Academic Medicine wiki-based narrative

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This exhibit is supplementary to the manuscript It’s Time to Wikify Clinical Documentation: How Collaborative Authorship Can Reduce the Burden and Improve the Quality of the Electronic Health Record.

The purpose of this page is to illustrate how a wiki-based clinical document might appear; the content is based on a series of synthetic notes that can found here. These notes are completely synthetic and any resemblance to a real patient is entirely coincidental. Text versions of the notes can be accessed here.

Note: some of the links below are to external websites such as Wikipedia and the NCI Thesaurus. In a true medical wiki, these external links would likely be replaced with application programming interfaces (APIs), which would enforce HIPAA-compliant authentication and authorization.


Demographics

Note: the linked "Sex" is to a value set that specifies a set of structured choices from the FHIR AdministrativeGender value set, as an example of how wiki-based formatting can be linked to structured concepts. Likewise, the "Race" and "Ethnicity" concepts can be linked directly to the CDC Race and Ethnicity Code Set Version 1.0, which is required for certified EHRs. Note also that some versions of wiki software can calculate dates, such as the current age based on DOB (not currently enabled here).

  • Patient Name: PatientX
  • Sex: Female
  • DOB: January 1, 1960
  • Race: White (2106-3)
  • Ethnicity: Not Hispanic or Latino (2186-5)
    • Note that "concept codes" such as 2106-3 do not have to be shown, and can be toggled/hidden.

Active medical problems

This is the core of the medical wiki and could be arranged by subheadings, as here, or across multiple linked pages. Each active problem can be split into multiple sub-headings, such as the diagnosis and treatment subheadings here.

Breast carcinoma

Diagnosis

This section illustrates the use of a standard wikitable for the various diagnostic procedures. Also illustrated is the use of color to specify which author has added the content: blue = radiologist; green = medical oncologist

  • HPI: In early 2010, she noticed a hard palpable lump in her left breast and sought medical attention. She has been adherent to a schedule of annual mammography since age 40, last in 2009 and normal. No particular family history of breast cancer. She denies weight loss, change in appetite, jaundice, fatigue, or focal pain.
Date Procedure Findings
2010/01/21 Full field digital mammography with CAD was performed including routine views of both breasts, spot magnification views on the right with a full 90 degree lateral and spot compression views on the left. Heterogeneously dense fibroglandular tissue is present throughout both breasts limiting the sensitivity of the mammogram. There is no evidence of mass or calcifications in the right breast.


A large firm mass is seen in the upper outer left breast at the 10:30 o'clock region. The mass measures 1x2 cm on the CC view. Calcifications are seen adjacent to the mass.

2010/01/21 Left breast and axillary ultrasound A large hypoechoic mass at the 10:30 location of the left breast is highly suggestive of a malignancy. The mass measures 1.2x3.4x5.6 cm.


Abnormal left axillary lymph nodes are highly suspicious of metastatic disease.

2010/02 CT A/P negative for metastatic disease

Prognosis

This cancer-specific section illustrates the use of a standard wikitable to summarize stage, and highlighting to emphasize pertinent biomarker information.

Modality AJCC Edition T-stage N-stage M-stage Summary stage
Clinical 7th cT3 cN1 cM0 IIIA
Pathologic 7th ypT1a ypN1 ypM0 IIA
  • More information at Cancer.net
  • Other prognostic factors:
    • Nottingham score: 8/9
    • Surgical margins: Negative
    • Response to neoadjuvant therapy: Grade 3 per the Miller Payne scoring system
    • Biomarkers: ER/PR/HER2-negative (triple-negative)

Treatment

Neoadjuvant therapy

These links go directly to details about the drugs, doses, and schedules used in these treatments.

  • Feb - May 2010: T x 9 -> ddAC x 4

Definitive therapy

  • 2010/06/30: Left modified radical mastectomy

Postoperative therapy

  • Observation

Current status

  • 2018/06/15: No evidence of disease

Diabetes mellitus type 2

Diagnosis

  • First noted to have gestational diabetes during her second pregnancy, at age 32. At age 43, she met the definition of DM2.

Treatment

Note that by linking to the medication list below, details do not necessarily need to be repeated here. Wikis also have the ability to bring external information such as lab results into the page through a process called transclusion, which could be employed here for the A1c.

Current

Previous

  • 2003-2005: Diet and exercise

Hypertension

Diagnosis

  • Initially noticed to have white-coat hypertension at age 42, developed into hypertension by age 46 per JNC Guidelines

Treatment

Note that by linking to the medication list below, details do not necessarily need to be repeated here.

Current

Previous

  • 2002-2005: Diet and exercise
  • 2005-2008: HCTZ for 3 years, initially effective but then was no longer working

Resolved medical problems

Peripheral neuropathy

Notice how this problem is linked to the drug that caused it (on a separate page) and to the disease for which it was used.

  • Cause: Paclitaxel (Taxol) chemotherapy, given for breast cancer
  • Treatment: removal of paclitaxel from the treatment regimen
  • Resolution: nearly complete, with some minor residual tingling in the fingertips

Allergies

Medications

This section illustrates a sortable table, which can be re-arranged by clicking on any of the columns. Notice that each drug name is linked to the structured concept of that drug in the RxNorm ontology, and some indications are linked back to the problem list section of the wiki. Here, aspirin is labeled as an NSAID, which is technically true but may not reflect the prescribed purpose. A user could update this drug class to anti-platelet medication.

Class of drug Drug Dose Route Frequency Scheduled or prn Indication
Anti-diabetic Metformin 500 mg PO once per day Scheduled T2 DM
Anti-hypertensive Lisinopril 5 mg PO once per day Scheduled HTN
NSAID Aspirin 81 mg PO once per day Scheduled Primary prevention of MI/CVA
Anti-emetic Ondansetron 4 mg ODT TID prn Prevention of CINV

Family history

  • Mother: living, with dementia
  • Father: d. of cerebral aneurysm, age 64
  • Sister #1: alive and well
  • Sister #2: alive and well

Social history

Alcohol

  • Occasional drinks

Tobacco

  • Former smoker
    • Smoked 1/2 PPD x 5 years
    • Quit 20 years ago