The authors define “structure” as having a predefined or conventional syntactic organization, and “standardized” as complying with a predefined semantic standard. Templates have long been used in CBD systems. The authors define “templates” as note outlines that have empty spaces that prompt users to enter missing information and that contain standard text. The authors categorize these documentation methods below based on the input method they support, the degree to which the notes they produce are created using templates, and whether the notes are structured or standardized.
This simple inclusion requirement allowed documents generated from any header-compliant documentation method to be used for clinical documentation into the EHR system.Ī variety of clinical documentation methods became available to healthcare providers using the EHR system at the VUMC. Document types and subtypes referred to the function the note serves, such as “clinic note” or “discharge summary”. To be included in the expanded EHR system, clinical documents were required only to be formatted to contain a metadata header that included the patient medical record number, name, document type (and subtype, if appropriate), date of clinical service (and time of service, if available), and a globally unique document identifier code. The new program was designed to build upon prior implementation of clinical provider order entry, a simple template-centric CBD system and a relatively more limited EHR system that provided results reviewing primarily for laboratory and radiology testing. In 2000, the Vanderbilt University Medical Center (VUMC) initiated a program to expand its existing EHR system with the goal of incorporating any clinical document into the patient chart regardless of how it was created. Three major goals for integrating clinical documentation in this way were:
The authors’ institution approached the challenge of incorporating clinical documentation into the local EHR system with the belief that healthcare providers should be able to choose from a broad palette of documentation methods, based on clinical workflow, document content standards and usability considerations. McDonald and Ash have demonstrated that structured entry adoption may be hampered by user interface complexity, inflexibility for documenting unforeseen findings, lack of integration with other clinical applications, and deficiencies in the underlying data model. However, structured entry systems typically have not enjoyed long-term or widespread adoption. Many structured entry systems have been developed.
Structured entry systems generally emphasize compliance with data formatting and content requirements, help healthcare providers be thorough and generate categorical data that can be reused for other needs (e.g., research, automatic coding or billing of clinical encounters). While healthcare providers value flexibility and workflow efficiency, many clinical documentation systems described in the biomedical literature place higher value on structuring the data entry to support subsequent machine readability. Because EHR system adoption relates in part to how well such systems support clinical documentation, healthcare providers must consider how their documentation needs align with the capabilities of an electronic health record (EHR) system. The notes that result from clinical documentation are generally intended to produce an objective record of a patient’s history, physical findings, medical reasoning, and patient care to recount the care and procedures that individual patients receive in case of potential future arbitration to justify the level of reimbursement for given services to determine the quality of care provided to patients to provide clinical data for research to apply computerized decision support algorithms and, to allow data mining for real time process improvement and quality monitoring. Creating clinical notes, herein called clinical documentation, consists of a process in which healthcare providers record the observations, impressions, plans and other activities arising from episodes of patient care, and generally occurs with each interaction between patients and the healthcare system. Healthcare providers documenting patient care delivery can use any of a spectrum of different documentation methods, including handwriting on paper, dictating note contents into a recording device from which they can later be transcribed and using any of various computer-based documentation (CBD) systems.
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