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The paper-based medical note arose in the 19th century as a highly personalized "lab notebook" that clinicians could use to record their observations and plans so that they could be reminded of pertinent details when they next saw that same patient.¹⁰

My colleagues and I spend a lot of time envisioning how technology can help physicians spend more time with patients and their own families, and less time on paperwork.  As part of this process we have asked a number of practices what about the current paper chart would they like to retain while moving to an electronic medical record.

Patient records contain valuable clinical information in free text form.  One of the challenges of electronic medical records has been to extract this data for use in activities such as research, quality reporting, and utilization review.

An Introduction to Natural Language Processing

The current format for documenting patient care has served physicians well for 40+ years.   So why are we making physicians change the way they document patient care, from dictation to point-and click data entry, from narrative notes to boilerplate text?

As part of my research on the future of dictation, I posited this question on a website:

Will apps like Apple's Siri and Android's Iris lead to dictated voice commands overtaking keyboard entry as the primary means of generating text for free text fields, documents etc?

The wired generation.  Raised on cell phones, the internet, social media, and video games, they are distinguished by their use of technology .²  Born after 1980, the first of the Millennial Generation is turning 30.   

I had my first chance to interact as a patient with a dental EMR.  The occasion was the extraction of four wisdom teeth for my 18 year old son by an oral surgeon.  I logged onto the practice site and filled out all the pre-operative paperwork.  The forms were well designed and easy to complete.  I was also able to access all the pre- and post-operative instructions on line.  In all, it was a very efficient process.

Until recently, my experience as a consumer of healthcare services had been on my own behalf, and limited to a comparative handful of mostly minor, acute instances during which I could ask questions directly, review physician recommendations and read the records that were produced in the context of my visits.  Fortunately, I have been limited to pretty benign interactions.  Then I became involved with the care of my aging parents.