Abstract
Objective: As healthcare practice transitions from paper-based to computer-based records, there is increasing need to determine an effective electronic format for clinical narratives. Our research focuses on utilizing a cognitive science methodology to guide the conversion of medical texts to a more structured, user-customized presentation in the electronic medical record (EMR). Design: We studied the use of discharge summaries by psychiatrists with varying expertise - experts, intermediates, and novices. Experts were given two hypothetical emergency care scenarios with narrative discharge summaries and asked to verbalize their clinical assessment. Based on the results, the narratives were presented in a more structured form. Intermediate and novice subjects received a narrative and a structured discharge summary, and were asked to verbalize their assessments of each. Measurements: A qualitative comparison of the interview transcripts of all subjects was done by analysis of recall and inference made with respect to level of expertise. Results: For intermediate and novice subjects, recall was greater with the structured form than with the narrative. Novices were also able to make more inferences (not always accurate) from the structured form than with the narrative. Errors occurred in assessments using the narrative form but not the structured form. Conclusions: Our cognitive methods to study discharge summary use enabled us to extract a conceptual representation of clinical narratives from end-users. This method allowed us to identify clinically relevant information that can be used to structure medical text for the EMR and potentially improve recall and reduce errors.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 346-368 |
| Number of pages | 23 |
| Journal | International Journal of Medical Informatics |
| Volume | 75 |
| Issue number | 5 |
| DOIs | |
| State | Published - May 2006 |
| Externally published | Yes |
Keywords
- Cognitive science
- Electronic medical records
- Medical narratives
- Mental health care
- User interface
ASJC Scopus subject areas
- Health Informatics
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In: International Journal of Medical Informatics, Vol. 75, No. 5, 05.2006, p. 346-368.
Research output: Contribution to journal › Article › peer-review
}
TY - JOUR
T1 - Customizing clinical narratives for the electronic medical record interface using cognitive methods
AU - Sharda, Pallav
AU - Das, Amar K.
AU - Cohen, Trevor A.
AU - Patel, Vimla
N1 - Funding Information: This study was supported in part from a grant by the Agency For Healthcare Research & Quality HS11806. A portion of this study was presented in the student paper competition (as one of the finalists) in the AMIA 2003 Annual Symposium, Washington, DC. Appendix A Section A : The table below shows comparison between the two sample cases, in terms of propositions in corresponding sections. Text sections Case 1 propositions Case 2 propositions Admitted 2 2 Discharged 2 2 Operation date 1 1 Dictated by 2 2 Attending physician 2 2 Identifying data 7 7 History of present illness 50 42 Past psychiatric history 65 47 Past medical history 2 12 Allergies 2 2 Medications 2 4 Social history 15 33 Mental status 22 21 Admitting diagnosis 11 10 Hospital course 39 49 Discharge diagnosis 9 9 Discharge plan 0 10 Section B : The text below is what was given as ‘Instructions’ document to the subjects, at the beginning of each session (format is modified here to conserve space). Overview and instructions . Our overall aim is to study the way clinicians review psychiatric problems when given a previous discharge summary in context of a patient visit. In this study, we would like to simulate a patient visit to the psychiatric emergency room (ER). Your task is to pretend that you are the physician who will evaluate the patient who has arrived in the ER. The patient was previously admitted at CPMC, and you have access to the discharge summary. In addition to the discharge summary, you are also given the patient information typically found on the ‘whiteboard’. • While reading through the texts, we would like you to “think aloud” as you form your opinions and treatment plan. To “think aloud” means to verbalize your thought process—any impressions you have of the patient based on the given information, and whatever you are thinking. • Note that it is not necessary for you to go through each section of the discharge summary, feel free to read it as you would in an actual clinical encounter. The study aims to analyze your thought process rather than your thought content. • Since we are trying to simulate an actual encounter, there will be a limited amount of time available to you to review the situation and form a tentative treatment plan (5–10 min). You would be reminded of the time limit at the end of 10 min. • To make sure that the instructions are clear, we would like you to please repeat them back, in your own words, to the researcher. After this, you would be given a “practice” problem (unrelated to the actual case), so that you can become accustomed to “thinking aloud”. Please turn the page, read the paragraph, and “think aloud” as you read through it. (Next Page) Practice paragraph . A 47-year-old male (G.S.) is admitted to your adult inpatient psychiatric unit. He was found wandering down the street, urinating on the doorsteps as he went. When a policeman attempted to stop him, he ran away screaming, “They are going to get me. They won’t leave me alone.” G.S. ran out into the street, oblivious of the traffic and the fact that he no longer had his shoes on. He was initially brought to the emergency room. When asked questions about his personal history, he just says, “I’m here to save you. That is why they are after me.” On further questioning, he says he has “No family any more.” and that he has not slept for several days because he “was afraid they were going to get me.” The E.R. physician orders a toxicology screen. He had been brought to this emergency room in 1999 with similar symptoms. However, at that previous time he had also been drinking alcohol and was acutely intoxicated. Clinical situation . A 29-year old white female arrives to triage, at which time the psychiatric ER nurse obtains the following information, which she writes on the board as: Location Name Age ID Time Clinical Zip/insurance Meds BAL/UTOX Dispo SW/PSAC B Mary G. 29 3434343 10 a.m. (today) BIB mother, pt. mute 10701/MCD At about 3 p.m., you sign up to see the patient and get an evaluation form. With the medical record number written on the board you access the WebCIS discharge summary for this patient's earlier visit. ( Remember to verbalize your thoughts as you go about reading the case .) Change in clinical situation . Just as you finish reading the discharge summary, you receive a call from an attending in Area B, who informs you that the patient has become agitated and is shouting out at the security officers. The attending asks for your advice on how to manage the patient. Please tell us about any change in interpretation that this piece of information produces. Elaborate on any specific changes regarding aspects like treatment plan or your overall understanding of the case. Summarize . Lastly, we would like you to summarize the salient features of the case. Without looking back at the text, please tell the experimenter specific points about the case that you consider as relevant and important. 03/04/2002 03/15/2002 Ana Smith MD Ana Smith MD Section C . The following is text for Case 1, in Narrative format. CASE 1 Admitted: Discharged: Operation date: Dictated by: Attending physician: Identifying data: This is a 27-year-old Hispanic woman, who is separated from her husband and is living with her mother. She is taking college courses and is currently unemployed. History of present illness: This is the first Allen Pavilion admission and the second psychiatric admission for this patient, who carries a past diagnosis of psychotic depression. The patient had brought herself into the CPMC ER with complaints of dizziness and trouble sleeping on 24 February 2002. She stated at that time that she was suffering from problems with depression and felt that she could no longer function. She denied any psychotic symptoms on that evaluation. She was evaluated over a 24 h period and discharged with an appointment for an outpatient psychiatrist. Her mother felt that the patient needed to be seen sooner and called the Mobile Crisis Service who brought her to the ER on 2 March 2002. In the ER, the patient was noted to be irritable and preoccupied that her college teacher was trying to “ruin her grades”. Her current symptoms apparently started 3 days prior to her ER visit. During this time, the patient's mother reported that she went out shopping frequently, seemed to be driven by a motor, was pacing around in the middle of the night talking to herself. When her mother confronted her about her behavior, she reported that she was hearing the voice of God and other voices talking about her. Her family also gave collateral that she was occasionally dancing around the house, singing loudly and reciting verses from the Bible. In the ER, the patient was not cooperative with staff and required constant redirection to stay in her room. She was noted to be loud and argumentative, occasionally bursting out in laughter. At one point she began screaming to herself. When this behavior was addressed by a resident, she claimed that someone was touching and arousing her although no one was in the room or had been in the room that morning besides the nurse. She refused to take any medications. Her physical exam and laboratory-test results were within normal limits. Her BAL was 0 and her UTOX was negative. Past psychiatric history: The patient and her family deny any past psychiatric history prior to 4 months ago. About 1 year ago, the patient separated from her husband, who was reportedly abusive to her. The patient decided to move back in with her mother and two brothers about 5 months ago. Shortly after