Health Care Informatics Capture Human Health Care Information

Can Health Care Informatics Capture Human Health Care Information?

Taking this in another direction, consider the following. I’ve been working with a client to enhance physician adoption of EMR at a large southwestern medical center. One of the areas the docs are hung up on is the transition to electronic clinical documentation. They’re mostly OK with CPOE. But many are concerned that using e-tools and scripts to document clinical histories and to communicate complex treatment plans sacrifices some of the art and nuance of telling the story – which are better expressed in a narrative history and physical or consultation note – in favor of capturing the “provable facts” which are essentially the data elements EMRs demand.

As a physician and management consultant, my role is to facilitate a useful conversation and process to bring the physicians and administration to an implementable conclusion. But we are left with these questions. Will the proper recommendations be made and decisions implemented if the narrative patient story is missing or truncated? Is this another example of losing a bit of humanity in favor of the data. While necessary, is the data sufficient to support the best decisions? Are we yet one step shy of getting it right – in favor of the patient? Will resources (and cost) be best conserved, and quality of care be most improved, by requiring fidelity to the EMR or by making compromises at some points – perhaps clinical documentation?

Physician leaders and executive healthcare leaders will need to wrestle with this dilemma for years until “the data” provides an answer. In the meantime, should we not choose humanity to satisfy patients and providers?

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