title: Validating free-text order entry for a note-centric EHR.
abstract: Electronic Health Records (EHRs) have increased the utility and portability of health information by storing it in structured formats. However, EHRs separate this structured data from the rich, free-text descriptions of clinical notes. The ultimate objective of our research is to develop an interactive progress note that unifies entry, access, and retrieval of structured and unstructured health information. In this study we present the design and subsequent testing with eight clinicians of a core element of this envisioned note: free-text order entry. Clinicians saw this new order-entry paradigm as a way to save time and preserve data quality by reducing double-documentation. However, they wanted the prototype to recognize more diverse types of shorthand and apply default values to fields that remain fairly constant across orders, such as number of refills and pickup location. Future work will test more complex orders, such as cascading orders, with a broader range of clinicians.
authors.affiliation: UC San Diego, La Jolla, CA.
authors.forename: Adam
authors.initials: A
authors.lastname: Rule
authors.affiliation: UC San Diego, La Jolla, CA; Veteran's Medical Research Foundation, San Diego, CA.
authors.forename: Steven
authors.initials: S
authors.lastname: Rick
authors.affiliation: UC San Diego, La Jolla, CA.
authors.forename: Michael
authors.initials: M
authors.lastname: Chiu
authors.affiliation: UC San Diego, La Jolla, CA.
authors.forename: Phillip
authors.initials: P
authors.lastname: Rios
authors.affiliation: Veteran's Medical Research Foundation, San Diego, CA.
authors.forename: Shazia
authors.initials: S
authors.lastname: Ashfaq
authors.affiliation: Veteran's Medical Research Foundation, San Diego, CA.
authors.forename: Alan
authors.initials: A
authors.lastname: Calvitti
authors.affiliation: UC San Diego, La Jolla, CA.
authors.forename: Wesley
authors.initials: W
authors.lastname: Chan
authors.affiliation: UC San Diego, La Jolla, CA; Veteran's Medical Research Foundation, San Diego, CA.
authors.forename: Nadir
authors.initials: N
authors.lastname: Weibel
authors.affiliation: UC San Diego, La Jolla, CA; West Health, La Jolla, CA.
authors.forename: Zia
authors.initials: Z
authors.lastname: Agha
mesh_terms: D000068598:Data Accuracy; D004282:Documentation; D057286:Electronic Health Records; D006801:Humans; D033262:Narration