There is a need in medicine for tools that permit clinicians to easily capture the relevant details of a patient encounter without reliance on a traditional dictation/transcription model. Ideally the resultant clinical databases could be used to drive everything from clinical research and outcomes analysis to automatic prescription writing and billing. Such systems are especially powerful when integrated into other information systems so that they can automatically generate patient specific content. Unfortunately, the widespread adoption of computerized clinical documentation tools has historically been constrained due to inefficiencies in the user interface, inflexibility and the inability to generalize tools designed for one knowledge domain to others.

Quill is a structured reporting tool that is being developed and deployed at Vanderbilt University Medical Center to permit easy documentation of categorical information using a simple interface that overlies a structured vocabulary. Quill's user interface is designed to allow input primarily by using "point-and-click" entry. However, typed free text, keyboard shortcuts, dictation/transcription, and voice recognition also are permitted as methods of data entry. Documentation using Quill occurs through the use of highly customizable templates. Templates are aggregations of elements of the Quill controlled vocabulary, can be designed by users or subject matter experts, and are created to prompt documentation of particular problems or to follow specific guidelines. Quill is designed to be useful across multiple knowledge domains, so that it could be used equally to detail the clinical assessment of a healthy two-month-old child or to document a history and physical exam of an elderly patient who is admitted to the hospital with chest pain.

User input into Quill is both stored as an XML file and computer generated clinical prose. The XML file currently is used to bring categorical information from prior sessions in Quill forward to populate subsequent notes. Its evolutionary use will include populating research databases and serving as a real-time information resource for other clinical applications such as order entry.

Primary Contact: Ed Shultz, MD, MS.