“Fifty years ago, in his 2-part landmark paper on the problem-oriented medical record, Larry Weed recommended reorienting physicians away from documentation tasks to allow them to focus on cognitive tasks. His work led to a revolution in how medical records are written but the cognitive aspect received less emphasis. With today’s pressures for increasing patient care throughput and decreasing work hours for house staff, documentation of clinical reasoning in narrative text is a lower priority and formal representation is practically nonexistent.
Consider, for example, if a clinician’s differential diagnosis was recorded in the same manner as a problem list, with each item enumerated and captured with a controlled terminology. It would then be possible for a decision support system to identify what might be removed from the list (based on evidence in the record), suggest additional conditions that may have been overlooked (based on evidence in a knowledge base), and provide the best evidence for diagnostic strategies. Similarly, when the goal is made explicit (e.g., anticoagulation for a specific indication), appropriate knowledge resources can be brought to bear for “just in time” decision support and an appropriate, comprehensive set of interventions can be ordered automatically. In addition, because the differential diagnosis and goals are structured, the EHR can detect when they are missing and assist with their inclusion. The addition of “why” in the EHR will mean that the data we collect can be used to make our medicine more personalized and, thus, more precise. These new data will also better inform a “learning health care system.”
Simply admonishing clinicians to write better notes and require additional, redundant data entry into some new documentation feature, however, is unlikely to succeed. Instead, our EHRs need to move away from being “billing diaries” and evolve into next-generation smart systems that actively participate in the management of the patient. In such a system, the clinicians would provide not only their orders, but also their reasoning in actionable form. The effort required for this new type of documentation would be offset by eliminating the need for writing the redundant, bloated, low-information clinical notes that plague us today, reducing the order entry workload through anticipatory work plans, and decreasing the fatigue caused by false-positive alerts.”