August 1st, 2014

Do Doctors Need a Better Way to Take Notes?


CardioExchange’s John Ryan interviews Dr. John W. McEvoy regarding his recent perspective piece on the shortcomings of current electronic health record documentation published in The American Journal of Medicine. You can find the full text of his original article here.

Ryan: Why did you write this paper?

McEvoy: The short answer is that I wrote it out of frustration with the EHR. We had a roll out of Epic at our institution around the time and I was amazed at the poor job it does for documentation. Do not get me wrong, these systems have vast potential and I remain an EHR optimist; however, it was immediately clear to me that the user-interface and documentation functionality where not designed with the physician in mind. As I state in my paper and others have noted elsewhere, current EHR systems have been tailored to satisfy regulatory and billing needs, often leaving the physician out in the cold. It is an interesting dynamic from a marketing and business perspective. The buyers of EHR systems are not the actual users. Imagine a scenario where doctors were the ones who were actually buying this vastly expensive technology. I have absolutely no doubts that, in this hypothetical scenario, these systems would be more user-friendly and the documentation capacity much more clinically intuitive. However, the fact is that physicians are not the buyers of these systems. This leaves them lower down the priority list of EHR vendors, who instead have focused more on satisfying the regulatory, administrative, and billing needs of the real buyers (managed health systems, etc.).

Ryan: What are your solutions for a functional EHR?

McEvoy: There needs to be far greater focus on the needs of the user (physicians) and not just the buyers. I cannot think of a single physician who is satisfied with the EHR at our institution, and I understand that this is a widespread phenomenon. To me, this situation is untenable. To be honest, if I were an EHR vendor, I would be worried about my long-term future—or at least concerned enough to focus on this problem. Given the amount of discontent in the physician community, current vendors may be vulnerable to disruptive innovations and more user-friendly options from competitors. Thus, I think a real push by vendors to satisfy their actual users is now necessary (is this not customer service 101?). This will require real input from a range of physicians. I expect such efforts are already well underway. Physicians may need to advocate more too. I am not an informaticist, so I will not try to tackle the technological challenges around documentation here. However, I do cite some prior efforts and other ideas in my paper for readers who are interested in this.

I think the take home message is that if EHR vendors were selling this to physicians, I can guarantee that they would do a better job with interface and documentation—the market would demand it. I believe the technology is available, right now, to make this better. However, to me, the motivation does not seem to be there for vendors. Thus, maybe the best idea of all would be to give actual clinicians more meaningful input into purchasing and renewal decisions (and contracts agreements) between health systems and EHR vendors.

Ryan: I often feel that we think fondly of the notes we wrote before EHR, but you know from our work in Ireland that, more often than not, those notes were pretty substandard (and short too), with minimal detail and legibility. How do you think the value of the note has changed in the past ten years since EHR became more widespread? Is it a symptom of EHR or is it just a feature of increasing clinical demands and emphasis on billing?

McEvoy: Sure, written notes were not perfect, and many of the deficits of written note-taking are overcome in the current EHR (for example, legibility is vastly improved and decision support is helpful). However, just because the old era of written note-taking was no better should not mean we should be satisfied with the current state of affairs. In some respects, the major problem with current EHRs is on the opposite end of the spectrum to written notes. I struggle with the vast quantity of information in current notes, the poor signal to noise ratio, and (most concerning to me) the lack of a meaningful clinical narrative for the reader. I think the this difficulty separating noise from important information interrupts the narrative flow of many notes, ending up in physicians losing interest and scanning ahead. I worry about the information that is thereby lost, and the clinical consequences of this loss, as physicians try to reconstruct the narrative from many EHR-based notes. I would be interested to hear the perspectives of other CardioExchange readers.

Ryan: Do all your papers now come with an analogy from the world of physics—first Schrodinger, now Turing…?

McEvoy: Mainly just in commentaries and opinion pieces, not my original research. I am no expert, but I do read widely and enjoy keeping abreast of other fields of science. I find it satisfying to think of how problems (and their solutions) from these varied fields may apply to medicine.

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