The benefits of creating digital notes are at risk of being overwhelmed by the inclusion of easily importable detail. Providers are the primary authors of encounters with patients. We must document clearly our understanding of patients and our communication with them and our colleagues. We want to document efficiently to meet without exceeding documentation guidelines. We copy and paste documentation, because it not only simplifies the documentation process generally, but also supports meeting coding and regulatory requirements specifically. Since the primary goal of our profession is to spend as much time as possible listening to, understanding and helping patients, clinicians need information technology to make electronic documentation easier, not harder. At the same time, there should be reasonable restrictions on the use of copy and paste to limit the growing challenge of ‘note bloat’. We must find the right balance between ease of use and thoughtless documentation. The guiding principles in this document may be used to launch an interdisciplinary dialogue that promotes useful and necessary documentation that best facilitates efficient information capture and effective display.
Citation: Shoolin J, Ozeran L, Hamann C, Bria W. II. Association of Medical Directors of Information Systems Consensus on Inpatient Electronic Health Record Documentation. Appl Clin Inf 2013; 4: 293–303http://dx.doi.org/10.4338/ACI-2013-02-R-0012
Background The pace of technological change dwarfs the pace of social and policy change. This mismatch allows for individual harm from lack of recognition of changes in societal context. The value of privacy has not kept pace with changes in technology over time; individuals seem to discount how loss of privacy can lead to directed personal harm.
Objective The authors examined individuals sharing personal data with mobile health applications (mHealth apps) and compared the current digital context to the historical context of harm. The authors make recommendations to informatics professionals to support consumers who wish to use mHealth apps in a manner that balances convenience with personal privacy to reduce the risk of harm.
Methods A literature search focused by a historical perspective of risk of harm was performed throughout the development of this paper. Two case studies highlight questions a consumer might ask to assess the risk of harm posed by mobile health applications.
Results A historical review provides the context for the collective human experience of harm. We then encapsulate current perceptions and views of privacy and list potential risks created by insufficient attention to privacy management.
Discussion The results provide a historical context for individuals to view the risk of harm and shed light on potential emotional, reputational, economic, and physical harms that can result from naïve use of mHealth apps. We formulate implications for clinical informaticists.
Conclusion Concepts of both harm and privacy have changed substantially over the past 20 years. Technology provides methods to invade privacy and cause harm unimaginable a few decades ago. Only recently have the consequences become clearer. The current regulatory framework is extremely limited. Given the risks of harm and limited awareness, we call upon informatics professionals to support more privacy education and protections and increase mHealth transparency about data usage.
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