After another conversation with Johannes Ernst I am thinking more about how we can make BirdDog more web-twoey. The concept of attention came up, prodded by a forum Jernst participated in earlier this year. He was saying that the bedside experience might be supplemented with emitting devices that could interact with a handheld device, say to deliver vital signs (VSs). I stated no, the big deal is getting information about the patient from systems that are remote (e.g., ECGs, images, clinical profile from the data repository). As I was elaborating in the last entry to this blog, there is value in understanding and declaring explicitly the log of all salient decision points that pertain to a particular encounter. The 'attention' path of the clinician is the basis for clinical decisions, but only a small proportion of the evidence is usually documented. To the extent that this can be automated, the power of the note will be enhanced, making for a more robust document.

The other Web 2.0 concept that we definitely want to exploit is RSS technology. The idea here is entirely compatible with the role of BirdDog as a passive information space. I subscribe to my patients' data feeds -- they render directly on my device without any need for repetitive requests on my part. (Though I might want to set some parameters for efficiency's sake.)

Finally there is the identity management part of the application. Besides achieving SSO, I might want to register various levels of presence to the application, depending on my role, devices and availability. Netmesh is working on this.

The elements of a good encounter note:
For those who are not in medicine or medico-legal disciplines, let me describe the clinical enocunter note. A patient arrives in the clinic or emergency room, with a complaint or complaints, and the physician asks a more-or-less directed series of questions, perhaps orders some tests, draws some conclusions and scribbles some summary notes. The resultant document is designed to be structured as an argument in support of a set of conclusions, resulting in a plan of action. A good note has the following characteristics: it is complete, coherent, and logically sound. That way, if something unexpected arises in the patient's condition, it is easy to understand why the physician decided on the course of action, and possible to compare what she did with what other similarly trained clinicians might have done with the same information. Of course, acknowledging all of the small elements that support a clinical diagnosis and plan can be time-consuming, so there is usually some truncation in the name of efficiency. But in the era of a fully electronic medical record, the task is infinitely easier, since much of the entire experience of the clnician is traceable as she retrieves the data in support of her conclusion. If she summons an electrocardiogram (ECG) taken on her patient, the reference to that retrieval belongs in the chart, along with comparison ECGs from the same patient. The same is true of other laboratory results, images, and any other digital records that are pertinent. The chart can be a hyper-linked access log with annotations summarizing the decision points along the way. Other decision support tools can be embedded at the same time, including treatment guidelines and reference articles. Much of this can be automated, saving the clinician time while creating a very robust document. The potential drawback of this kind of solution is that the parts of the chart that are left out may be quite important but harder to document; nuances, intuition, and the art of observation are harder to describe verbally, but may be very crucial. I would still argue that this kind of chart would be an improvement.