Save The Clinical Narrative

By Ken Congdon, editor in chief, Health IT Outcomes

Environmental activists often become immersed in movements like "Save The Whales" or "Save The Rainforests." Physicians may want to follow suit and start their own movement called "Save The Clinical Narrative."

The HITECH (The Health Information Technology for Economic and Clinical Health) Act and other government incentives are driving healthcare facilities to install and adopt EHR (electronic health record) systems as a means to standardize and facilitate patient data exchange enterprise-wide and externally. The end goal of streamlining health information exchange is noble and necessary, but there is a potentially grave oversight that can often accompany the adoption of EHR systems - the effective extinction of the clinical narrative. In other words, to use an EHR, physicians are sometimes forced to interact with computer screens and enter data as opposed to focused, straightforward verbal communication. Obviously, physicians are still speaking with their patients, but oftentimes the essence of these conversations is lost in the "copy-and-paste" world of EHRs because the actual clinical narratives are no longer recorded, stored, and included as part of the patient record.

EHR Adoption, Clinical Decision Making Hindered By Narrative Exclusion
The omission of the clinical narrative can cause a few crippling problems for the healthcare industry. First and foremost, it can impede physician adoption of EHRs. According to Dr. Nick van Terheyden, CMIO of clinical language understanding at Nuance Communications, the inability for many EHRs to effectively incorporate clinical narratives have contributed to the dismal rate of adoption of EHR technology to date.

"Physicians have been dictating patient histories for ages," he says. "Speech has always been the preeminent means of capture in healthcare and old habits die hard. Many physicians prefer to interact with patients the same way they always have. They don't want to change their processes to accommodate technology."

Second, the absence of the clinical narrative can also decrease the ongoing value of the patient record and weaken clinical decision making. For example, many EHRs contain repetitive and unnecessary information for patient care. In fact, a patient history recorded by an EHR software package can often balloon to five pages or more even though the actual dictated and transcribed patient history is only two pages long. Physicians can quickly become frustrated searching through pages of boilerplate EHR text and data fields to find the information pertinent to a patient's current condition. In essence, important clinical data often becomes buried in the EHR and other important information from the narrative may never be entered into the EHR. All of these factors can have a negative impact on data analysis.

Integrating Speech With EHRs
According to Dr. van Terheyden the key to overcoming these challenges is to seamlessly integrate the clinical narrative with the data-centric EHR workflow. "EHR technology does its part to standardize data in an easy-to-exchange format, but oftentimes these data points don't tell the whole story. The narrative is an essential part of the patient history that can't be ignored."

Today's speech recognition technologies allow physicians to capture and store the clinical narrative. Some platforms also allow for basic file integration with EHR platforms. However, according to Dr. van Terheyden, further technological innovation is necessary to bridge the divide between the clinical narrative and the EHR more seamlessly. Specifically, Dr. van Terheyden refers to an application that extracts the pertinent facts from the clinical narrative and automatically populates the data-hungry EHR with this information. Nuance Communication is currently developing a clinical language understanding module that will allow for this fact extraction. Other speech recognition technology manufactures have been rumored to be developing similar applications. In the meantime, physicians should continue to wave their "Save The Clinical Narrative" banners until verbal data becomes an indispensable piece of the EHR puzzle.

Ken Congdon is Editor In Chief of Health IT Outcomes. He can be reached at ken.congdon@jamesonpublishing.com.