Tuesday, July 13, 2010

Keeping Medicines Narrative

Thought critical free-text physician notes are under threat in the current slew of Electronic Medical Records and are at risk of being washed away in the rush towards the digitization of medical records. In Jeff Barry's article in Health Management Technology; "Value of Unstructured patient narrative" he cites examples of
Throwing the patient out with the paper

In fact there has been increasing coverage of the challenge associated with delivering high quality medicine when you drive out the clinical narrative. As one colleague complained to me;
"the narrative is a big part of the value I bring, removing it dumbs down the information"

The challenge is described well in the piece "Mining Clinical Data: Road to Discovery"
For administrators and researchers, who need to extract data to develop reports, they would prefer all clinicians to enter information to the exact same manner, which means time is saved for the administrator, but not for the clinician...it's a trade off of who spends more time and who saves more time

For the busy clinician who currently derives little from the capturing of structured codified data there is little benefit for the extra and often frustratingly challenge extra time required to capture data in this structured form. It's very difficult to get clinicians to enter coded data as opposed to entering patient conditions.

There is a big push demanding structured data that is sweeping over clinicians who are increasingly highlighting the issue and pushing back refusing to become data entry clerks. While some may see this as simple resistance to change it is not just the physician who is loosing information. Patients will find their records relegated to a series of check boxes and lists and while this may provide information it does not cover the full story. The Clinical Narrative must be integrated into the EHR.

In addition to the patient and the clinical team as Jeffrey Barry notes the public health researchers also stand to gain from richer electronic patient narrative. As I frequently cite - Henry VIII medical record remains a shining example of the value of the narrative providing far more detail than could ever have been captured using a rigid form based data entry tool. There are many details available and exposes including this brief review refuting the common view that he died of syphilis

And this posting reviewing possible causes of death comparing to his symptoms and this article in the Journal of History of Medicine: "Henry VIII and Medical Study".
The unstructured free text of the physicians progress notes provide color to the unstructured data's black and white

In a recent case I observed the clinical note captured in free form using speech recognition that allowed the physician to record the information directly into the patents digital record providing immediate access to critical information to everyone on the care team. There was no delay in generating the note and even if it was possible to put this information into a structured form it would have taken far more time than the 1-2 minutes this took to create using speech recognition and since it was generated immediately and included in the EMR it was available to the full clinical team.

But all is not lost and as both articles highlight there are emerging tools that will bridge the divide between the free from narrative and the need to generate structured codified data both for analysis but also driving improvements in quality of care. In the examples provided a post processing by Natural Language Processing (NLP) technology that in a study from 2008 at the Regenstrief Institute and Indiana University School of Medicine where
researchers were able to produce sensitivity, specificity and positive predictive values exceeding 99 percent (detecting Methicillin Resistant Staphylococcus aurerus - MRSA)

That's impressive and already showing value from automating the extracting of information from free form text. There are limitations and the accuracy as variable as the terminology used by clinicians for the same condition but as IBM is showing with Watson the application of NLP in healthcare is rapidly approaching significant exciting new frontiers

Human interaction also is required because of the complexity of language and providing tools and a blended approach to capturing this information will be key to making this work. In this example Rob Stewart demonstrates a variety of ways of capturing structured information in a radiology setting:

There are many ways of approaching the problem and offering multiple choices that make physicians more efficient as they interact with patients will be the key to success and adoption.

Do you have tools or techniques that work well in your setting. What balance have you achieved between the digital need for structured data and the human need for narrative. Let me know - share your experiences or views.