Data from clinical notes: a perspective on the tension between structure and flexible documentation

Abstract

Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

Cooperative Epistemic Work in Medical Practice: An Analysis of Physicians’ Clinical Notes

“…Medical informatics researchers and hospital managers have for decades been pushing for the inclusion of more 'structured content' in the record (see, e.g., (McDonald, 1997)). Their aim is to eliminate or at least limit physicians' use of so-called 'free text' in the medical record and replace it with codes or 'structured data' which can be reused for secondary purposes such as clinical research, quality assessment, resource allocation, and billing (Rosenbloom et al, 2011). However, structured data entry has met with considerable resistance from clinicians who complain that it is too restrictive, time-consuming, and cumbersome (Powsner et al, 1998;Walsh, 2004;Khorana 2010;Lewis, 2011).…”

“…In other words, as pointed out by Rosenbloom et al (2011), there is an essential 'tension' between the clinicians' needs for concise and nuanced documentation and the needs of those who want to reuse data from the EMR for secondary purposes such as billing and reimbursement, quality assurance, resource planning, and clinical research. Clinicians generally value efficiency, flexibility, and narrative expressivity while those reusing data cherish structure and standardization (Winthereik and Vikkelsø, 2005;Rosenbloom et al 2011).…”

“…As of the 1990s, researchers within the field of medical informatics have been working hard at 'taming' and 'domesticating' physicians' clinical notes (McDonald, 1997, p. 219) by replacing them with codes or 'structured data' (Rosenbloom et al, 2010;Rosenbloom et al, 2011). They have promoted the use of 'structured data entry' where the physician enters data by selecting from a list of predefined medical concepts and typing values into fields (Bleeker et al, 2006;Rosenbloom et al, 2011). The aim being to generate standardized data that can be reused for secondary purposes such as clinical research, quality assessment, decision support, resource allocation, and -last but not least -billing.…”

“…Clinicians generally value efficiency, flexibility, and narrative expressivity while those reusing data cherish structure and standardization (Winthereik and Vikkelsø, 2005;Rosenbloom et al 2011).…”

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults

“…With the increasing use of electronic record systems, the structured but fragmented information that is common in electronic record notes can increase cognitive workload and reduce the quality of communication among those caring for the patient (Cusack et al 2013;Embi et al 2013;Mamykina et al 2012;Rosenbloom et al 2011). A greater emphasis on synthesizing information through documentation may ameliorate some of those difficulties.…”