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Are EMRs Killing the Clinical Narrative?

Scott Mace, for HealthLeaders Media, March 20, 2012

Could your new electronic medical record system be missing vital information the old paper-based system captured?

Even the most seasoned technology champion has to stop and ask that question, if for no other reason than the new medical record looks very different than the old one. To put it in classroom terms, today's EMR is often multiple-choice, not essay.

But almost as long as there have been doctors, the preferred way for them to communicate has been through a narrative—a story.

EMRs may introduce gaps in that narrative, says Philip Resnik, professor of linguistics in the Institute for Advanced Computer Studies at the University of Maryland.

Since 1999, Resnik's been studying the limitations of entering clinical information into discrete fields and checkboxes in an EMR. At the recent South by Southwest conference, Resnik described the dilemma clinicians face: to embrace the EMR with all its limitations, or to push ahead for new technologies such as natural language processing that rarely see clinical use today.

Resnik illustrates the problem with a sample narrative of a woman complaining of shortness of breath. In a slide he highlights snippets that are easily entered into EMRs, such as symptoms and actions taken. But he also underscores much text that helps tell the story of the patient's encounter in the ER but doesn't readily map to fields in an EMR.

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11 comments on "Are EMRs Killing the Clinical Narrative?"


S. Silverstein MD (3/28/2012 at 12:21 PM)
I remind that the goal of the medical informatics pioneers was lexical and semantic clarity, not ambiguation. They intended that computational linguistics-based analysis of free text would accomplish this. The commercial sector, however, saw fit to ignore this work and try to make EHR's a "medicine by template" affair - much faster to market, and much more profitable. Imagine lawyers trying to practice "template law." Their briefs would be impaired beyond use. I note that it is possible to prevent EMR's from producing "legible gibberish." An example is here: http://www.ischool.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story

Beth Friedman (3/26/2012 at 2:10 PM)
Yes. Anyone who uses the doctors narrative reports day in and day out, such as coders, CDI, researchers, and auditors, is aware of this problem. EMRs make cutting and pasting, shortcuts and over-documenting way too easy. While I understand that physician documentation should be there for patient care - not necessarily all the various downstream functions - that's not the reality in the U.S. Physician documentation is the basis for so many downstream functions and reports. The onus is really on the physicians and the vendors to make the process of documenting a by-product of care. Until then, it will be a difficult balancing act between ease of use for MDs and enough information for downstream functions and quality reporting.

Steve Wilkins (3/22/2012 at 6:16 PM)
Scott, Add to the issues you articulated so well in your post the issue of EMRs and physician de-skilling. As physicians switch over to filling out the EMR, they are not documenting so much of what they used to capture in their notes before. Check out a piece on physician de-skilling at http://wp.me/pGXmn-t4 Steve Wilkins www.healthecommunications.wordpress.com