Clinical-Notes

Have We Lost Something as a Result of Technology?

With the growing adoption of EHRs, EMRs, data repositories, and cloud-based computing, as well as a wide range of related technologies, clinical IT systems produce vast amounts of data. Understanding this information is crucial to the care delivery process. Medicine has transitioned from a cottage industry of small clinical practices with varying treatment methodologies to one that is based upon data. However, providing high quality care is more than just increasing information volume — no technology system will ever be 100% dependable and should never take the place of clinical diligence and good medical practice.

Care complexity is increased as a result of teams of individuals (clinical and non-clinical) who need to share information on jointly managed patients in real time. Data volume has become a barrier to quality of care due to the large amount of analysis that is necessary to make the data usable. What this has resulted in are “islands of excellent care in an ocean of mediocrity.” This raises a lot more questions that need to be answered. How does one develop practical and usable sets of data for clinical purposes? Which are the important ingredients?

Consider the days before EHRs and other clinical IT systems: not the limitations of paper, but rather the diligence that was required to conduct clinical assessments and manage patients. Without computers, smartphones, and tablets, doctors needed to take detailed histories, conduct clinical examinations, and — in large part — commit the information to memory. This was particularly true in training programs where interns and residents were required to study the patient chart and be able to provide a detailed summary of the patient’s clinical condition and investigations without referring to the record. I am not suggesting that we go back to the days of pen and paper, but there was a certain utility and accuracy that was required when using paper charts that no longer exists with the high reliance on structured data, templates, and reams of information that are generated by machines.

A good narrative and clinical summary has a certain elegance to it that engenders pride. The ability to document a clear history, an objective set of findings, and a plan of management, using the fewest number of words, is somewhat of an art form. Read an earlier blog article: Are You Proud of Your Documentation Using an EHR? A complaint that we hear regularly from users of EHRs is that they have lost the ability to easily produce high-quality narrative notes from the structured data. All of the information is available in the record; it is just more difficult to produce a good narrative in comparison to the old paper chart. More is not necessarily better.

Measurement, analysis, and research are the lifeblood of evidence-based care delivery, necessitating the need to build capability for analytics-driven systems. However with all of the reliance on data, have we lost something important in the process? The ability to generate a good narrative note that tells the story of the patient?

Perhaps this is no longer important. Share your thoughts below.

Comments:

3 responses to "Have We Lost Something as a Result of Technology?"
  • April 30, 2013
    Bob Hoyt MD
    said:

    For those of us with gray hair it is difficult to disagree with your statements. In addition, it looks like more time is being spent documenting on the computer, instead of important time spent with the patient. An article this month in the J. Gen Int. Med indicated that interns only spent 12% of their time in direct patient care but 40% on the computer. This is not a good trend for the future of US Medicine for either patients or clinicians.

  • May 1, 2013
    Hunter McQuistion
    said:

    Perhaps even more disturbing is the automaticity of thinking that EHR documenting enourages — that is, as a psychiatric educator, i and some of my colleagues are seeing a drift toward difficulty among residents in putting together a cogent and thoughtful case FORMULATION, or summary, in writing.

    In part, this may be an unintended consequence of healthcare transformation –even as the ACA is encouraging us to integrate care (and therefore become more adept at synthesis).

  • May 2, 2013
    Cynthia T Henderson MD
    said:

    ACA encourages the EHR, but the construct of the EHR was based on lists before the EHR became the predominant method of our documentation. The SOAP note and problem list made my life a lot easier, and helped me focus on my patients’ short and longer term problems.
    With automation, the important parts of the patient’s story may be lost in the lists: The problem list (not cleaned up regularly as there is not enough time to do so); the medication list (not clearly linked to the reasons for the prescriptions; the reasons for nonadherence lost in the acute problem lists or maybe not even mentioned); the personal history list (not easily reflecting the changes as the history is lived and created); the family history list (not updated as regularly as family histories are very messy when properly, repeatedly excavated over time).
    Our patients do not live in electronic lists. And we cannot type/point/click as much as we must, to make the lists live in our patients’ lives. I cannot type as much as I need to, to catch and record the nuances of all my patients’ stories.
    I would love to be more adept at clinical synthesis. The lists don’t necessarily serve me in this effort.
    I would also love to be more adept at typing, pointing and clicking. But my time is limited, so I type less, produce sparse prose, parse my verbiage.
    What I really worry about is that the loss of thoughtful, descriptive narrative, generated through observation, knowledge, skill and ability to write, will be lost. I worry that my notes won’t provide a picture of the person I am caring for and my thought processes as I deliver care.
    I wonder if those who come after me will be able, willing, have time or the electronic lattitude to paint my own clinical portait.
    It also gives me pause to consider, that regardless of issues with electronic records, good writing skills are well-taught less widely. With erosion of language usage and well written narrative, we risk reducing our patients’ narrative to word burdens. Further,a utilitarian, reductionist approach to medicine drives us and future practitioners to do less with and for less, and with potentially less meaningful information.

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