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Monday, September 17, 2012

Data entry is an under-discussed grand challenge for informatics

Everyone, including this blog writer, has been touting the virtues of the vast troves of data already or soon to be available in the electronic health record (EHR), which will usher in the learning health care system 1, 2.

There is sometimes unbridled enthusiasm that the data captured in clinical systems, perhaps combined with research data such as gene sequencing, will effortlessly provide us knowledge of what works in health care and how new treatments can be developed 3, 4. The data is unstructured? No problem, just apply natural language processing 5.

I honestly share in this enthusiasm, but I also realize that it needs to be tempered, or at least given a dose of reality. In particular, we must remember that our great data analytics and algorithms will only get us so far. If we have poor underlying data, the analyses may end up misleading us. We must be careful for problems of data incompleteness and incorrectness.

There are all sorts of reasons for inadequate data in EHR systems. Probably the main one is that those who enter data, i.e., physicians and other clinicians, are usually doing so for reasons other than data analysis. I have often said that clinical documentation can be what stands between a busy clinician and going home for dinner, i.e., he or she has to finish charting before ending the work day.

I also know of many clinicians whose enthusiasm for entering correct and complete data is tempered by their view of the entry of it as a data black hole. That is, they enter data in but never derive its benefits. I like to think that most clinicians would relish the opportunity to look at aggregate views of their patients in their practices and/or be able to identify patients who are outliers in one measure or another.

Yet a common complaint I hear from clinicians is that data capture priorities are more driven by the hospital or clinic trying to maximize their reimbursement than to aid clinicians in providing better patient care.

Another challenge for clinicians is the time required for electronic data entry. There is no question that the 20th century means of clinical documentation, mostly consisting of scribbling illegible notes on paper, was much easier and faster than typing and/or clicking. While I think that few clinicians want to go back to hand-written notes, there is an appeal of their ease of use, at least for the person doing the entry.

Related to the time for electronic data entry is the "tension" between structured data, which makes aggregation and analysis easier, and "flexible" (or narrative) data, which allows the clinician to tell the story of the patient 6. Many clinicians report that excess structuring of data (i.e., pointing and clicking) loses the story of the patient, although those who process the data know that structured data is easier to analyze.

An additional challenge for electronic data entry for clinicians is the shift of the focus from the patient to the computer. This was exemplified in a cartoon published earlier this year in JAMA that showed a seven-year-old's sketch of an exam room with the physician hunched over the computer, his back turned away from the patient and her family 7.

An excellent example of the promise but limitations of current data entry systems was recently documented by Parsons et al. 8, who found in a wide sample of primary care EHRs in New York City that the accuracy of data for measuring breast cancer screening quality measures was highly variable due to differing practices in documentation, workflow, and related factors. While some physicians had the quality of their care measured accurately, for many others it was underestimated due to data limitations and not the care they provided.

I cannot claim to have easy answers to this grand challenge, but two related aspects of it sit in front of us.

We need to find better and faster ways for clinicians to enter data into the EHR that allow data whose quality is good enough to be re-used for other purposes, such as research, quality measurement and improvement, and public health. And, we must reward clinicians for their efforts in entering high-quality data. We must allow them to see aggregate views of patients in their practices and be able to identify outliers. We must also engage them in research, quality improvement, and other system uses of their data.

In short, the concept of "garbage in, garbage out" still remains a problem for computers and information technology nearly a half-century after it was coined. In health care, we must give clinicians the best tools and incentives for them to participate in the learning health care system. For informatics, the problem of data entry is a grand challenge every bit as important as how to make use of its growing quantity, since the knowledge derived from that data will only be as good as the quality of what is input.

References:
1. Friedman, C., Wong, A., et al. (2010). Achieving a nationwide learning health system. Science Translational Medicine, 2(57): 57cm29. http://stm.sciencemag.org/content/2/57/57cm29.full.
2. Greene, S., Reid, R., et al. (2012). Implementing the learning health system: from concept to action. Annals of Internal Medicine, 157: 207-210.
3. McCarty, C., Chisholm, R., et al. (2010). The eMERGE Network: a consortium of biorepositories linked to electronic medical records data for conducting genomic studies. BMC Genomics, 4(1): 13. http://www.biomedcentral.com/1755-8794/4/13.
4. Rea, S., Pathak, J., et al. (2012). Building a robust, scalable and standards-driven infrastructure for secondary use of EHR data: The SHARPn project. Journal of Biomedical Informatics, 45: 763-771.
5. Nadkarni, P., Ohno-Machado, L., et al. (2011). Natural language processing: an introduction. Journal of the American Medical Informatics Association, 18: 544-551.
6. Rosenbloom, S., Denny, J., et al. (2011). Data from clinical notes: a perspective on the tension between structure and flexible documentation. Journal of the American Medical Informatics Association, 18: 181-186.
7. Toll, E. (2012). The cost of technology. Journal of the American Medical Association, 307: 2497-2498.
8. Parsons, A., McCullough, C., et al. (2012). Validity of electronic health record-derived quality measurement for performance monitoring. Journal of the American Medical Informatics Association, 19: 604-609.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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