Capturing Clinician Reasoning in Electronic Health Records: An Exploratory Study of Under-Treated Essential Hypertension.

Monitoring response to antihypertensive medications is a frequent reason for outpatient visits. Blood pressure (BP) is often documented as elevated, but no change in medication occurs (Medication Non-adjustment or MNA). We studied the frequency of MNA, reasons for non-adjustment, how reasons (including reasons for patient nonadherence) were documented, and whether they could be represented in a clinical care context ontology. We examined 129 visit notes with MNA occurring in 80 cases (59%). We coded MNA as Conscious Maintenance (patient adherent but clinician continues therapy for stated reason), Nonadherence (clinician attributes BP elevation to patient nonadherence), and Finding Not Addressed (clinician does not indicate reasoning for MNA). We characterized Conscious Maintenance with 11 subcodes and Nonadherence with 6 subcodes. Our ontology successfully represented relationships between concepts and reasoning, supporting the feasibility of formal representation of clinical care contexts for patient care, decision support and research.