Are EHRs getting all the right notes?


In recent posts, we've taken a technical look at EHR workflow issues and heard from a doctor who wants the chance back to tell his patients' story.

So it seems appropriate to consider the perspective of this long-time doctor and teacher, who provides an interesting historical perspective at the same time as he “asks for” some changes to the new way of doing things.

Before turning his eye to the current landscape, he points to the arguments of a prominent doctor from decades ago who had very clear ideas of what was wrong with medical records and how they needed to change.

But if we had to sum up our writer’s main point, it would be, “while things needed to change, we may have gone too far.”

To be sure, he likes the brand new EHR system his hospital recently implemented, but he contends that something is lost if patients are reduced to mere lists of problems.

“I’m saying that even if you are a coot who doesn’t give a damn about what the patient is feeling,” he argues, “even if you gloss over the social history in a mad dash to the liver function tests, even if you think that ‘patient-centered care’ is mostly an empty slogan, even if you’re the kind of doctor who simply wants to figure out your patient’s problems and deal with them effectively, you must balance the simplicity and practicality of a systematic approach with the need to see patients as more than the sum of their problems.

“With paper notes, this tension usually managed to work itself out…there was something about the act of writing things down that made you realize that there was a person attached to the problems, and that each patient needed an über-assessment – a paragraph or two summing up his or her issues. The reason for this was not so much to honor the patient’s humanity (although that’s nice, too) as it was to offer a crucial synthesis of what was otherwise a jumble of facts and impressions.”

He goes on to argue that “If Epic was the only thing promoting this kind of reductionist approach, it might be survivable. But it’s not. In the face of duty-hours limits, our trainees are increasingly programmed to operate in a ‘just the facts, ma’am’ mode, to approach patients as a series of problems to be addressed expeditiously and algorithmically.”

What he wants, then, from his new system is “a mandatory field, and call it ‘Über Assessment’ or ‘The Big Picture.’”  

In this field, he says, he would prompt providers to “please tell the many people who are coming to see your patient – nurses, nutritionists, social workers, consultants, your attending – what the hell is going on. What are the major issues you’re trying to address and the questions you’re struggling to answer? Describe the patient’s trajectory – is he or she getting better or worse? If worse (or not better), what are you doing to figure things out, and when might you rethink the diagnosis or your therapeutic approach and try something new?”

And the time, he says, “is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive forcing functions, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not.”

Comments (1)

David Abrams: As a teacher of Year II med students I can see 2 things quite clearly. 1) EHR training needs to start in medical school and 2) There is definitely a generational difference in the facility of use of computers -- in the next few years physician griping should diminish and the "Big Picture" is more likely to be digitally taken.

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