November 16th, 2014

Electronic Medical Records and the Demise of the Useful Medical Note

Electronic medical records (EMRs) are much on my mind, as last week at Medical Grand Rounds Robert (Bob) Wachter, chief of the medical service at UCSF, gave a brilliant talk on the unanticipated consequences of our move towards what he calls the “Digital Doctor.”

Bob has thought a lot about this issue, so much so that he’s about to publish a book on the topic. In his talk, after a brief history of how we got to where the vast majority of U.S. physicians use EMRs, he focused on three main consequences:

  1. The fact that doctors now interact as much (if not more) with screens as they do with patients — the “iPatient” phenomenon. The no eye contact problem. The lack of doctors on the medical wards, as we gravitate toward “work rooms” full of computers. You know how pediatricians sometimes get drawings from their school-age patients that include the doctor? He showed a remarkable example, in crayon of course, of a doctor facing away from the artist (the child), the MD staring at a computer screen and typing. From the book: “I’m guessing this one didn’t make it onto the doctor’s Wall of Fame.”
  2. The loss of interaction between doctors when the data are digital rather than something you can hold. Remember that brilliant radiologist who used to go over all chest films on your medical team? Now a radiologist may be reviewing films at home overnight, or in India, reports filed digitally and not requiring any human-to-human contact with the ordering doctor. Radiology rounds are slowly disappearing, along with the time for clinicians to pause — and think collectively — about what the images mean.
  3. The potential for automated systems to amplify medical errors. We’ve grown increasingly reliant on computers to help with decisions, for better and worse. In a taut, complex story involving a series of increasingly unlikely errors, he described how a child received a massive overdose of medication during hospitalization — all the indirect result of how a poorly designed systems can usurp clinician autonomy.

What he didn’t have time to cover (but does so in the book — he shared the excerpt with me), is the powerful effect EMRs have had on clinical notes.

It’s a fact that the note as means of communicating how the patient is doing has all but been destroyed. Notes even from the best clinicians routinely have the following features:

  • A massive amount of repetition. Cut/paste phenomenon #1.
  • “Required” elements that serve no clinical purpose. How useful is a lengthy review of systems? And isn’t a history-directed, targeted physical examination of far greater value than a comprehensive one “done” merely to meet higher billing criteria?
  • Giant chunks of computer-generated data. Cut/paste phenomenon #2. It’s mostly lab and imaging results, with no interpretation of what the data mean.
  • Factual errors. Cut/paste phenomenon #3. In the ambulatory record, one of my favorites is that some children never age:  “Has three children, a son age 10, daughters ages 8 and 1” — which is then written unchanged in the social history over the next five years. Reminds me of The Simpsons — Bart, Lisa, and Maggie never age either. On the inpatients, we routinely see this: “ID consulted, considering pneumonia, UTI, C diff, disseminated fungal infection as cause for fevers” — then these same words are repeated for many days after some or all of these diagnoses have been ruled out.
  • Sentences whose sole purpose is to avoid getting sued. You know ’em when you see ’em. They sound defensive, are depressing to read, and communicate no useful clinical information.
  • Boilerplate text of highly dubious relevance to the individual case. During a mandatory “compliance” review of my notes (shudder — is there anything in modern medicine more painful?), I had someone suggest I add the following phrase to all of my notes: “More than 50% of this 30-minute visit was spent counseling the patient on the chronic nature of his/her condition, the rationale behind the laboratory tests ordered, the importance of taking medications directed, and the directions for making follow-up visits. Contact information provided, and patient’s questions answered.” The rationale? “You don’t do a procedure, so you need to improve the documentation of what you’re doing with your time.” Lovely.

The genesis of this problem, of course, is that the medical note is trying to do too many things at once. Previously a way of summarizing the clinical course of the patient, both for our own individual use and to communicate with other clinicians, it now has other masters with different motivations. Facilitated by EMRs, the note has subsequently evolved into a Jackson Pollock-like canvas of disjointed text, much of it of marginal or no clinical significance, with sections held together only loosely by the name and medical record number at the top of the page or screen.

Here’s a solution that will never happen — let’s have the medical note evolve even further, breaking it down into distinct sections based on their primary purpose. Imagine three tabs on the top of the note; you get to read only the one you want or need:

  1. Clinicians, here’s your section — it includes the stuff you really want to know, such as the history, exam, and lab/imaging results that matter (not all the labs/imaging, thank you), plus what the clinician writing the note thinks is going on, and what he/she plans to do.
  2. Billing compliance folks, read this part — it will have the required review of symptoms (most of them irrelevant), lengthy rubber-stamp documentation of counseling and education, and whatever other parts are required by whatever payor this patient has. And it will be inserted there by someone who’s not a doctor — or even better, by some automated bot — because successfully generating this kind of documentation is not why we went to medical school.
  3. Medicolegal guys, this is for you — lots of defensive phrases here, none of them of any clinical relevance, but they’re here just in case something untoward happens and the case ends up in court.

