Abstract
Clinical documentation can be transformed by Electronic Health Records, yet the documentation process is still a tedious, time-consuming, 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. MedKnowts leverages this structure to enable easier parsing of long notes, auto-populated text, and proactive information retrieval, easing the documentation burden.
Highlights
Electronic Health Records (EHRs) have been adopted in the hope that they would improve quality of care, save time, support collaboration and data sharing, and prevent clinical errors [8, 16, 19, 46]
For approximately 7 months the prototypal deployments were used as the primary documentation tool by 1 physician and 4 scribes across 1185 patients; the evaluation lasted 1 month and was used by the same physician and 4 scribes (2 scribes had participated in the prototypal deployments) across 234 patients
Our prototypal deployment ended after the hospital stopped using scribes in the wake of COVID-19; the second deployment began soon after scribes returned to the hospital
Summary
Electronic Health Records (EHRs) have been adopted in the hope that they would improve quality of care, save time, support collaboration and data sharing, and prevent clinical errors [8, 16, 19, 46]. Because structured and unstructured data can be hard to reconcile, EHRs often store and display information in separate pages or windows, and physicians have to synthesize the patient narrative by navigating across a variety of sources [3, 44]. This creates increased cognitive burden to discover unstructured information, and studies have shown that clinicians spend more time reading past notes than doing any other activity in the EHR [12]. Indiscriminate use of these auxiliary functions causes documentation to become bloated, making it diffcult for clinicians to parse important clinical information, and potentially even propagating errors [24, 43, 53, 57]
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