she moved back in, one of her brothers was sent to jail and a new boyfriend wrecked her mother's car. About a month or so after moving in with her family, her mother noticed that she was not taking care of herself, was not bathing regularly, and was not eating. She appeared depressed and isolated herself in her bedroom. A few days before Christmas, she was found by a friend in the subway station in a confused state. She was taken to the ER at St. Luke's, where she was observed to be agitated and hallucinating, with prominent thought disorder. She complained of voices making negative comments about her and she endorsed having command auditory hallucinations to kill her husband and herself. The patient was admitted to Harlem Hospital and treated with Haldol. She was also started on Prozac. She was discharged after 4 days to the care of her mother and had follow-up appointment at the Upper Manhattan Mental Health Council. The patient made it to her evaluation appointment but eventually dropped out of treatment a month ago. She apparently stopped taking her medications at this time. In the ER, the patient had reported that she was having anxiety, insomnia, and auditory hallucinations for the 3 weeks prior to her current ER visit. However, she reported to this MD that she had been experiencing hallucinations and paranoid delusions over the past 2 months, but her fear of being readmitted to the hospital prevented her from telling her outpatient psychiatrist. She believes that her mother and her teacher at college are trying to hurt her. She says that the television is trying to control her thoughts and that other people can read her mind. She admits that she has being hearing voices frequently since her first admission. The patient denies any history of marijuana, cocaine, heroin, or alcohol abuse. She has no criminal history and no history of being violent toward others. She denies any past history of suicide attempts. There is a family history of psychotic illness in a maternal aunt and of drug abuse in her two brothers. None. None. No standing medications on admission. Past medical history: Allergies: Medications: Social history: The patient was born in NYC and is the youngest of six siblings born to immigrant parents. Her mother reports that she was born prematurely, weighing four pounds, but had no perinatal complications. Her developmental history was normal. She did well in school, had many friends, and went to work in a bank after graduating from high school. She then married her husband 4 years ago and they have no children. The patient has not worked since she got married, but began to classes at a local community college last year. Mental status: On admission, a 26-year-old medium build, Hispanic woman, unkempt, wearing a hospital gown, and making angry remarks. She was not cooperative, acting in a guarded and entitled manner. She had psychomotor agitation. Her speech was loud and pressured at times. Her mood was “upset” and her affect was irritable. Her thought process was with occasional flight of ideas. Her thought content was preoccupied with the persecutory delusion that her mother and her college teacher were out to destroy her because of the “sacred knowledge” she had obtained. She endorsed hearing voices but would not reveal their content. She denied any command auditory hallucinations, visual hallucinations, suicidal ideation, or homicidal ideation. AXIS I: bipolar disorder, mixed versus dysphoric manic state, with psychotic features. AXIS II: deferred. AXIS III: none. AXIS IV: boyfriend destroyed mother's car, brother in jail, separation from husband, unemployed. AXIS V: 22. Admitting diagnosis: Hospital course: The patient refused to take oral medications for the first day of admission. However, by the second day, she agreed to start Haldol to help her sleep and feel calmer. The medication was increased up to a dose of 5 mg BID over 4 days, which made her sedated and less psychotic but did not help with her irritability. Depakote was added to regimen and increased to 500 mg BID. After 7 days of Depakote, she reached a therapeutic blood level, and her mental status was clear of manic or psychotic symptoms. On the unit, the patient was initially guarded in her interaction with staff and patients. After several days, she attended unit activities for short time periods, but tolerated sitting in groups for their entire session. The patient had several uneventful visits from her mother, according to the evening nursing staff. Mental status on discharge: alert, awake, and oriented × 3. Adequately groomed. Speech was coherent and linear with normal tone and rate. Mood: Good. Affect: euthymic and reactive. Thought content. Denies any auditory and visual hallucinations and any suicidal ideation. She no longer endorses paranoia toward her mother or college teacher. Judgement and insight fair. AXIS I: schizoaffective disorder, bipolar type. AXIS II: deferred. AXIS III: none. AXIS IV: boyfriend destroyed mother's car, brother in jail, separation from husband, unemployed. AXIS