โMetadataโ sounds highly technical.
But the basic concept is actually pretty simple:
Metadata is information about data.
In the context of an electronic health record, the clinical note is the information you read.
Metadata may provide information about the electronic activity associated with that information.
Depending on the EHR system and the data available, metadata and audit information may help provide context regarding things such as:
- Dates and times associated with electronic activity
- Users associated with certain actions
- Entry, signing, or modification activity
- The sequence of electronic events
- Other system-generated information surrounding documentation
Why could that matter in a medical case?
Because the visible medical record generally presents the clinical documentation as we see it now.
๐๐ฎ๐ญ ๐ฌ๐จ๐ฆ๐๐ญ๐ข๐ฆ๐๐ฌ ๐ญ๐ก๐ ๐ฅ๐๐ ๐๐ฅ ๐ช๐ฎ๐๐ฌ๐ญ๐ข๐จ๐ง ๐ข๐ฌ๐งโ๐ญ ๐ฌ๐ข๐ฆ๐ฉ๐ฅ๐ฒ:
โWhat does the note say?โ
๐๐ญ ๐ข๐ฌ:
โWhat is the electronic history surrounding this documentation?โ
For example, suppose a note documents that a provider was notified about a significant change in a patientโs condition.
The note itself may be clinically important.
๐๐ฎ๐ญ ๐๐๐ฉ๐๐ง๐๐ข๐ง๐ ๐จ๐ง ๐ญ๐ก๐ ๐ข๐ฌ๐ฌ๐ฎ๐๐ฌ ๐ข๐ง ๐ญ๐ก๐ ๐๐๐ฌ๐, ๐๐๐๐ข๐ญ๐ข๐จ๐ง๐๐ฅ ๐ช๐ฎ๐๐ฌ๐ญ๐ข๐จ๐ง๐ฌ ๐ฆ๐๐ฒ ๐๐ซ๐ข๐ฌ๐:
When was the documentation entered?
Was it subsequently modified?
What electronic activity occurred around the relevant clinical event?
Metadata doesnโt answer every question, and it should never be interpreted without understanding the particular EHR system and the clinical context.
It also doesnโt automatically establish that something improper occurred.
Instead, think of metadata as another layer of information that may help reconstruct the electronic history surrounding the medical record.
The chart tells us the clinical story that was documented.
The metadata may help us better understand the electronic story behind that documentation.
๐ ๐ช๐ฎ๐๐ฌ๐ญ๐ข๐จ๐ง ๐๐จ๐ซ ๐๐ญ๐ญ๐จ๐ซ๐ง๐๐ฒ๐ฌ:
Before this series, had you ever considered requesting or reviewing metadata as part of a medically complex case?
Iโd love to know whether this is something youโve encountered in discovery.
Beyond the Medical Record
A weekly series exploring EHR audit trails, metadata, and the electronic story behind the medical record.