MedKnowts: Unified Documentation and Information Retrieval for Electronic Health Records

Abstract

Clinical documentation can be transformed by Electronic HealthRecords, yet the documentation process is still a tedious, timeconsuming, and error-prone process. Clinicians are faced with multi-faceted requirements and fragmented interfaces for information exploration and documentation. These challenges are only exacerbated in the Emergency Department-clinicians often see 35 patients in one shift, during which they have to synthesize an often previously unknown patient's medical records in order to reach a tailored diagnosis and treatment plan. To better support this information synthesis, clinical documentation tools must enable rapid contextual access to the patient's medical record. MedKnowts is an integrated note-taking editor and information retrieval system which unifies the documentation and search process and provides concise synthesized concept-oriented slices of the patient's medical record. MedKnowts automatically captures structured data while still allowing users the flexibility of natural language. Med-Knowts leverages this structure to enable easier parsing of long notes, auto-populated text, and proactive information retrieval, easing the documentation burden.