V: 55. Discharge diagnosis: Discharge plan: The patient was discharged to the care of her mother. She has a follow appointment with Dr. Rodriguez at the Upper Manhattan Mental Health Council for 3/18/2002. Medications: Haldol 5 mg BID, Cogentin 1 mg BID, Depakote 500 mg BID. DD: 03/17/2002 03/04/2002 03/15/2002 Ana Smith MD Ana Smith MD Section D : The following is the text for Case 2, in narrative format. CASE 2 Admitted: Discharged: Operation date: Dictated by: Attending physician: Identifying data: This is a 29-year-old Caucasian divorced woman, living with her parents and who is a single mother of an 8-year-old son. She is currently on SSI. History of present illness: This is the 2nd Allen Pavilion admission and the 18th psychiatric admission for this patient. The patient has had a number of past diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, PTSD, and borderline personality disorder. The patient had brought herself into the CPMC ER on 2 March 2002 with the chief complaint of hearing a voice commanding her to kill herself by cutting her wrists. She also stated at that time that she was suffering from depression and having flashbacks to a past sexual assault. She endorsed racing thoughts, but denied change in energy, sleep, appetite, and concentration. She denied SI or HI. She cites current stressors as her son not doing well in school and fights she has been having with her boyfriend. In the ER, the patient was mostly calm and cooperative with the medical staff, but became irritable and challenging with the security officers when asked to comply with their requests. When confronted about her agitation, she claimed “the voices made me do it.” She agreed to take Risperdal but continued to endorse command AH. The staff felt that the patient may be malingering, but she could not contract for safety, saying “I don’t know what the voices might make me do.” Her physical exam and laboratory-test results were within normal limits, except for a cardiac murmur. Her BAL was 0 and her UTOX was negative. Past psychiatric history: The patient has a history of numerous psychiatric admissions since the age of 22 for complaints of paranoid ideation and command AH in the context of feeling depressed or “hyper”. She also has a history of self-destructive behaviors such as cutting her wrists superficially, banging her head against the wall, and abusing opiate analgesics and alcohol. She has no prior suicide attempts and never been known to act on command Ahs to kill herself. Of note, she has a history of an elopement during a transfer to a psychiatric hospital. The patient has a history of poor compliance with outpatient treatment, and did not follow up with the appointment following her last admission at the Allen Pavilion 3 months ago. Her longest period of outpatient treatment was when she was a teenager and received counseling to help with her recurrent medical problems. As an outpatient, she has been tried on Haldol, Zyprexa, Risperdal, Prozac, Paxil, Depakote, and Neurontin. She claims that these medications have not helped her, but, by her report, has not taken any medication for more than 3 months. The patient denies any current marijuana, cocaine, heroin, or alcohol abuse. Her last opiate use was prescription narcotics 1 year ago, and her last ETOH use was 1 week ago. She has never been in detox or rehab. She has no criminal history and no history of being violent toward others. Her psychosocial history is notable for several years of sexual abuse during her childhood by her oldest brother. There is a family history of bipolar disorder in a paternal uncle and of drug abuse in her two brothers. Past medical history: The patient has had numerous medical admissions. Her medical history includes a congenital heart defect that required several reconstructive surgeries during her preschool years and repeated hospitalizations at ages 10, 13, 17, and 21 because of endocarditis. Her last medical admission was 6 months ago for complaints of dizziness, SOB, and chest pain. No acute cardiac or respiratory conditions were found on that admission. None. Risperdal 1 mg BID, started in ER. Allergies: Medications: Social history: The patient was born in NYC and is the youngest of three siblings born to married parents. Her developmental history was normal. She did poorly in school, had few friends, and went to work briefly as a cashier after graduating from high school. She married her husband 10 years ago, and they had a son 8 years ago. The patient has not worked since she got married, and is currently on disability for her psychiatric condition. She divorced her husband 4 years ago. She currently lives with her son and her parents in Westchester County. She describes her current home life as very tense. Her parents constantly fight and are threatening to separate after 40 years of marriage. Shortly before she presented to the ER, the patient's parents made plans to go away to see if they could resolve their difficulties. The patient's son has learning difficulties in