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Collaborative Intelligence & the EHR

A provider's essential critical knowledge is often so obscured that the EHR becomes more of an obstacle than a useful source of clinical information.

The meaningful use-compliant electronic health record (EHR) has quickly become very adept at capturing and sharing standardized, structured clinical content that can be communicated, stored, and to some extent consumed by other systems. Unfortunately, this strength is also the EHR's greatest limitation. Amid the structured templates and required fields of the EHR, the essential critical knowledge a provider needs to know is often so obscured that the EHR becomes more of an obstacle or annoyance than a truly useful source of clinical information.

No Place for Clinician's Thought-Process?
The critical clinical insights that providers most need from an EHR are simply not available to allow for informed decision-making. The required fields may all be populated, but the patient's story remains frustratingly incomplete.

The reason for this is simple: by its very nature, the EHR paradigm of capturing clinical information by way of mouse-and-keyboard input into structured forms limits the expressiveness of content. Because there is no place for non-standard information or for the clinician's thought process in reaching certain diagnoses in the templates, we not only miss out on the details of a patient's clinical history, but also on the critical information that reflects the way doctors think.

Documentation of the rationale for conclusions, relevant temporal and sequential facts, causal information, etc. is either lost or obscured beyond efficient retrieval. Some EHRs have incorporated options to allow providers to capture unstructured narrative information, but the resulting text usually has limited utility since it remains unstructured data buried inside various notes fields.

This dilemma is significant. It will take more than incremental feature improvements to realize the promise of the EHR: to support everything from disease management to clinical decision support to major operational efficiencies. To deliver on the expectations for eHealth, we need the EHR not only to capture and effectively use structured data, but also to capture the full patient story and support clinical collaboration based on that story.

What is needed is collaborative intelligence, a solution that enables and supplements the kind of complete and focused clinical picture physicians convey via face-to-face collaboration. Providing such intelligence requires an understanding of clinical workflows, and an ecosystem of people, process and technology to provide the clinical insights that permit clinicians to zoom in on the most critical information quickly and effectively.

All of the pieces required for such collaborative intelligence are in place today: Recognition and understanding of spoken content, semantic coding and analysis to drive actions and learning algorithms that continuously improve the performance of automated systems based on human feedback. Four key technologies provide the backbone:

Speech Understanding: Speech is the most natural way for humans to convey complex information, and it is the preferred mode of clinical documentation for most physicians today. Speech-based documentation is fast and interferes with the provider-patient interaction least. Converting speech into structured clinical notes using computers reduces costs and time lag associated with human transcription.

The availability of next-generation speech understanding technology now provides significantly higher accuracies across medical disciplines and documentation types than what has previously been available through speech recognition systems. Integration with various clinical systems further optimizes the efficiency of the technology.

Natural Language Understanding (NLU): Sophisticated technology to "read" and understand unstructured clinical narrative is a critical ingredient for collaborative intelligence. We can now produce meaningful structured information from narrative content, merging the benefits of dictation and structured documentation.

Irrespective of whether clinical narrative is captured through dictation or directly in textual form, the synergistic combination of speech and natural language processing (NLP) technologies now yields highly accurate, context-aware clinical content that is codified to standardized medical ontologies such as SNOMED-CT. This in turn drives actionable information and together with structured EHR data enables clinical decision support and improves the quality of care.

Semantic Clinical Reasoning: Once meaningfully structured narrative information is available, it must be made accessible in workflow-friendly, flexible modes. Newly available tools allow physicians to gain access and insights into clinical data that were impossible to get a few years ago. Also, these tools make physicians more productive because they are capable of abstracting and summarizing the relevant clinical information for each provider. They can reason across millions of documents or drill down on the relevant information about one patient in a given context.

Information mined from narrative content can be combined with structured data from EHRs to obtain holistic insights into the patient's story. From retrospective analyses to real-time feedback for physicians at the time of documentation that enables more timely clinical documentation improvement (CDI) to the ability to share clinical insights among caregivers in a collaborative system, the fruits of this reasoning are game-changing.

