We all do! Electronic health records (EHRs) were designed to facilitate workflows, record narrative and capture data. More specifically, to capture discrete data such as machine processable vital signs, laboratory test values, patient demographic information and binary data points such as smoking status.
Initially, everyone saw the benefit of capturing discrete data to support computer processing of EHR information. More recently, stakeholders are coming to understand the value of the narrative found in clinical notes. With this recognition comes the challenge of exchanging that narrative with other providers and with patients. While many systems now include methods of capturing clinical notes, few systems are including them in document exchanges or making them available to patients.
The Value of Clinical Notes
Clinical notes tell the patient’s story. The nuances and details they contain guide the clinician’s medical decision-making as they craft a unique and appropriate care plan. Clinical notes provide vital context and tie together otherwise disparate data points, and most importantly, allow clinicians to record their thought processes and rationale for treatment decisions. Patients with access to their clinical notes realize their physician sees them as a whole person, is listening and is considering their values and preferences when constructing a care plan.
Take for example two stories of women who both went to the emergency room following a fall down their home staircases. Both are 67 years of age, take the same medications for hypertension and diabetes, and have similar lacerations to their face and arms. These facts would be captured in the EHR through templates and check boxes, and the patients would appear to require the same treatment and follow-up. But the narrative would show that while one patient simply tripped over her grandchild’s toy, the other was grieving the loss of her husband and couldn’t recall if she had taken her medications for several days. These important psychosocial factors would be captured in the clinical notes and would explain why the grieving patient was admitted for observation and referred for social services while the other was treated and released.
New Guidance for Exchanging Clinical Notes
The HIMSS Health Story Project’s September Roundtable presentation took a holistic look at the value of clinical notes from the perspective of multiple stakeholders including patients, clinicians and health information exchanges. The panelists offered technical guidance on newly developed templates for encoding clinical notes using Clinical Document Architecture and making them part of the interoperable information available for exchange.
We invite you to listen to their presentation, increase your understanding of the value of narrative and learn about recent specification changes to include these notes in the data sharing standards.
The views and opinions expressed in this blog or by commenters are those of the author and do not necessarily reflect the official policy or position of HIMSS or its affiliates.
HIMSS Health Story Project
The Health Story Project works to educate the health IT community on tools and resources to aid in the creation of comprehensive electronic records that tell a patient's complete health story.