“Social Documentation” for Healthcare

Every day CIOs are inundated with buzzword-compliant products – BYOD, Cloud, Instant Messaging,  Software as a Service, and Social Networking.

In yesterday’s blog post, I suggested that we are about to enter the “post EHR” era in which the management of data gathered via EHRs will become more important than the clinical-facing functions within EHRs.

Today, I’ll add that we do need to a better job gathering data inside EHRs while at the same time reducing the burden on individual clinicians.

I suggest that BYOD, Cloud, Instant Messaging, Software as a Service and Social Networking can be combined to create “Social Documentation” for Healthcare.

In previous blogs, I’ve developed the core concepts of improving the structured and unstructured documentation we create in ambulatory and inpatient environments.

I define “social documentation” as team authored care plans, annotated event descriptions (ranging from acknowledging a test result to writing about the patient’s treatment progress), and process documentation (orders, alerts/reminders) sufficient to support care coordination, compliance/regulatory requirements, and billing.

Here are a few core principles I’d like to see as the foundation of “social documentation” products:

  • Incorporates data input from multiple team members, reducing the documentation burden for each participant
  • Eliminates redundant entry of the same information by different caregivers (nurse, pcp, specialist, resident, social worker)
  • Supports Wikipedia like summaries (jointly authored statement of history, plans, and decision making)
  • Supports Facebook/Twitter like updates i.e. “Patient developed a fever, ordered workup, will start antibiotics”
  • Incorporates data already present in the EHR such as orders and results without having to re-describe them in narrative form

Accomplishing this is likely to require a modular architecture with some services offered in the cloud, some on mobile devices, and some via new enterprise software that improves upon insecure consumer offerings (such as institution hosted HIPAA-compliant instant messaging).

I recognize that implementing “social documentation” at a time when we’re implementing ICD-10, Meaningful Use Stage 2, new security imperatives, accountable care organization tools to support care management, and healthcare information exchange may seem overly burdensome.

However, Yogi Berra said “If you don’t know where you are going, you might wind up someplace else.”

I believe that our strategy for ICD-10, Meaningful Use Stage 2, new security imperatives,  ACOs, and HIEs can incorporate the modules that will be foundational for “social documentation” in healthcare.

If 5 years from now, Beth Israel Deaconess is known as the birthplace for the “post EHR” care management medical record and “social documentation”, I’ll have stories to tell my grandchildren about.

John Halamka, MD, is the CIO at Beth Israel Deconess Medical Center and the author of the popular Life as a Healthcare CIO blog, where he writes about technology, the business of healthcare and the issues he faces as the leader of the IT department of a major hospital system. He is a frequent contributor to THCB.

7 replies »

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  2. Sounds like the perfect time. If you want to make a big change do it during chaos!

  3. At BIDMC: Privacy Issues and security issues: A presentation by Mark Olson, chief information systems officer, Beth Israel Deaconess Medical Center (Boston, MA, USA), detailed medical device security issues at his facility.

    John, what do you have to say about that?

  4. The dinosaurs among the physicians will be screaming soon.

    But yes, the blog is a Rx for addressing many maladies. Futuristic possibly, but accurate.

    In the process we need to remember, ‘garbage in, garbage out…’

  5. “we are about to enter the “post EHR” era in which the management of data gathered via EHRs will become more important than the clinical-facing functions within EHRs.”

    I’d say it sounds like a post-patient era in which management of the EHR will become more important than the clinical activities involving patients.

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