Opportunities for and challenges of computerisation

Powsner, Seth M.; Wyatt, Jeremy C.; Wright, Patricia

doi:10.1016/s0140-6736(98)08309-3

Cited by 102 publications

(59 citation statements)

References 24 publications

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“…Reviewing the few studies that look at the expressivity of CBD systems compared to natural language notes, Rosenbloom et al report that prose can be more accurate, reliable, and understandable [12]. Powsner, Wyatt, and Wright refer to structured data as freezing clinical language and restricting what may be said [13]. Much of medical language is nuanced and makes heavy use of negation, temporal expressions, and hedging phrases.…”

Section: Analyzing the Text Of The Ehrmentioning

confidence: 99%

Language, Structure, and Reuse in the Electronic Health Record

Roberts

2017

AMA Journal of Ethics

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Medical language is at the heart of the electronic health record (EHR), with up to 70 percent of the information in that record being recorded in the natural language, free-text portion. In moving from paper medical records to EHRs, we have opened up opportunities for the reuse of this clinical information through automated search and analysis. Natural language, however, is challenging for computational methods. This paper examines the tension between the nuanced, qualitative nature of medical language and the logical, structured nature of computation as well as the way in which these have interacted with each other through the medium of the EHR. The paper also examines the potential for the computational analysis of natural language to overcome this tension. IntroductionThe past few decades have seen a shift away from paper-based medical records towards computerized electronic health records (EHRs). Whereas paper-based records had their roots in a largely textual representation, the digital nature of computers lends itself more readily to the structuring and organization of data. The shift to the EHR has therefore been accompanied by a pressure on clinicians to record patient information in a structured way by choosing options such as diagnosis, medications, and symptoms from lists and completing onscreen forms. Structured information is computationally tractable, unlike the natural language of the textual portion of the record. Structured information, it is argued, can be reused to support research, audit, and the clinical process [1].

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Section: Analyzing the Text Of The Ehrmentioning

confidence: 99%

Language, Structure, and Reuse in the Electronic Health Record

Roberts

2017

AMA Journal of Ethics

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“…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).…”

Section: Clinical Documentation Practicesmentioning

confidence: 99%

“…They find it timeconsuming and error prone to input data by clicking radio buttons, selecting clinical concepts from pop-up menus, or searching long lists of controlled vocabularies for the right term to use (Powsner et al, 1998;Walsh, 2004;Khorana, 2010;Lewis, 2011). A recent policy paper from the American College of Physicians summarizes the criticism in the following way:…”

Section: 'Structured Data' Versus Clinical Narrativesmentioning

confidence: 99%

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

Bansler

Havn

Schmidt

et al. 2016

Comput Supported Coop Work

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Abstract. We examine an important part of the medical record that has not been studied extensively: physicians' clinical notes. These notes constitute an explanatory medical narrative that documents the patient's illness trajectory by combining each physician's notes into a common text. Although several prior CSCW studies have addressed the role of the medical record in patient care, they have not dealt specifically with the role, structure, and content of these notes. In this article, we present a detailed analysis of a set of physicians' clinical notes recording the acute hospitalization and subsequent treatment of a patient with chronic heart disease. We show that clinical notes are highly structured and conventionalized texts that promote conciseness while at the same time allowing physicians to express themselves in a precise and nuanced way. Based on this analysis, we argue that physicians' clinical notes form the core of the medical record. They serve both as a 'tool for thinking' for the individual physician, enabling him or her to make sense of the patient's past history and current condition, and as a coordinative artifact used by physicians, nurses, and other health care professionals. We conclude by discussing the implications of this research for the design of Electronic Medical Record (EMR) systems.

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“…The rationale for these investments stems from numerous concerns of quality and safety related to paper-based systems, which include problems with legibility, access limited to a single provider at a single location, difficulties with aggregating information from multiple records, and problems maintaining confidentiality of records and accurate backup copies. 7 Comprehensive, well-implemented electronic health records with advanced clinical decision support interventions have potential to reduce errors with medications 8 and to increase the quality, efficiency and reliability of information transfer. 9,10 Despite progress in the use of electronic health records, 11 their adoption has resulted in larger than expected challenges in day-to-day clinical processes.…”

mentioning

confidence: 99%

“…For example, problem-oriented summaries that integrate data from different sources on one screen could potentially facilitate better information processing and exert a lower cognitive load. 7 Clinicians conversely have the responsibility to maintain accurate, up-to-date problem lists using a controlled clinical terminology (e.g., SNOMED CT [Systematized Nomenclature of Medicine -Clinical Terms]) and link them with corresponding diagnostic and treatment elements through the electronic system to prevent "incomplete care. "…”

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confidence: 99%

Rights and responsibilities of users of electronic health records

Sittig

Singh

2012

CMAJ

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Analysis CMAJ• Despite the potential benefits of electronic health records, clinicians have experienced several challenges in their adoption and use.• To encourage debate on strategies to overcome these challenges, we developed a set of 10 "rights" of clinicians that represent important features, functions and user privileges of electronic health records that clinicians need to provide safe, high-quality care.• Each right is accompanied by a corresponding responsibility of clinicians, without which the ultimate goal of improving quality of health care might not be achieved.

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Opportunities for and challenges of computerisation

Cited by 102 publications

References 24 publications

Language, Structure, and Reuse in the Electronic Health Record

Language, Structure, and Reuse in the Electronic Health Record

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

Rights and responsibilities of users of electronic health records

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