Clinical Informatics: The Document Should Drive
The above link is an Interesting video presentation by Kevin Kelly. He really invites us all to think and dream big about the future of the internet. It wont be what we expect. It inspired me to think about the current state of electronic medical records and where it could go.
I like his idea of the new extended self, which now includes all the knowledge accessible on the net. Without access we feel like we are missing something of ourselves. That power of extending myself beyond my physical body is actually what makes us able to use tools and technology so well.
I also like the ideas of teaching search engines to pull data from text, and make it smart. I feel I am most creative when I have a blank document, or even better, a blank piece of paper in front of me. If I can create and keep typing or writing I can get into a flow. If i have to constantly switch from mouse to click then back to my keyboard to type, my flow, my thoughts, and patterns are interrupted. This makes for a difficult to read document with the added negative trait of being slower.
This idea, I believe is going to be what breaks open the field of medical informatics. Physicians are used to thinking and speaking or dictating. They are used to the old form of note writing or order writing which includes a blank piece of progress note paper, or a blank order form. The old records follow a similar format.
Medical programs should PULL the diagnosis and relevant medical history FROM the medical document. Our current format allows a diagnosis to drive a note. I believe the note should actually drive actions. It should automatically develop billing codes, diagnoses, as well as order & fax prescriptions and set up follow appointments.
For example:
1. Hypertension
- well controlled, will refill HCTZ 25mg daily for another year
- recheck BMP in 2 weeks
- follow-up in 6 months
Is all one would need to drive billing, diagnoses, prescriptions, labs, and follow-up for this patient encounter.
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