I’ve been working with the latest electronic medical record (EMR) for almost a year now. You know the one. There are many positive changes, to be sure. It has helped me more than a few times with calculating doses for kids’ medications. I can now easily check in on my patients’ progress when they are admitted to the hospital. And, of course, the notes are far more legible.
But what do the notes actually tell me? Sadly, sometimes, not much.
We are in the age of copy and paste medicine, an unintended (I hope) yet predictable consequence of the EMR. I see it on the outpatient side, but it was really driven home after my latest stint on the pediatric ward. There, I see the patients every day. Their status changes. But, sometimes the notes don’t. It’s little things- like a patient who’s been extubated for a couple days but still has vent settings in the note. Or a note (written using a template) that tells me that a 17-year-old’s fontanelle is closed. Technically true, but definitely hasn’t been relevant for about 16 years.
But it’s the assessments, or lack thereof, that really get me. My favorite part of the progress note, the assessment, tells me how the patient is doing. Better? Worse? Clear diagnosis? Still up for debate? What’s more, when I’m working with trainees it shows me how (and whether) they are thinking. It helps me to know whether they understand why we are doing what we’re doing. In the EMR the assessment often degenerates into a computer-generated problem list without any particular assessment by the author of the note. Or, a cut and paste of the assessment from a colleague that is a few days old, not adjusted for what we’ve learned and decided since admission.
But, don’t think this is just affecting trainees. It happens at all levels, and to even the most conscientious of physicians. When following a high number of patients on a given day it gets very difficult to review every single line of a long note or catch every needed change. The sheer amount of documentation we are now asked to do for each patient encounter often makes me feel that the system values quantity over quality. The best note I read recently as ward attending came from an unlikely source, the attending surgeon. Only a few lines long, it likely didn’t meet criteria for “meaningful use”, but it told me what I needed to know. I quickly gleaned the surgeon’s opinion about how this patient was doing clinically, their thoughts on the most likely diagnosis, and whether they felt the patient needed surgery.
I can’t help thinking that current medical practice stands in stark contrast with the type of medicine described by Victoria Sweet in her wonderful book, God’s Hotel. She describes a slower kind of medicine, with focus on the patients and time to “just sit”,
“. . .after Ms. Gilroy, I took the time to “just sit” in this way with all my patients. Especially if they took a turn for the worse, or if a nurse or family member was worried that something wasn’t quite right. I would leave my cell phone in the nursing station, turn off my beeper, move a chair next to the patient, and sit down. Not for long- five or ten minutes. Sometimes the patient would want to chat, and we would chat, and sometimes I would study the patient’s face, bedclothes, and bureau. But mostly I would just sit. And something, somehow, would happen. It would become clear what, if anything, was wrong with the patient and what, if anything, I could do about it.”
Instead of this experience, new doctors are sitting with computers.
I remain hopeful that we are simply in version 1.0 of all of this. That future iterations will bring improvement and a return to more a patient-centered and provider-friendly form. That technology will begin to help rather than hinder. And, I’m certainly grateful that I can now easily read the consult note that previously remained mysterious until a conversation with its author. But I can’t help feeling a bit nostalgic for the good ol’ days.
Sadly, I completely agree. EHRs are ideally meant to improve documentation and effective communication and, ultimately, improve care. However, most often, they are programmed to satisfy the requirements of insurance companies, medical billers, and lawyers, with little attention to medical necessity and actual substance.