Almost every physician I have talked to groans when I tell them they will need to use some form of templates if they are going to use their EHR effectively. I can’t honestly say that I “know” their pain, as I am not a physician, but I have come across some common threads.
To many physicians, templates have come to represent cookie cutter medicine and the fear that they are simply becoming a cog in a wheel. Some feel that the use of templates fails to capture the nuances of their thoughts. To others the use of checklists/templates seems pointlessly burdensome. Others find them difficult to use as they are presented in a manner that is discordant with their processes. I doubt that anything I can say will dissuade you from these beliefs but let me attempt to explain why templates are an intricate part of any EHR system.
While EHR systems function as a vast repository of patient information, they also do more than just serve as a big filling cabinet. If used correctly EHRs allow you to automate routine tasks, provide clinical decision support, view patient information longitudinally, and give you the ability to create population-based reports. The way that EHR systems do this is by categorizing information, capturing that information in a database and then acting on that information based upon a series of defined actions triggered by that information. In general, the way that computers understand information is by having it entered into pre-defined fields and in a standard format. (For all the technical people out there, please bear with my simplified explanation). While new technologies are being experimented with that may enable computers to gather this categorized information using free text or voice dictation, EHR systems currently need to use some type of template to capture this data reliably. These templates come in many different flavors. Some systems use “smart” templates, which utilize predictive logic to automatically present the questions most relevant to users, while others systems resemble a paper template.
The way in which EHR systems manage data through templates has several important implications regarding use of that system.
- First it creates the need for a user to enter as much of the data as possible into the patient notes using the templates rather than typing or dictating the note in one large block of narrative text. This does not mean you should not use free text to explain nuances that the templates cannot capture, just remember that you should limit its use. Generally speaking, information entered via free text will not populate the EHR database in such a way that it can be used by the EHR for quality reporting or alerts. There is nothing worse than learning that none of the information you have tediously been typing into the EHR for years can be extracted automatically for quality reporting and/or research. For all who are considering meaningful use, generating these types of reports is essential to meeting the requirements.
- When customizing or creating templates make sure that any new fields you create are being correctly defined by your EHR. For instance just because you named the field “Diabetes” does not mean that your EHR system recognizes this as being the same as a field they have already defined as ‘Diabetes’. These discrepancies can cause quality reports produced by the system to be inaccurate and any automatic actions linked to system rules may not function correctly.
- Standardization will increase the accuracy of quality reports. When multiple fields or terms are used to collect the same information, reports may not correctly produce all of the terms used in your charts.
For those of you looking for an EHR, keep in mind that EHR systems vary substantially in the ways that templates are displayed and the manner in which they use smart templates. When evaluating different EHR systems, look for a system in which templates follow your thought process and documentation style.
If you are in the process of implementing an EHR I will echo the advice of a physician who stated, “Do not settle for using the system part way or taking short cuts by typing out the whole note. Invest extra effort and learn to use the templates. While it takes more time to learn, it works better in the end.”
Read Dr Atul Gawande’s article in The New Yorker on how a checklist can improve medicine
This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.