JMIR Publications

ABSTRACT

Background:

Clinicians spend large amounts of their workday using electronic medical records (EMRs). Poorly designed documentation systems contribute to the proliferation of out-of-date information, increased time spent in the medical record, clinician burnout, and medical error. Beyond simple software interfaces, examining assumptions about the underlying paradigms and organizational structures for clinical information may provide insights about ways to improve documentation systems. In particular, our attachment to the “note” as the major organizational unit for storing unstructured medical data may be a cause of many of the problems with modern clinical documentation. Notes, as currently understood, systematically incentivize information duplication and information scattering, both 1) within a single clinician’s notes over time, and 2) across multiple clinicians’ notes. It is therefore worthwhile to explore alternative paradigms for unstructured data organization.

Objective:

To demonstrate the feasibility of building an EMR which does not use “notes” as the core organizational unit for unstructured data, designed specifically to disincentivize information duplication and information scattering.

Methods:

We used specific design principles to minimize the incentive for users to duplicate and scatter information. 1) By default, the majority of a patient’s medical history remains the same over time, so users should not have to redocument that information. 2) Clinicians on different teams or services mostly share the same medical information, so all data should be collaboratively shared across teams and services (while still allowing for disagreement and nuance). 3) In all cases where a clinician must state that information has remained the same, they should be able to attest to the information without redocumenting it. We designed and built a web-based EMR based on these design principles.

Results:

We built a medical documentation system which does not use notes, instead treating the chart as a single, dynamically-updating, fully-collaborative workspace. All information is organized by clinical topic or problem. Version history functionality is used to enable granular tracking of changes over time. Our system is highly customizable to individual workflows and enables each individual user to decide what is “structured data” and what is “unstructured data”, enabling individuals to leverage the advantages of structured templating and clinical decision support as desired without requiring programming knowledge. The system is designed to facilitate real-time, fully collaborative documentation and communication between multiple clinicians.

Conclusions:

We demonstrate the feasibility of building a non-note based, fully-collaborative EMR system. Our attachment to the “note” as the only possible atomic unit of unstructured medical data should be re-evaluated, and alternative models should be considered.