Have fun.

Next up — an example of an ideal ID consult note, just for old-time’s sake.


22 Responses to “Electronic Medical Records and the Demise of the Useful Medical Note”

  1. Loretta S says:

    A local ophthalmologist writes consult notes with a prominent section on page 1: “Practice Corner: What the Referring Physician Needs to Know”. I bless him every time I see it, because I can scan right to that section and get the executive summary that tells me what is going on with my patient. I can read everything else for more detail, if I need it.

  2. Jeanne says:

    Great post, Paul. I look forward to reading Wachter’s book. In looking at his blog, it appears that that crayon drawing of the inattentive physician at the computer was in a 2012 JAMA piece called “The Cost of Technology”. I wonder how much higher that cost is these two years later. I fear the day will come when doctors don’t even touch patients any more.

    • Paul Sax says:

      it appears that that crayon drawing of the inattentive physician at the computer was in a 2012 JAMA piece called “The Cost of Technology”

      Jeanne, thanks for the reference, have added the link. My wife of course loves this one (she’s a pediatrician), though she questions the authenticity. Skeptic!

  3. Susan says:

    Reminds me of what a psychiatrist who specializes in addictive disorders once told me, “Nothing ever good comes of telling the truth about drug or alcohol use”. With all the cutting and pasting, even if a person gains recovery, they remain an ‘abuser’ in the EMR.

  4. Gary R Botstein MD says:

    Great blog. As someone who wrote (and still uses) a DOS based EMR for personal use only in 1994 (which will NEVER, thank goodness ever qualify for Meaningful Use), and as an AMA committee member who wrote “Improving Care: Priorities to Improve Electronic Health Record Usability” released by AMA in September 2014, I applaud your piece. As a father of a medical resident I would also add that the young people training in medicine will NEVER understand the critical role of the office/clinic note. So if we (medicine and harmed patients) ever do convince HHS and the EMR vendors to get EMR’s right, who will be left to remember how quality medicine and communication was done? My fear is that the damage will be permanent.

  5. Cecile says:

    Very provocative! How do we as physicians “rage against the machine?” Do we continue as glassy eyed lemmings beholden to an inept government that requires us to treat their “directives” rather than the patient? It seems regardless of the outcome, the patient loses. . .again!

  6. Ray Ross says:

    I have enjoyed reviewing records that state the chief complaint ” follow-up” Next there is a page and a half of boxes checked then plan refer to pulmonary. The ABC,s of medicine Airway Breathing, Circulation have now been replaced by “All Boxes Checked”

  7. Thank you for your great analysis, as usual. I find the problem with EMR totally epidemic, and feel that when I try to change this new culture, I swim against a huge tide. Trying to keep reminding house staff of the importance of time spent with the patient, and limiting mindless copy pasting of non updated data, let alone complete nonsense copy pasted from someone else’s misinformed note! For example, a patient with cellulitis and lymphedema of the right lower extremity and unilateral AKA of the left lower extremity, was described daily in the house staff’s’ notes as AKA on the left, and BKA on the right, despite change of house staff’s team over time, and I hope/assume, daily exams of the right lower extremity! Another example: a patient had a methicillin sensitive infection (MSSA), but somehow one house officer wrote in their progress note methicillin resistant (MRSA), and for one entire month, the error was copy pasted on, despite my notes mentioning that the information was being copy pasted incorrectly. It shows that since notes are becoming too long, repetitive, and unreliable, noone bothers reading them any longer! The solution to that is probably to write a non repetitive and assessment and plan, so that hopefully that section will get read.

    I suppose that with each new system, new problems arise. But the idea of EMR was to improve communication and prevent errors. As far as I can tell, so far the benefits are that I don’t waste time looking for charts (but I waste time reading long semi-useful copy pasted notes), and being able to read notes instead of hand-writings, although at least with hand-writings, I wasn’t understaning some of the nonsense I was supposed to read!
    MH, MD

  8. Riddell says:

    I learned to put the Assessment and Plan portion of the soap note at the beginning, from a few savvy colleagues a couple of years ago. It helps me when I check prior notes and I assume it helps any referring doctors look at what was important to me and them. All of that info remains, but it is hidden below the bottom edge of the screen. We can ignore it if we avoid the scroll button. Sounds a lot like the “Physician’s Corner” which Loretta mentioned.

  9. Jonna Gaberman says:

    I love the recommendation for an automated bot doing #2 and #3. Nice! I am all for that. In addition to these crazy notes, we are now doing computer order entry for labs… Don’t get me started on the percent of visit needed for screen time. It’s only getting worse.

