AMIA Health Policy Meeting Addresses Shortcomings of Clinical Data Capture and Documentation

Thursday, December 8, 2011

WASHINGTON, DC — AMIA, the leading professional association for informatics professionals, concluded its 6th Annual Health Policy Meeting this week in Washington, DC. Meeting participants identified numerous limitations with existing data capture, recording and documentation approaches, systems and processes. As a result, users often experience significant frustrations such as data overload, documentation redundancies, and data entry inefficiencies. Furthermore, technological capabilities such as the emergence and convergence of devices are outpacing current public policies. At the same time, potentially outdated legacy documentation requirements are hampering source data capture and documentation and hindering innovations in health information technology design.

Caitlin Cusack, MD, MPH, Principal Insight Informatics and the AMIA Policy Meeting Steering Committee Chair, emphasized, “With documentation and data capture being significant areas of dissatisfaction for clinicians using electronic health records, it is crucial to re-assess current regulations and policies that drive those practices, especially as pressure to adopt technology becomes increasingly intense. “ Meeting attendees, who are all leaders from various public and private sector organizations involved in expanding the use of informatics and health information technology (health IT), discussed their visions for achieving the “ideal” future state of technology-enabled data capture and documentation. Participants also helped to refine AMIA’s proposed guiding principles for clinical data capture and documentation, and proposed attributes for high-quality clinical information.

AMIA Board Chair-elect Gil Kuperman, MD, PhD, FACMI, and Director, Interoperability Informatics, New York-Presbyterian Hospital noted, “ It was important for us to consider the strengths and weaknesses of current approaches to clinical documentation and data capture from multiple stakeholder perspectives in order to identify knowledge gaps and research priorities.“

George Hripcsak, MD, MS, FACMI, Chair, Department of Biomedical Informatics, Columbia University and Vice Chair of the AMIA Policy Meeting Steering Committee, emphasized “that there are potential shortcomings to current approaches, which can impede efficient data capture and presentation, misrepresent clinicians’ thinking, and interfere with clinical workflow.”

More than 80 participants attended the AMIA meeting, including leaders from various Federal agencies, such as the Agency for Health Care Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the National Library of Medicine (NLM), the National Institute of Standards and Technology (NIST) and the Office of the National Coordinator for Health Information Technology (ONC). Jon White, MD, Director of the Health IT Portfolio at AHRQ and Farzad Mostashari, MD, ScM, National Coordinator, ONC participated as plenary session speakers.

Edward H. Shortliffe, MD, PhD, FACMI, president and CEO of AMIA, emphasized that “from personal experience I can attest that entering patient data, often following non-intuitive series of screens or clicks, can be a source of tremendous frustration and inefficiency for busy clinicians. I am therefore delighted that our meeting participants confirmed that the need for high quality data underlies all clinical work and that enhancing ways to assure efficient data capture and documentation is critical to achieving the Nation’s strategy for high quality health and healthcare.”

AMIA will broadly disseminate meeting findings and policy recommendations as well as strategies to promote widespread dissemination and application of the guiding principles and information attributes. A formal report will be forthcoming. For more information about the meeting please visit:

About AMIA

AMIA serves as the voice of the nation’s top biomedical and health informatics professionals and plays an important role in medicine, health care, and science, encouraging the use of data, information, and knowledge to improve both human health and delivery of healthcare services.


For more information, contact:
Meryl Bloomrosen