school, is frequently truant, and has conduct problems. The patient fears that her ex-husband may try to take him away from her because of inadequate mothering. The patient's current boyfriend, with whom she has been with for the past 6 months, is threatening to break up their relationship. Although she has been physically abused by this man, she refuses to give up the relationship. Mental status: On admission, a 29-year-old medium build, Caucasian woman, who is wearing a hospital gown loosely. She was cooperative, but was guarded with this interviewer. She had no psychomotor agitation or retardation. Her speech was normal volume and not pressured. Her mood was “sad” and her affect was constricted. Her thought process was linear. Her thought content was preoccupied with problems she had at home with her son and boyfriend. She endorsed hearing voices, would not reveal their content in detail, and denied they were command in nature. She denied visual hallucinations, suicidal ideation, or homicidal ideation. Her cognition is intact. AXIS I: psychotic disorder NOS. R/O Malingering. AXIS II: deferred. AXIS III: congenital heart defect, S/P numerous reconstructive surgeries. AXIS IV: conflict with boyfriend, son's school difficulties, unemployed. AXIS V: 35. Admitting diagnosis: Hospital course: The patient continued to take Risperdal for the first day of admission. However, by the second day, she stated that her command auditory hallucinations had disappeared completely, and she refused to take any more oral medications, claiming “it's my right to refuse.” Her mental status was clear of depressive, manic or psychotic symptoms. However, the patient's behavior had a marked change after she arrived on the unit and she became regressed with childlike speech and mannerisms, dependence on staff members for help in ADLs, and increased self-destructive acts (banging her head), which required physical restraint and IM medication with Haldol and Ativan. Her physician and other staff felt that the patient was behaving in this manner to stay on the unit and to prevent her parents from leaving on vacation. The staff began to confront the patient about her acting-out behaviors and to encourage her independence in doing ADLs. Phone calls and visits from her parents were limited with agreement from the family, because the patient would worsen after them. After 1 week, she attended unit activities for short time periods, and became more involved in the inpatient milieu. At the end of the second week, the patient was discharged, since she appeared to be functioning at her baseline, had no further outbursts on the unit, and denied depression or AH. Mental status on discharge: alert, awake, and oriented × 3. Adequately groomed. Speech was coherent and linear with normal tone and rate. Mood: Good. Affect: euthymic and reactive. Thought content. Denies any auditory and visual hallucinations and any suicidal ideation. Judgment and insight fair. AXIS I: psychotic disorder NOS. AXIS II: borderline personality traits. AXIS III: congenital heart defect, S/P numerous reconstructive surgeries. AXIS IV: conflict with boyfriend, son's school difficulties, unemployed. AXIS V: 55. Discharge diagnosis: Discharge plan: The patient was discharged to the care of her parents. She has a follow appointment with Dr. Rodriguez at the Westchester Medical Center Outpatient Clinic for 3/18/2002. Medications: Risperdal 0.5 mg q6hr prn anxiety. DD: 03/17/2002 DT: 03/18/2002 03/04/2002 03/15/2002 Ana Smith MD Ana Smith MD None. No standing medications on admission. Section E : The following shows the text in Case 1 discharge summary, in structured format. CASE 1 Admitted: Discharged: Dictated by: Attending physician: Identifying data: • 27-year-old Hispanic woman • separated from her husband • living with her mother • taking college courses • currently unemployed History of present illness: • First Allen Pavilion admission. • Second psychiatric admission for this patient. • Carries a past diagnosis of psychotic depression. • She brought herself into the CPMC ER with complaints of dizziness and trouble sleeping on 24 February 2002. ∘ She stated at that time that she was suffering from problems with depression. She denied any psychotic symptoms on that evaluation. She was evaluated over a 24 h period and discharged with an appointment for an outpatient psychiatrist. • Her mother felt that the patient needed to be seen sooner and called the Mobile Crisis Service who brought her to the ER on 2 March 2002. • In the ER, the patient was noted to be irritable and preoccupied that her college teacher was trying to “ruin her grades”. • Her current symptoms apparently started 3 days prior to her ER visit. ∘ She went out shopping frequently, seemed to be driven by a motor, was pacing around in the middle of the night talking to herself. She reported that she was hearing the voice of God and other voices talking about her. She was occasionally dancing around the house, singing loudly and reciting verses from the Bible. • In the ER, the