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Are EMRs Killing the Clinical Narrative?

Scott Mace, for HealthLeaders Media, March 20, 2012

In half the records, there was at least one thing the two doctors independently concluded should have been in the patient's record.

The researchers did another experiment where they assumed that the EMR, which happened to be in use in British Columbia, could capture more of the narrative with some extra engineering.

The cardiologists still found a severe problem in one out of four records, Resnik says.

Another issue with EMRs is the advance of medical science. In the early 1990s, a higher-resolution CT scanner was introduced. Radiologists started discovering semi-opaque nodules in the lungs which indicated a much higher probability of lung cancer. But older medical records simply offered the choice of "opaque" or "transparent" and had no way of expressing the newer notion of "semi-opaque."

Such examples must abound in medicine as it advances. How valuable will today's EMRs be in tomorrow's realities?

The traditional clinical narrative also has another set of nuances not present in the typical modern EMR. Narratives may say that something is "suggestive of" a particular condition without that condition actually being present. Patients may deny the presence of a particular condition, such as chest pain, but the EMR may not allow for such a denial to be a structured part of the record. In another example, doctors may agree that a particular pilot-as-patient should not be recertified to fly without undergoing a particular procedure.

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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