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Capturing the full story is essential for good care

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The usefulness of electronic health records must be improved if patients are to be well managed, argues one clinician in England. The comment is timely as service providers to implement a national Integrated Care Record Service have just been appointed.

Patients sharing their perspective with their doctor often have better outcomes. So getting electronic health records to reflect the truest clinical picture is essential to ensuring good patient care. That is a challenge because doctors intuitively get their information from patients in the form of narratives and communicate with each other in this form too. Narratives allow doctors to refine their diagnosis as they unfold, but are not readily captured by current electronic systems. Structured, selective systems of capturing information simply do not compare.

Preserving the process of clinical reasoning is also paramount. This could best be achieved by developing systems which could cope with direct handwritten input—notes and sketches—and voice input by doctors themselves, preferably into a portable device. Many useful tools—diagnostic aids, best evidence, and local and national clinical guidelines—can be incorporated into the systems, but the knowledge structure must not intrude on the clinical reasoning process, and more research is needed to establish their true benefits. Retrieving and presenting the information usefully is just as much of a challenge.

“Clinicians need to be closely involved in ensuring that software for documenting patient encounters complements the way they work.” It’s now or never.

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