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Validating free-text order entry for a note-centric EHR

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Abstract

Electronic Health Records (EHRs) have increased the utility and portability of health information by storing it in structured formats. However, EHRs separate this structured data from the rich, free-text descriptions of clinical notes. The ultimate objective of our research is to develop an interactive progress note that unifies entry, access, and retrieval of structured and unstructured health information. In this study we present the design and subsequent testing with eight clinicians of a core element of this envisioned note: free-text order entry. Clinicians saw this new order-entry paradigm as a way to save time and preserve data quality by reducing double-documentation. However, they wanted the prototype to recognize more diverse types of shorthand and apply default values to fields that remain fairly constant across orders, such as number of refills and pickup location. Future work will test more complex orders, such as cascading orders, with a broader range of clinicians.
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... Vendors of electronic health record systems have advocated the use of automation to facilitate record-keeping by use of structured data formats. [36][37][38] Natural language processing can be used to dissect patient-doctor conversations and create notes. 39 How to ensure the validity and reliability of such systems has been the subject of much research and remains a controversial topic. ...
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... Studies suggest workload caused by clinical documentation is an important barrier to effective patient care [12]. Using existing technologies, vendors of electronic health record systems and researchers have long looked for ways to facilitate the process by pulling in structured data/format into doctor's note to reduce duplicate work [13]. Recently some researchers have advocated for the application of AI systems to streamline and automate documentation tasks in healthcare [3,4], for example, by using natural language processing to dissect patient-doctor conversation and create notes [14]. ...
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Clinicians' perceptions of usability of eNote
  • J P Haas
  • S Bakken
  • T J Bright
  • G B Melton
  • P Stetson
  • S B Johnson
Haas JP, Bakken S, Bright TJ, Melton GB, Stetson P, Johnson SB. Clinicians' perceptions of usability of eNote. AMIA Annual Symposium Proceedings. American Medical Informatics Association; 2005. p. 973.