Structuring Clinical Data for Improving Departmental Functionality

Abstract

A practical clinical information system used in a hospital's Department of Obstetrics and Gynecology is described, demonstrating its utility to automatically provide required regulatory reports and potential clinical performance improvement, in an easy-to-use way. Its use demonstrates how physician's workflow can be left unimpeded, while centralizing scribe activity to translate textually based documentation to structured data, to improve functionality within its departmental activity. The ability to easily view clinical trends from the collected data continues to demonstrate the value of structured data.

Keywords

medical informatics - obstetrics gynecology - natural language processing - medical scribe

Note

All ethical standards have been followed in the creation of this manuscript.

• References

• 1 Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect 2016; 6 (05) 32643
• 2 Park A, Hartzler AL, Huh J, McDonald DW, Pratt W. Automatically detecting failures in natural language processing tools for online community text. J Med Internet Res 2015; 17 (08) e212
• 3 Pearson E, Frakt A. Medical scribes, productivity and satisfaction. JAMA 2019; 321 (07) 635-636
• 4 Eisenberg M, Hom J, Sharp C. The electronic health record as a healthcare management strategy and implications for obstetrics and gynecologic practice. Curr Opin Obstet Gynecol 2013; 25 (06) 476-481
• 5 Raglan GB, Margolis B, Paulus RA, Schulkin J. Obstetrician/gynecologists' experiences with electronic health record systems: a narrative study. J Reprod Med 2015; 60 (3-4): 95-102
• 6 McCoy MJ, Diamond AM, Strunk AL. ; American Congress of Obstetricians and Gynecologists' Committee on Ambulatory Practice Operations. Special requirements of electronic medical record systems in obstetrics and gynecology. Obstet Gynecol 2010; 116 (01) 140-143
• 7 Available at: https://www.jointcommission.org/perinatal_care/ . Accessed February 20, 2019
• 8 Altman MR, Colorafi K, Daratha KB. The reliability of electronic health data used for obstetrical research. Appl Clin Inform 2018; 9 (01) 156-162