An Easily Adopted Markup Discipline for Annotating Electronic Medical Records with Ontological and Epistemological Qualification: Toward Disciplined Asterisks, Parentheticals, Marginalia, Footnotes, and Hashtags

Structured data and controlled vocabularies in medical records are common goals, but widespread and eager clinical adoption might require more modest, incremental change. One small step along the path to structured data is a voluntary discipline of annotation, supported by simple, user-friendly, dynamic text affordances. A second step is to discipline the meta-vocabulary rather than the clinical vocabulary: one can target the epistemological attitudes (probability, degree of uncertainty, pedigree of claims) and ontological criteria (fuzziness or vagueness, version of definition, reporting standard) for optional mark up, and even plain text can support disciplined annotation. The methods seem especially useful for summary views of patient records that have multiple authors, contributing at different times, using various criteria. The methods may also support more nuanced outcomes research and reporting, and aid transitions between policies, regulations, and billing codes. It may be too difficult to impose ontologies on so many different participants in medical record-keeping, all at once, with little room for customization. A more organic, evolutionary path to the same end starts with the smaller step of asking medical records keepers to settle on the common annotations. Even as a crowd-sourced meta-language takes shape, the freedom to use epistemic and ontological qualifiers makes controlled terminologies and vocabularies, with discrete and structured data, easier to live with.