Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm.
Jackson Steinkamp1, Jacob Kantrowitz2, Abhinav Sharma3
1Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.
Journal of Medical Internet Research
|April 20, 2021
Summary
This viewpoint proposes organizing electronic medical notes by topic, not time, to improve clinician efficiency. This collaborative framework enhances patient assessment and data retrieval, boosting healthcare delivery.
Area of Science:
- Health Informatics
- Clinical Workflow Optimization
- Medical Documentation Systems
Background:
- Clinicians dedicate significant time to reviewing and writing electronic medical notes.
- Current electronic medical note organization is suboptimal for individual clinicians and medical teams.
- Existing frameworks often hinder efficient data access and patient assessment.
Purpose of the Study:
- To propose a reconceptualization of the electronic medical record (EMR) structure.
- To advocate for a topic-based, collaborative workspace over traditional time- or writer-based organization.
- To highlight the potential for improved healthcare delivery effectiveness and efficiency.
Main Methods:
- This viewpoint discusses a paradigm shift in EMR organization.
- It proposes organizing the medical chart (notes, labs, imaging) as a dynamic, collaborative workspace.
- The proposed framework prioritizes topic-based organization over chronological or author-based structures.
Main Results:
- The topic-based framework facilitates more accurate and complete patient state assessments.
- It enables easier and faster historical data review.
- Clinicians can achieve substantial time savings in both data input and retrieval.
Conclusions:
- Reorganizing electronic medical notes by topic offers significant advantages over current systems.
- This approach enhances clinical efficiency and reduces time spent on documentation and data retrieval.
- The proposed collaborative workspace has the potential to improve overall healthcare delivery.
Keywords:
clinicianselectronic medical noteselectronic medical recordshealth informaticsinformation chaosmedical documentationmedical notesmedical teamMore Related Videos
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