Role for Electronic Documentation |
Goals and Features of Redesigned Systems |
Providing access to information
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Ensure ease speed and selectivity of information searches and cognition through aggregation trending contextual relevance and minimizing of superfluous data |
Recording and sharing assessments
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Provide a space for recording thoughtful succinct Assessments, differential diagnoses, contingencies and unanswered questions facilitate sharing and review of assessments by both patient and other clinicians |
Maintaining dynamic patient history
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Carry forward information for recall, avoiding repetitive patient querying and recording
while minimizing copying and pasting |
Maintaining problem lists
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Ensure that problem lists are integrated into workflow to allow for continuous updating |
Tracking medications
|
Record medications patient is actually taking patient responses to medications and
adverse effects to avert misdiagnoses and ensure timely recognition of medication
problems |
Tracking tests |
Integrate management of diagnostic test results into note workflow to facilitate review,
assessment, and responsive action as well as documentation of these steps |
Ensuring coordination and continuity
|
Aggregate and integrate data from all care episodes and fragmented encounters to permit thoughtful synthesis |
Enabling follow up
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Facilitate patient education about potential red flag symptoms track follow up
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Providing feedback
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Automatically provide feedback to clinicians upstream facilitating learning from out
comes of diagnostic decisions |
Providing prompts
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Provide checklists to minimize reliance on memory and directed questioning to help in
diagnostic thoroughness and problem solving |
Providing placeholder for resumption
of work
|
Delineate clearly in the record where clinician should resume work after interruption
preventing lapses in data collection and thought process |
Calculating Bayesian probabilities
|
Embed calculator into notes to reduce errors and minimize biases in subjective estimation of diagnostic probabilities |
Providing access to information sources
|
Provide instant access to knowledge resources through context specific “infobuttons”
triggered by keywords in notes that link user to relevant textbooks and guidelines |
Offering second opinion or
consultation
|
Integrate immediate online or telephone access to consultants to answer questions related to referral triage, testing strategies or repetitive diagnostic assessments. |
Increasing efficiency |
More thoughtful design, workflow integration, and distribution of documentation bur
den could speed up charting, freeing time for communication and cognition.
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