Policy Recommendations for EHR System Design to Support 21st-Century Clinical Documentation
The EHR should remain the domain of the clinicians and not be manipulated to serve the needs of multiple stakeholders with varying objectives in their content and output. The Medical Informatics Committee of the ACP has developed this review of clinical documentation processes to suggest a better outcome to help capture the burgeoning data sources that will become relevant to patient care in the years to come.
Observe, record, tabulate, communicate.--Sir William Osler
Communication was the primary goal of early patient records. A clear and concise record of patient presentation, diagnoses, and treatment to be consulted by any member of the care team either at the present or future but beginning in the early 1900s the data capture became formalized. Template standardization and structure forms replaced the more narrative prose in communicating clinical findings and decisions regarding care.
Patient centricity and the need for real world evidence to inform point of care clinical decisions will also challenge data collection and integration into EHR systems. As information becomes bi-directional systems will need to regulate and control the provenance of data sources and privacy concerns of transmission and evaluation of patient-related data. The opportunities to engage the business needs around this enterprise are not trivial. I believe that there will be a return of the narrative and unique voice of the clinician perspective as guidance into the capture and utility of structured and unstructured data.
Future blogs will address how this evolution can be managed both at the patient level and for the entire care pathway for a variety of therapeutic needs. You can send any questions or comments to firstname.lastname@example.org
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In a world of "evidence-based" medicine I am a bigger fan of practice-based evidence.
Remember the quote by Upton Sinclair...
“It is difficult to get a man to understand something, when his salary depends upon his not understanding it!”
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