  10. Carlos del Rio says:

    Brilliant post. “I have personally seen and examined the blog, I agree with Dr. Sax note as outlined above”……Can I now “bill” for my time spent on your webpage?

  11. Melanie Thompson says:

    To me, the most egregious infractions occur in the ICU. The intensivists themselves cut and paste and carry forward such that there may be only one sentence – or no sentences – in the note relating to interpretation of the day’s data or a plan for care. In addition, because patients are desperately ill, there are scads of specialists – and specialists cross-covering for specialists – who cut and paste from an initial consult as well as from the intensivists’ notes and even each other’s notes! The nursing notes once were among the most helpful in the chart but now even nurses cut and paste and carry forward. It is almost impossible to figure out what people are thinking about the patient’s care plan. I have decided that when patients are critically ill and time matters, it is better (and faster) to just call the individual doctors to ask what they think should be done for the patient. And it turns out that this unintended consequence of bad EHRs is the practice that has improved my patient care the most. It’s a silver lining of the implosion of medical documentation. Great blog, Paul.

  12. Jo Ann D says:

    As one who really likes the EMR and what it can be, I think this piece is a public service. It points out that now the chart is not the (perhaps never has been) the sole province of the physician and other care providers. The EMR does serve competing purposes. However, are physicians so powerless that there are few suggestions and pilots for EMR improvements such as the tongue-in-cheek (or maybe not!) one above? Is there not an over-arching purpose of contributing to the improvement in health of the person and humanity as a whole?
    The physician who never looks at the patient–why is this happening? I don’t think this is an outcome for which there is no answer. Perhaps the child and other patients can help if we pay attention.
    Really a thoughtful essay and I look forward to that book.
    I know this environment is daunting but do we just give up?

  13. Roger Beneitone says:

    I personally circumvent the usual emr BS by dictating free text into all sections of my notes.There are transcription services that will type notes directly into an emr.

  14. Roger Kimber says:

    I hope all you who posted here who voted Democrat are suitably shamed, contrite and chagrined (but I expect not). This is all consequence of the left’s philosophy that central planning by “technocrats” is superior to flexible organic market driven solutions. Dante has a special place for those behind these things.

    It is only going to get worse under Obama(non)Care, until/unless it implodes or is dismantled by the courts or subsequent administrations.

    An apology is owed to those of us that did not drink the kool aid. I won’t beholding my breath, however.

  15. Nahum Kovalski says:

    Let me start by saying that my personal significant experience with an EMR, is with the EMR that I wrote and was continuously developing and using for 11 years. I used my own clinical experience as well as [endless] comments from doctors, nurses, secretaries and lab technicians to customize the EMR to everyone’s needs. I should point out also, that I am in Israel, and that this EMR is used by an urgent care service with 13 clinics, and close to 700,000 patient visits a year. The EMR includes a web interface and a readily accessible data warehouse which has been used for publishing a number of articles as well as generating tens of presentations for various meetings over the last few years. While Israel does not demand HIPAA compliance, the software in any case does comply.

    I felt my introduction important to understand the source of my comments. Let me say that such articles as by the author Dr Sax tend to have a nostalgic overtone. They give the impression that things were better before all of this computerization. Yet we all know that the number of patients who die every year from human error in their medical management is nothing less than frightening. And these statistics are not related to the introduction of EMRs.

    There is no question that documentation distracts a doctor from a patient. I personally have seen countless medical records written by hand by family physicians and specialists, who I assume spent more time looking at their patients. Most of the medical notes were illegible. Most were incomplete. Most did not hold to any standard that is reasonable, let alone the standard now demanded by the present American government.

    There is a solution for minimizing distraction by note taking. Even today, one could develop a front-end for a medical documentation system that is based on a 10 inch tablet. Using a digital pen, the user could write as they did before. The difference would be that this digital interface would be designed to force the doctor to formally document key elements. Whether by a checkbox or by clicking with the pen on a drop-down, or by using OCR for limited text situations, you could have all of the key documentation filled in, but with an experience not much different than when doctors wrote their notes by hand with pen and paper.

    I would argue that one of the reasons why doctors spent more time looking at the patient’s back when notes were handwritten, was because the notes were very sparse and likely often only understandable to the physician writing them. And of course, none of this information was shareable.

    When using a hand written note system, there is no smart agent that is watching you to make sure that you have written the appropriate dose of the medication, that you have not prescribed a problematic medication, that you have immediate access to films and other reports and so on. In my own experience, it is only when we added clinical assist software to our EMR, that we saw dramatic drops in unnecessary antibiotic use. By virtue of the same software, we also saw a significant increase in the number of pregnancy tests done on women with suspicious abdominal pain.