patient was not cooperative with staff and required constant redirection to stay in her room. ∘ She was noted to be loud and argumentative. At one point she began screaming to herself. She claimed that someone was touching and arousing her although no one was in the room or had been in the room that morning besides the nurse. Her physical exam and laboratory-test results were within normal limits. Her BAL was 0 and her UTOX was negative. Past psychiatric history: • The patient and her family deny any past psychiatric history. • About 1 year ago, the patient separated from her husband. • The patient decided to move back home. • One of her brothers was sent to jail and a new boyfriend wrecked her mother's car. • Her mother noticed that she was not taking care of herself, was not bathing regularly, and was not eating. • She appeared depressed and isolated herself in her bedroom. • She was found before in a confused state. She was taken to the ER where she was observed to be agitated and hallucinating, with prominent thought disorder. • She endorsed having command auditory hallucinations to kill her husband and herself. • The patient was admitted and treated with Haldol. She was also started on Prozac. • She was discharged to the care of her mother and had follow-up appointment at the Upper Manhattan Mental Health Council. • She eventually dropped out of treatment a month ago. She apparently stopped taking her medications at this time. • She had been experiencing hallucinations and paranoid delusions over the past 2 months, but her fear of being readmitted to the hospital prevented her from telling her outpatient psychiatrist. • She believes that her mother and her teacher at college are trying to hurt her. She says that the television is trying to control her thoughts. She admits that she has being hearing voices frequently since her first admission. • The patient denies any history of marijuana, cocaine, heroin, or alcohol abuse. • She has no criminal history and no history of being violent toward others. • She denies any past history of suicide attempts. Family history: • Family history of psychotic illness in a maternal aunt. • Family history of drug abuse in her two brothers. Past medical history: Medications: Social history: • She is the youngest of six siblings born to immigrant parents. • Her mother reports that she was born prematurely. • She did well in school. • She began to take classes at a local community college last year. Mental status: • She was acting in a guarded and entitled manner. • She had psychomotor agitation. • Her speech was loud and pressured at times. • Her mood was “upset” and her affect was irritable. • Her thought process was with occasional flight of ideas. • Her thought content was preoccupied with the persecutory delusion that her mother and her college teacher were out to destroy her because of the “sacred knowledge” she had obtained. • She endorsed hearing voices. Admitting diagnosis: • AXIS I: bipolar disorder, mixed versus dysphoric manic state, with psychotic features. Hospital course: • The patient refused to take oral medications. • However, by the second day, she agreed to start Haldol to help her sleep and feel calmer over 4 days, less psychotic but did not help with her irritability. • Depakote was added to regimen. • After 7 days of Depakote, she reached a therapeutic blood level. • The patient was initially guarded in her interaction with staff and patients. After several days, she attended unit activities for short time periods, but tolerated sitting in groups for their entire session. • Mental status on discharge: ∘ Thought content: denies any auditory and visual hallucinations. She no longer endorses paranoia toward her mother or college teacher. Discharge diagnosis: • AXIS I: schizoaffective disorder, bipolar type. Discharge plan: • She has a follow appointment with Dr. Rodriguez. • Medications: Haldol 5 mg BID, Cogentin 1 mg BID, Depakote 500 mg BID. 03/04/2002 03/15/2002 Ana Smith MD Ana Smith MD Section F : The following shows the text in Case 2 discharge summary, in structured format. CASE 2 Admitted: Discharged: Dictated by: Attending physician: Identifying data: • This is a 29-year-old • Caucasian • divorced woman, • living with her parents • and who is a single mother of a 8-year-old son. • She is currently on SSI. History of present illness: • This is the second Allen Pavilion admission and • The 18th psychiatric admission for this patient. • The patient has had a number of past diagnoses, including bipolar disorder with psychotic features, schizoaffective disorder, PTSD, and borderline personality disorder. • The patient had brought herself into the CPMC ER with the chief complaint of hearing a voice commanding her to kill herself by cutting her wrists. • She also stated at that time that she was suffering from depression and having flashbacks to a past sexual assault. • She endorsed racing thoughts, but denied change in energy, sleep, appetite, and concentration. • She denied SI or HI. • She cites current stressors