Biomedical Informatics 4th Edition by Edward Shortliffe, James Cimino

Exercise 6

It has been argued that the ability to cap ture "nuance" in the description of what a clinician has seen when examining or interviewing a patient may not be as crucial as some people think. The desire to be able to express one's thoughts in an unfettered way (free text) is often used to argue against the use of structured data-entry methods using a controlled vocabulary and picking descriptors from lists.
(a) What is your own view of this argu ment? Do you believe that it is important to the quality and/or efficiency of care for clinicians to be able to record their observations, at least part of the time, using free text/natural language?
(b) Many clinicians may be unwilling to use an electronic health record (EHR) system requiring structured data entry because of the increased time required for documentation at the point of care. What are two strategies that could be used to address this problem (other than "designing a better user interface for the system")?