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Are EMRs Killing the Clinical Narrative?



Do electronic medical records miss vital information captured by paper-based systems? The traditional clinical narrative contains nuances that don't translate well to the typical modern EMR. New technologies offer a better way.



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
Randy Smith (3/22/2012 at 4:35 PM)

I recently had a routine appointment with my GP, who has transitioned to a new hospital-based EHR system. He was struggling to update my health history, as apparently years of prior "narrative" info was NOT converted to the new system. My doc commented that the EHR design was inefficient, and required multiple selections to make simple entries. Seems that the whole process is being pushed along by HIPAA and HiTech (and related incentives), and are leaving details of efficiency and value in the dust. The whole situation was kind of ironic, since my business is the provision of practice management software to the dental field!
Arun K. Potdar (3/22/2012 at 12:27 PM)

There are some valid points in arguing that narratives are killed by the EMR. However it should be noted that EMR is a tool and like all tools from the first stone chisel they need to be constantly improving. The first batch of EMRs were driven by same end-results and that is maximization of reimbursement dollars because E&M levels were driven by the complexity (real and creatively narrated) presented in the MR. Many offer blank templates to add or [INVALID] texts. The examples sighted in the article as effectiveness or outcome of a treatment plan in ER is valid one but that data is not really lost. It is there but not properly placed in the database or linked to fields which can be accessed by the analyst. It is the ultimate goals of having EMR will determine the design of Software and the architectural design of the data and databases. Older doctors should not hold technology at bay and narratives can be done for most routine patient care provided right after patient leaves the examination room. Todays' assembly line practice management tries to maximize patient seen in a given time and that can be changed if quick and legally up-coding based billing is not the only criteria in [INVALID]ion of EMR –cum-Practice Management software. The writing of long narrative reports which very few receiving physicians read in entirety must go and only pertinent information that would strengthen the case management process should be made part of EMR. Many Mal-Practice Lawyers will prefer the long and detailed reports over short and accurate EMR because it will take away from them the fertile ground to search for a cause and effect scenario. The portability of EMR is a great advantage to both patients and practitioners when patients move. Availability of patient history on demand is also advantage over the bulky folders. Question is adaptability and willingness to change to new technology is in the interest of all parties involved? I am a VAR of EMR –Practice Management-Billing Software and have had opportunities to study the decision making processes of Physicians and Managers when it comes to [INVALID]ion of EMR Product. My experience with new generation of Physicians who are PC technology savvy is very encouraging in development of next generation of EMR products and senior physicians' input in designing of this tool is also valuable provided one can make them accept it as the right way to go.
Tony D'Antonio (3/21/2012 at 3:57 PM)

scott, love to talk to you live about an article that I authored that would compliment your article. As the leading provider of paper-based medical records, I think you and your readers would find it valuable. Good Job. Tony D'Antonio
Julie Lloyd (3/21/2012 at 1:06 PM)

Enough already with the word "narrative," easily the most fashionable and overused word of the moment Nobody can write an article, a letter to the editor or an editorial without it. What's wrong with saying "clinical history"? File under "pet peeve."
Gus Geraci, MD (3/21/2012 at 11:57 AM)

Poor design by technology folks who don't understand the real workflow is the issue. You can't think of medicine as having discrete data points for every issue. Not every bit of information can be in a checkbox. But checkboxes can also be designed to allow for expansion and addition. And data extraction can be done from narratives in a way that allows physicians to do things the way they're used to, without detracting from the data collected. It's out there, and it's being done. Let's not lump all EMR's together in a negative description. That some EMR's kill the narrative does not mean all do.
Dan Purdom, MD (3/21/2012 at 11:03 AM)

This really does capture the issue I have with an EHR. Traditionally, our notes tell a story and computers don't tell a story very well. Having had the experience of reading my own note in the EHR and being unable to tell what exactly happened to the patient was eye opening. So then we start writing two notes, the computer note and the narrative, which impacts productivity. No good answers yet. And I agree that we are being driven quickly by those who see the meaningful use dollars being offered without truly appreciating the impact of these systems.
Ken Rubin, MD, MA, HCHM, FACEP (3/21/2012 at 10:06 AM)

Interesting viewpoint, but the Author gives physicians too much credit for the quality of hand-written narratives. Most hand-written physician notes: >are illegible, >contain very little information, subtle or otherwise, >tend to be wrote, not reflecting patient's true conditions. Every patient is in no apparent distress, and has stable vital signs (there's no such thing); reading those progress notes, one must wonder why the patient is hospitalized. >contain no medical decision making, or other indication of how the physician arrived at the documented conclusion(s). With healthcare reimbursement obligating physicians to rush through rounds, the main underlying problem, far outweighing the shortcomings of the electronic medical record, is the same (lack of thoughtful documentation), regardless of whether notes are hand-written or entered on a computer.
Richard Burruss, MD, FACEP (3/21/2012 at 12:57 AM)

Can you say Dragon? For the HPI and the Medical Decision part of every patient encounter, Dragon allows for the input of a narrative into that part of the EMR where it is important and most useful. Virtually all of the rest of the modern day medical record has deteriorated into a mindless computer game where the object is to fill in boxes necessary for reimbursement, but really not necessary for the timely care of the patient. A scribe can perform this function perfectly well freeing the doctor to focus on the patient and their personal narrative.