The woes of clinical documentation: 40 books a year and counting

I just started reading a 400-page book about the Battle of Spotsylvania Courthouse that took place during the Civil War. As I was talking with a colleague, he told me that physicians produce 7.2 million words of clinical documentation a year – that’s enough to fill the pages of 40 of my history books. It’s time for better tools that help make their lives a little easier.
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Trying to capture the patient's story, doctors create enough clinical documentation each year to fill the pages of 40 of the 400-page books I’m reading

One of my many jobs is to serve as the family historian-keeper of the family tree.  When I discovered that my great-great-grandfather was killed in the Battle of Spotsylvania Courthouse during the Civil War, I started to research it. I am currently reading a 400-page book about this battle. Then I found out today from some recent cloud-based speech recognition data that a busy doctor will produce enough clinical documentation to fill the pages of 40 such books each year, the equivalent of 7.2 million words. And I know that these documents are even less exciting to read than books about obscure Civil War battles.

As a physician, I am now pondering a difficult question-how can I produce this volume of EMR documents while doing all the other tasks involved in taking care of patients, and what can I do to make them more readable for other caregivers?

There is no single, easy answer to this problem, but there are several things that can help. Today’s doctors are on the move more than ever, and they need technology that keeps up. There is a need for quicker and easier access to a note creation tool during all parts of the clinical workflow. Tools like single sign-on and medical speech recognition support this, especially as doctors move to different sites and work with different systems. A secure medical cloud platform that safeguards physicians who are using mobile devices for note creation and smartphones as microphones for dictating physician documentation will help, too.

There’s also a need for better control of the EMR and help comes from voice navigation, floating dictation boxes that allow the note to be created while a physician is in different parts of the patient record, and clinical language understanding (CLU) for fact extraction to remove the burden of entering data into fields.  And finally, all this information needs to be presented in a way that makes it easier for other caregivers to understand, incorporating things like templates that put a narrative “up front” while providing the needed factual data in a separate part of the note.

Now, going back to my story. Great-great-grandfather Francis wrote a brief note to his family. It was cold and rainy, he was sleeping in mud, many men were sick, and his company was expected to charge uphill the next day against a Confederate fortification. To write the note required paper; he needed a pencil that he sharpened with his knife, the company messenger had to carry the note to the brigade headquarters to be mailed. In my opinion, he could have been helped by better tools to produce and transmit the note; it wasn’t the note’s contents that needed help. Hopefully we can help doctors produce notes and allow them to create good content (telling the patient’s story) on their own.

New data: Doctors on the move need tech that keeps up

Inundated with endless clinical documentation, doctors are searching for cloud-based dictation solutions that work for them even while on the go. This infographic tells their story.

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Dr. Reid Coleman

About Dr. Reid Coleman

As the Chief Medical Information Officer for evidence-based medicine, Reid works to improve both the quality and safety of healthcare by implementing information technology solutions in the clinical setting. He is currently investigating the use of natural language processing (NLP) of big data sets to enhance evidence-based knowledge and clinical-decision support. Before joining Nuance, Reid practiced internal medicine on a full-time basis for 20 years. In 1998, he became medical director for a physician-hospital joint venture, and in 2001 became medical director for informatics at Lifespan, a four hospital, 1,150 bed integrated delivery system in Providence, Rhode Island. In 2010, he was ranked by Modern Healthcare Magazine as one of the “Top 25 Medical Informaticists in the U.S.,” and the following year received the Beckwith Family Award for Outstanding Teaching at Brown. Reid attended the Alpert Medical School at Brown University, where he also currently serves as an Associate Professor of Clinical Medicine. Reid moved to the Providence RI area with plans to stay for four years of college. He is still there today due to the influence of a woman, who has been his wife for the last 35 years.