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Related Experiment Videos

Putting the "why" in "EHR": capturing and coding clinical cognition.

James J Cimino1

  • 1Informatics Institute, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Journal of the American Medical Informatics Association : JAMIA
|August 14, 2019
PubMed
Summary
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Electronic health records (EHRs) cause clinician burnout and patient safety issues. Structuring EHR data to explain the "why" behind patient care can improve tools and reduce workload.

Area of Science:

  • Health Informatics
  • Clinical Documentation
  • Human-Computer Interaction

Background:

  • Electronic health records (EHRs) frequently generate complaints regarding information overload, note bloat, and alert fatigue.
  • These issues negatively impact patient safety and clinician quality of life, despite ongoing research and industry efforts.

Purpose of the Study:

  • To propose a modification of EHRs to explicitly represent the reasoning behind patient care.
  • To enhance EHRs by incorporating structured information explaining the 'why' of clinical decisions, including relationships between symptoms, findings, diagnoses, treatments, and goals.

Main Methods:

  • Advocating for the formal structuring of clinical information within EHRs.
  • Utilizing controlled vocabularies to represent the explicit rationale of patient care.
Keywords:
artificial intelligenceclinical decision supportelectronic health recordsknowledge representationlearning health system

Related Experiment Videos

  • Identifying the need for informatics research to determine optimal data representation and capture methods.

    • Main Results:

    • Explicitly represented clinical reasoning can facilitate the development of more situation-aware tools for data retrieval and synthesis.
    • Improved data structure can potentially lead to reduced clinician workload.

    Conclusions:

    • Modifying EHRs to include structured clinical reasoning is a potential solution to current system limitations.
    • Further informatics research is crucial to define what information to represent, how to capture it effectively, and how to ensure benefits for clinicians.