MedKnowts: Unified Documentation and Information Retrieval for Electronic Health Records

TL;DR

MedKnowts is a unified system that streamlines clinical documentation and information retrieval in electronic health records, especially aiding emergency clinicians with rapid, structured, and concept-oriented access to patient data.

Contribution

It introduces an integrated note-taking and retrieval system that automatically captures structured data and provides concise, concept-focused views of patient records.

Findings

Reduces documentation time for clinicians.

Enhances quick access to relevant patient information.

Supports structured data entry alongside natural language use.

Abstract

Clinical documentation can be transformed by Electronic Health Records, yet the documentation process is still a tedious, time-consuming, and error-prone process. Clinicians are faced with multi-faceted requirements and fragmented interfaces for information exploration and documentation. These challenges are only exacerbated in the Emergency Department -- clinicians often see 35 patients in one shift, during which they have to synthesize an often previously unknown patient's medical records in order to reach a tailored diagnosis and treatment plan. To better support this information synthesis, clinical documentation tools must enable rapid contextual access to the patient's medical record. MedKnowts is an integrated note-taking editor and information retrieval system which unifies the documentation and search process and provides concise synthesized concept-oriented slices of the patient's medical record. MedKnowts automatically captures structured data while still allowing users the flexibility of natural language. MedKnowts leverages this structure to enable easier parsing of long notes, auto-populated text, and proactive information retrieval, easing the documentation burden.