An electronic health record based on structured narrative.
OBJECTIVE
To develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.


METHODS
We propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry.


RESULTS
The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules.


CONCLUSIONS
The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.


CONCLUSIONS
Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.
Johnson
Stephen B
SB
Department of Biomedical Informatics, Columbia University, New York, NY, USA. sbj2@columbia.edu
Bakken
Suzanne
S
Dine
Daniel
D
Hyun
Sookyung
S
Mendonça
Eneida
E
Morrison
Frances
F
Bright
Tiffani
T
Van Vleck
Tielman
T
Wrenn
Jesse
J
Stetson
Peter
P
D004282:Documentation; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods; D008487:Medical History Taking; D016347:Medical Records Systems, Computerized; D009323:Natural Language Processing; D012984:Software; D018511:Systems Integration; D014584:User-Computer Interface; D018875:Vocabulary, Controlled