Computers in Healthcare

How Important is Syntax in the EHR Note?

Over the past two weeks, hundreds of EHR users have completed satisfaction ratings for their EHRs. Over 2,200 user ratings are now available through AmericanEHR and 30 of the most popular EHR products have more than 10 ratings (the minimum number necessary to display EHR product ratings).

Many users have submitted additional comments relating to their experiences. Some have identified inadequacies in the clinical notes that fail to present the correct nuances gathered during the clinical interaction. For example:

“The [satisfaction] survey is interesting in that it fails to reveal the primary flaw of the EHR, its inability to produce an office note in a clear format. The notes are invariably larded with long lists of extraneous data which obscures the gist of the encounter. The notes which the EHR produces from its point-and-click menus are redundant and often unintelligible because of their syntax. In addition, the inability to prioritize problem lists leads to very long lists filled with insignificant problems again obscuring the significant problems.”

My EHR along with every other are inadequate in design because the creators fail to recognize that the final product, the note, is the basis for communication and revenue. Each of these systems fails to incorporate the integration that occurs prior to the final note, into the final note and creates inefficiency by allowing redundancy.”

There is a tension between the desire to collect clinical information in a structured data format vs. a narrative note that tells the story of the complaint and the clinical encounter.

How important is the ability to apply syntax to clinical notes? What have been your experiences using an EHR in terms of documentation and the ability to create the correct context in your clinical notes?

Comments:

4 responses to "How Important is Syntax in the EHR Note?"
  • July 15, 2011
    Norm Numerof, MD
    said:

    Succinctly put. I recommend that questions regarding this point be included in future surveys. After all, lets not get away from the original purpose of the clinical note, which is documentation and communication.

  • August 18, 2011
    KAREN HERNANDEZ
    said:

    This is exactly what I want to know BEFORE we buy an EHR system! Who recommends the documentation of their notes?

  • August 19, 2011
    Chris MD
    said:

    We have looked at 15 EHR’s . MAny of the notes are just painful to read, and are clearly designed by billers, not a doctor.
    We have all received those notes.
    The point and click quality of hospital notes have rendered them useless for any useful kind of care.

  • September 24, 2015
    Nidheeshp
    said:

    So, here is another question along these lines: what do you do if the provider (in this case a hospital clinic) has the EHR but the caregivers you are talking with don’t even turn on the monitor? Everything is on paper I asked the question to different people, different departments a few times with various answers: can’t log in, I don’t use it I find it puzzling and ridiculous.

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