These “doctor’s notes” or “sick leave” are the attestations we do for a patient when they’re ill and they need a proof of that for work and/or insurance. The contents will differ greatly in different countries, but the ones I describe here are similar to the Swedish ones1.
We can also greatly enhance and streamline the entry of running notes in the medical record. These notes are usually structured as a list of “items”, where each item corresponds to a type of data, or a clinical sign or symptom. The actual selection of which items to use depends on why we’re seeing the patient, as expressed through the “type of contact” (or “problem”). The content (value) of the items, however, is free text, but usually limited to a few variations only. These, the system can learn and present.
While creating referrals in a record system, the workflow is fairly predictable. For any particular kind of problem, there’s only a relatively limited range of referrals you are going to write, so we can let the system record which ones we use and pop up a list of last used referrals the next time we see a patient with the same problem (“type of contact”).
When you’re seeing a patient, it’s very often useful to do a search for diagnostic and therapeutic guidelines, medical articles, regional or institutional recommendations and so on. These searches need to be restricted to appropriate sources, not just the wild internet. Once you’ve done a search and found some useful information, you’d probably want to save a reference to it and be able to locate it again the next time you see this patient, or another patient with a similar problem.
As I see the structure of medical knowledge and its application to patients, there are three levels:
- Biological science, pathology, EBM, epidemiology, etc. In other words, everything we know about human biology and pathology in the large, not at the individual level.
- Applications and methods that apply biological science to the individual patient, and methods using the history of the patient to search for applicable science.
- Knowledge about a particular patient, signs, symptoms, treatments and diagnostics that have already been performed. In short, the individual patient history.
Each of these three levels correspond to particular processes and methods, and computer applications also fit one or more of these levels. For instance, IBM Watson sits squarely in level 1, while current Electronic Healthcare Record (EHR) systems are fully in level 31.