Docs to walk data tightrope

July 1, 2013 in Medical Technology

Healthcare, which has always been based on the doctor-patient interaction, is nearing the end of Stage 1 meaningful use, and as the industry increases its reliance on electronic health records, it faces a new challenge.

That conundrum, says Nick van Terheyden, MD, and CMIO at Nuance Communications, is how to reconcile the need for standardized structured data capture with the importance of narrative in patient-doctor interactions.

“When a patient walks into the office…they want the attention of the clinician and unfortunately what the process of data entry and data capture has done is defocus that interaction,” van Terheyden told Healthcare IT News.

The start of meaningful use Stage 2 for many organizations in 2014 will usher the implementation of more rigorous standards for data capture, as well as new rules for using EHRs to collect a wider array of structured data, including demographic information, encounter diagnosis, medications and medication allergies, and lab results.

Documenting data in a structured format to meet the standards for meaningful use Stage 2 will be important for allowing physicians to capture detailed and accurate information on their patients, but also for maintaining that detail and accuracy when moving patient data to other settings. This means that when patients have to move from provider to provider within the healthcare system, they can do so without having to input their information repeatedly whenever they enter a new clinical setting. The idea is to provide better and more efficient care.

[See also: Beacons put data to work on pop health.]

However, physicians are used to taking their own free-text notes from patient interactions, and it has been their preferred mode of data capture for a long time.

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