as her son not doing well in school and fights she has been having with her boyfriend. • The patient was mostly calm and cooperative with the medical staff, but became irritable and challenging with the security officers when asked to comply with their requests. • When confronted about her agitation, she claimed “the voices made me do it.” She agreed to take Risperdal but continued to endorse command AH. • The staff felt that the patient may be malingering, but she could not contract for safety, saying “I don’t know what the voices might make me do.” • Her BAL was 0 and her UTOX was negative. Past psychiatric history: • She also has a history of self-destructive behaviors such as cutting her wrists superficially, banging her head against the wall, and abusing opiate analgesics and alcohol. • She has no prior suicide attempts and never been known to act on command Ahs to kill herself. • Of note, she has a history of an elopement during a transfer to a psychiatric hospital. • The patient has a history of poor compliance with outpatient treatment. • Her longest period of outpatient treatment was when she was a teenager. • She has been tried on Haldol, Zyprexa, Risperdal, Prozac, Paxil, Depakote, and Neurontin. • She claims that these medications have not helped her, but, by her report, has not taken any medication for more than 3 months. • The patient denies any current marijuana, cocaine, heroin, or alcohol abuse. • Her last opiate use was prescription narcotics 1 year ago, and her last ETOH use was 1 week ago. • She has never been in detox or rehab. • No history of being violent toward others. • Several years of sexual abuse during her childhood by her oldest brother. • There is a family history of bipolar disorder in a paternal uncle and of drug abuse in her two brothers. Past medical history: • The patient has had numerous medical admissions. • Her medical history includes a congenital heart defect that required several reconstructive surgeries and repeated hospitalizations at ages 10, 13, 17, and 21 because of endocarditis. • Her last medical admission was 6 months ago for complaints of dizziness, SOB, and chest pain. • No acute cardiac or respiratory conditions were found on that admission. Medications: • Risperdal. Social history: • The youngest of three siblings • She did poorly in school, and • went to work briefly as a cashier after graduating from high school. • She married her husband 10 years ago, and they had a son 8 years ago. • The patient has not worked since she got married, and is currently on disability for her psychiatric condition. • She divorced her husband 4 years ago. She currently lives with her son and her parents in Westchester County. • She describes her current home life as very tense. Her parents constantly fight. • The patient's son has learning difficulties in school, is frequently truant, and has conduct problems. • The patient fears that her ex-husband may try to take him away from her because of inadequate mothering. • The patient's current boyfriend, is threatening to break up their relationship. Although she has been physically abused by this man, she refuses to give up the relationship. Mental status: • She was cooperative, but was guarded with this interviewer. • She had no psychomotor agitation or retardation. • Her speech was normal volume. • Her mood was “sad” and her affect was constricted. • Her thought process was linear. • She endorsed hearing voices, would not reveal their content in detail, and denied they were command in nature. • She denied visual hallucinations, suicidal ideation, or homicidal ideation. Her cognition is intact. Admitting diagnosis: • AXIS I: psychotic disorder NOS. R/O malingering. • AXIS II: deferred. • Numerous reconstructive surgeries. Hospital course: • She stated that her command auditory hallucinations had disappeared completely, and she refused to take any more oral medications, claiming “it's my right to refuse.” • However, the patient's behavior had a marked change after she arrived on the unit and she became regressed with childlike speech and mannerisms, dependence on staff members for help in ADLs, • She required physical restraint and IM medication with Haldol and Ativan. • Her physician and other staff felt that the patient was behaving in this manner to stay on the unit and to prevent her parents from leaving on vacation. • Phone calls and visits from her parents were limited because the patient would worsen after them. • After 1 week, she attended unit activities for short time periods. • At the end of the second week, she appeared to be functioning at her baseline. • Mental status on discharge: thought content. Denies any auditory and visual hallucinations and any suicidal ideation. Discharge diagnosis: • AXIS I: psychotic disorder NOS. • AXIS II: borderline personality traits. • AXIS III: congenital heart defect, S/P numerous reconstructive surgeries. Discharge plan: • She has a follow appointment at the Westchester Medical Center Outpatient Clinic. • Medications: Risperdal prn anxiety.
