Encounter: Structured Data vs Free Text

When completing a medical encounter, a physician enters a wide variety of data depending on the purpose of the patient’s visit and patient’ condition. Recording vital signs, complaints, physical examination findings, treatment plan, prescriptions, and other details is part of a doctor’s everyday routine.

Every EHR (Electronic Health Record) developer faces a recurring dilemma: should the system primarily support structured data entry, or should physicians be given greater flexibility to enter information in free-text form? It’s important to note that we’re talking about a predominant — not exclusive — use of structured or unstructured data, as it’s widely understood that relying solely on one or the other is an unacceptable extreme. Let’s first briefly explore the pros and cons of each data type.

Structured data enables physicians to quickly select relevant patient health parameters and treatment plan options. The doctor chooses values from predefined lists, clicking on parameters that match the patient’s condition. Additionally, a system built around structured data allows for more comprehensive reporting thanks to standardized and parameterized entries. The key advantage is the apparent simplicity — everything is done with a mouse clicks. However, this approach comes with a significant drawback: it often doesn’t allow for a personalized description of the patient’s condition or tailored treatment strategies. Physicians using heavily structured EHRs frequently feel constrained by the system’s rigid framework.

Free text, on the other hand, allows physicians to describe patient complaints, examination results, and treatment decisions with 100% precision and nuance. The downside is that doctors may find themselves acting more like secretaries, spending valuable working hours typing. Clearly, a doctor’s primary focus should be on diagnosis and treatment, aligned with medical protocols.

So, what is the ideal “golden mean” for documenting encounter data? Naturally, the best approach is a smart combination of structured and unstructured data. Our perspective is based both on our experience developing Intellia EHR — our medical process management platform — and on feedback from healthcare professionals regarding their preferences.

Let’s examine each component of the encounter individually:

  • Vital Signs – Here, structured data entry is unquestionably the right choice.
  • Patient Complaints – Free text is likely to provide the most accurate and individualized description of the patient’s concerns.
  • Physical Examination – As with complaints, doctors generally prefer to document this in unstructured form.
  • Diagnosis – Structured data is essential here, typically using ICD-10 or ICD-11 codes. However, it’s useful to supplement the structured diagnosis with an unstructured clinical narrative that adds context or detail.
  • Treatment Plan – A balanced combination is optimal:
Unstructured data works best for general recommendations, treatment duration, contingencies, points of attention for the patient, and treatment personalization based on comorbidities.
Structured data is ideal for prescriptions (medications, diagnostic and therapeutic procedures, lifestyle recommendations), using internal system classifiers.

As you may have noticed, unstructured data plays an important role in much of the encounter. So how can we prevent physicians from turning into data-entry clerks?

There are several effective solutions:

  • The simplest: use encounter templates and reusable components. System-wide templates help maintain consistency in documentation across all staff in a medical organization. This can be further enhanced by allowing individual physicians to create personalized templates, tailored to the needs of their specialty. All the doctor needs to do is choose the most appropriate template and fill in the key details in a pre-populated encounter. This solution is typically available in mid-range EHR systems, including Intellia EHR.
  • AI support: In simpler systems, AI can serve as a transcription tool; in more advanced (and more expensive) systems, it can act as a digital assistant.

Conclusions

Our experience and survey data show that templates are the most preferred solution, as they are intuitive and give physicians confidence in their documentation.

The EHR you choose ultimately depends on your organization’s needs and preferences. However, we hope this article has helped guide you toward making the right decision.