We hypothesize that the functionality of electronic health records could be improved with the addition of formally representations of clinicians’ cognitive processes, including such things as the interpretation and synthesis of patient findings and the rational for diagnostic and therapeutic decisions. We carried out a four-phase analysis of clinical case studies to characterize how such processes are represented through relationships between clinical terms. The result is an terminology of 26 relationships that were validated against published clinical cases with 85.4% interrater reliability. We believe that capturing patient-specific information with these relationships can lead to improvements in clinical decision support systems, information retrieval and learning health systems.
Learning Objective 1: To understand the motivation for representing clinical cognition terms in electronic medical records
James Cimino (Presenter)
University of Alabama at Birmingham
Ziran Li, Columbia University
Chunhua Weng, Columbia University