Adding “Social Documentation” To EMRs

While EMRs store key clinical information, a vast amount of clinical communication goes on outside the system, via instant message, text, e-mail, fax, phone and social media.

Most health IT managers don’t concern themselves much with the chatter outside the EMR, other than to see that — where possible — it takes place in a secure manner. But according to John Halamka, MD, chief information officer for Beth Israel Deaconess Medical Center, this communication is too important to be ignored.

Rather than let these conversations stream on without ever entering the EMR, he argues that it’s time to begin mining these discussions and integrating them into the EMR.  As he sees it, smart devices, the cloud, instant messaging, SaaS and social networking should be combined to create what he calls “social documentation” for healthcare.

Just what is social documentation?  Here’s his definition:

I define “social documentation” as team authored care plans, annotated event descriptions (ranging from acknowledging a test result to writing about the patient’s treatment progress), and process documentation (orders, alerts/reminders) sufficient to support care coordination, compliance/regulatory requirements, and billing.

So, in social documentation, the various channels clinicians are already using to connect with each other go from ancillary information to key ingredients in a team approach to care. But Halamka breaks it down further. Social documentation, he says:

*Incorporates data input from multiple team members, reducing the documentation burden for each participant
*Eliminates redundant entry of the same information by different caregivers (nurse, pcp, specialist, resident, social worker)
*Supports Wikipedia like summaries (jointly authored statement of history, plans, and decision making)
*Supports Facebook/Twitter like updates i.e. “Patient developed a fever, ordered workup, will start antibiotics”
*Incorporates data already present in the EHR such as orders and results without having to re-describe them in narrative form

I don’t know about you, but to me this makes enormous sense. As Halamka himself concedes, creating a new modular architecture that can support such documents might be “burdensome” but it’s still something to bear in mind as we move forward.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

   

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