PY - 2006/5
Y1 - 2006/5
N2 - Objective: As healthcare practice transitions from paper-based to computer-based records, there is increasing need to determine an effective electronic format for clinical narratives. Our research focuses on utilizing a cognitive science methodology to guide the conversion of medical texts to a more structured, user-customized presentation in the electronic medical record (EMR). Design: We studied the use of discharge summaries by psychiatrists with varying expertise - experts, intermediates, and novices. Experts were given two hypothetical emergency care scenarios with narrative discharge summaries and asked to verbalize their clinical assessment. Based on the results, the narratives were presented in a more structured form. Intermediate and novice subjects received a narrative and a structured discharge summary, and were asked to verbalize their assessments of each. Measurements: A qualitative comparison of the interview transcripts of all subjects was done by analysis of recall and inference made with respect to level of expertise. Results: For intermediate and novice subjects, recall was greater with the structured form than with the narrative. Novices were also able to make more inferences (not always accurate) from the structured form than with the narrative. Errors occurred in assessments using the narrative form but not the structured form. Conclusions: Our cognitive methods to study discharge summary use enabled us to extract a conceptual representation of clinical narratives from end-users. This method allowed us to identify clinically relevant information that can be used to structure medical text for the EMR and potentially improve recall and reduce errors.
AB - Objective: As healthcare practice transitions from paper-based to computer-based records, there is increasing need to determine an effective electronic format for clinical narratives. Our research focuses on utilizing a cognitive science methodology to guide the conversion of medical texts to a more structured, user-customized presentation in the electronic medical record (EMR). Design: We studied the use of discharge summaries by psychiatrists with varying expertise - experts, intermediates, and novices. Experts were given two hypothetical emergency care scenarios with narrative discharge summaries and asked to verbalize their clinical assessment. Based on the results, the narratives were presented in a more structured form. Intermediate and novice subjects received a narrative and a structured discharge summary, and were asked to verbalize their assessments of each. Measurements: A qualitative comparison of the interview transcripts of all subjects was done by analysis of recall and inference made with respect to level of expertise. Results: For intermediate and novice subjects, recall was greater with the structured form than with the narrative. Novices were also able to make more inferences (not always accurate) from the structured form than with the narrative. Errors occurred in assessments using the narrative form but not the structured form. Conclusions: Our cognitive methods to study discharge summary use enabled us to extract a conceptual representation of clinical narratives from end-users. This method allowed us to identify clinically relevant information that can be used to structure medical text for the EMR and potentially improve recall and reduce errors.
KW - Cognitive science
KW - Electronic medical records
KW - Medical narratives
KW - Mental health care
KW - User interface
UR - http://www.scopus.com/inward/record.url?scp=33645411224&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=33645411224&partnerID=8YFLogxK
U2 - 10.1016/j.ijmedinf.2005.07.027
DO - 10.1016/j.ijmedinf.2005.07.027
M3 - Article
C2 - 16125455
AN - SCOPUS:33645411224
SN - 1386-5056
VL - 75
SP - 346
EP - 368
JO - International Journal of Medical Informatics
JF - International Journal of Medical Informatics
IS - 5
ER -