Machine Learning: To realize the full scope of its benefits, a collaborative intelligence system must be both highly scalable and responsive to the incessant changes in medical knowledge. The only way to achieve these objectives is through "machine learning" - intelligent systems that improve their predictions as they process more information.

Many NLP systems lack a robust capability to do this or rely on hand-crafted rules for knowledge updates, an inherently non-scalable approach. Learning from human feedback is crucial as it provides a constant opportunity to adapt to the changing environment as well as to improve the results and insights gained from collaborative intelligence.

Taken together and combined in the right manner, these technologies and workflows offer the best path to fulfill the goals of eHealth. The EHR remains an essential tool for advancing the quality and efficiency of care, but all stakeholders in healthcare have to remember that it is far from a panacea. To reach the goals of complete, accurate and seamlessly interoperable clinical information, we need to take into account that the most complete, accurate and interoperable way of communicating clinical information is via the spoken word. It also happens to be the most efficient way of capturing such information.

Juergen Fritsch is the chief scientist of MedQuist. He was previously chief scientist and co-founder of M*Modal, and before that, he was one of the founders of Interactive Services (ISI), where he served as principal research scientist.

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Joe's post brings some interesting points. I had an opportunity to sit down with a physician this last week and talk about how the EHR was working. He said two things that I think were pertinent: 1) The EHR is doing away with the communication we used to have in health care, and 2) nobody will know the real story of the patient anymore because it's all about structured data. While it's great to have and use the technology to improve things, I'm not sure either of those two things really will improve health care. I wonder when we might see a switch to remembering that the patient should be the North Star in health care. I repeatedly hear physicians say yes they know that the technology isn't necessarily putting in the RIGHT information, but that's not the push right now, the push is to just get it electronic. Guess at some point there will be some great jobs for people to go in and fix all the mess we are creating by not doing it right the first time.

Kathy NichollsFebruary 02, 2012
Pueblo, CO

Dr. Fritsch eloquently defends the continuation of dictation as the primary form of clinical documentation. He infuses recent technologies, such as natural language understanding, into the equation in order to accomplish the lofty and critical goals of an EHR. We surely need to analyze real-life clinical encounters. This clinical practice research is the only way we will be able to dramatically advance the science of medicine and increase the cost effectiveness of healthcare. It's the only way we can determine which treatments actually work best for certain conditions and under what circumstances. It's the only way we can find out what findings are early indications of serious disease.

However, methinks the "patient's story" is a bit overrated. A focus on this narrative assures that the EHR will be more like a diary than an information system. True, technology can automatically extract clinical facts and convert them to codes. But there are errors and omissions in these codes. That means an editor must review and correct. And that's only after an editor has reviewed and corrected the draft provided by speech recognition. Then the codes must be mapped to the EHR fields, a messy process at best. This all results in a significant time delay, which means we can't have an interactive "clinical guidance system" operating at the point of care. Codified data enable real-time clinical guidance. Delayed narrative-based data do not.

Nonetheless, not all clinical information fits neatly into little boxes. The codified data will often benefit from narrative elaboration. I'd just like to have coded entry wherever that makes sense. The narrative should be an escape hatch, not the primary documentation method.

Oh, one more point. When physicians do the point-and-click gig, their productivity decreases. Imagine, however, if they didn't have to perform any documentation at all. Not even dictation. Their productivity would substantially increase, rather than decrease. This is attainable with Medical Coordinators, essentially remote scribes trained to be expert in direct EHR documentation. There's some information about this approach at

Joe Weber ValadocJanuary 28, 2012
Palm Beach Gardens, FL

I do agree with Mr. Fritsch's comment regarding the loss or obscurity of non standard information from the patient chart as a result of the EHR's current limitations. Why not add another section to the chart, 'Doctor's Notes' with an integrated format, to capture the patient's story. It would also allow for the clinicians to record their decision making process, reflecting the way they think.

I concur with the previous entries of esteemed colleagues, that the technology is not there yet. I also believe Mr Fritsch's summation alleviates all concerns of human replacement in the work flow process.

Ms. Sam Massanopoli, RHIT

Sam MassanopoliJanuary 27, 2012

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