    What everyone is experiencing in terms of computerization is most simply described as “growing pains”. I have heard senior representatives of the development teams from Cerner and AllScripts and other major EMR companies, almost begging to get major feedback from physicians. I suspect that if a major hospital that is already using a major EMR, sat with the EMR development team, you could very well soon see a dramatic change in the interfaces. In fact, definitely for the bigger hospitals, they could make this a condition for purchase. In other words, if, for argument’s sake, EPIC was offering a major hospital a multi-hundred-million-dollar installation, the CMO and CIO of the hospital could make it a requirement that there would be regular interaction with the development team, with the expectation of seeing requested changes appear in the code.

    Doctors are not powerless in the present scenarios. The EMR companies are under tremendous pressure to answer to the demands of the present American government. From the EMR company’s point of view, there is no ROI in adding endless bureaucratic interfaces to their system. The EMR companies are fully aware of the fact that these additional interfaces bother physicians and slow medical work. The solution is at least partly to develop a close relationship between open-minded, innovative physicians and the EMR company CEO. If a group of physicians offer an EMR company information that would make their product better, the CEO of the EMR company would jump at the opportunity.

    At least in my experience, my EMR as used by my previous employer, allowed for remote consultation which included x-rays, other imaging, photographs of the patient, ECGs and any digitally collected information. At the time I left, my previous employer was working with a start up which had a tool for recording and transmitting images of the middle ear and throat as well as audio recordings of the heart and lungs. The same tool also functions as a camera and can be used to send images of rashes and isolated lesions. The ability to remotely provide consultations of this type, as well as to review charts post discharge of the patient, provided a means of remote mentoring and quality assurance. I personally interacted with multiple physicians who within six months of their starting to work at my previous employer, had matured into independent, well informed doctors. And they themselves stated that the EMR was critical to their clinical development.

    The day will soon come when a version of Google glasses will make it possible to see every patient, see the important clinical information for that patient, verbally record a note and request tests, and even record reminders to review the patient’s results later on. Present day medicine will become a whole new world of efficient medical care within the next 20 years. I admit that 20 years is a long time. On the other hand, revolutionizing a system that has been effectively stagnant for millennia, takes time.

    I do truly wish everyone luck in finding a path to a far better version of medical care.

  16. Bruno Belezia says:

    Dear Paul Sax, I agree with you. A work with medical residents in a teaching hospital in Brasil and i also see this phenomenon.

  17. elizabeth toll says:

    Great discussion. I can assure you the child’s picture was original! To me, it embodied the whole problem in a single picture. I have tried unsuccessfully to paste in this comment box the child’s doctor side- by- side with Luke Filde’s iconic image The Doctor. Same intensity — different focus!

  18. Nat Kuhn says:

    How do you get a psychiatrist to read an ID blog? Have Paul Sax write it. As a solo-private practice psychiatrist with a strong computer background and such poor handwriting that he started lugging a laptop for doing consults in 1995 who sometimes now moonlights doing inpatient consults, I have to say that the copy/paste problem is truly a menace. And people need to do what you are doing–stand up and say it’s a menace until people pay attention. Technology can help wiht solutions: e.g. fields that you CANNOT paste stuff into, ways to flag new info vs carried forward info, etc. Someone needs to develop a better EMR and then RESEARCH physician satisfaction, patient satisfaction, and ERROR RATE. I didn’t follow the details of the Houston Ebola case, but my impression is that there was travel history info in the EMR that was not flagged in a way that it would come to MD attention. These are two parts of the same problem, and better technology going forward can help, as opposed to trying to go backward to less technology. (PS I was really happy when I figured out how to print my notes by faxing them to the machine on the floor, rather than carrying a printer!)

  19. Thomas Hunt says:

    Yes, but…

    I agree with all you say but remember, the information is now available and legible.

    I can find the chart now, tonight, from home, from another hospital, another clinic. And someone else can be working inside the chart at the same time, so no more fighting over it. And I can read it.

    In my mind, this accessibility is worth skimming over the crap that’s in the canned note.

    Instead of bellyaching over EHRs, let’s focus on your most important point: let’s write a “clinician’s note for clinicians.”

  20. Caleb says:

    I think that the electronic aspect of the medical field for doctors has brought many positive improvements to the doctor patient experience. With that being said, that interaction between the two parties has also faltered as the technological advancements continue.

  21. Dr Hugh Nelson says:

    One simple problem is that doctors don’t learn to touch-type.
    It actually only takes 8 hours with a typing tutor program to be able to keep eye contact with a patient as you make typed notes – avoiding the need to click all the boiler plate tick boxes.
    We would not hesitate to spend 8 hours updating our PALS or ALS or improving our golf swing – why don’t doctors learn to touch-type?

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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