Electronic health records have the potential for enormous good, but in order for them to live up to their full potential, information about patients -- their symptoms, diagnoses, allergic reactions, medical backgrounds, family histories -- must take the form of standardized, structured, easy-to-manipulate data. One obvious way to get there is to tightly structure the way that doctors create the medical record. As a result, physicians are under increasing pressure to abandon unrestricted natural language and the clinical narrative, and turn the medical documentation process into a jungle of pull-down menus, checkboxes, and restricted vocabularies. In this presentation I argue that the results could be catastrophic, I make the case for preserving the clinical narrative, and I argue for a practical way out of the dilemma: using natural language processing technology to produce the structured records we need, while still allowing physicians the freedom of unrestricted clinical language.
9th–13th March 2012