Change the Paradigm
Today’s EHRs have changed the medical records mechanism from paper to electronic, but not the paradigm.
For example, we have told doctors not to write on paper anymore, so now they are doing largely the same thing they were doing before, just on the computer. Yes, EHRs can legitimately claim to have reduced transcription errors. But computerization of clinical notes has had unintended negative consequences: notes have become more cluttered—and therefore less helpful—as physicians now routinely include the last 24 hours of results in their notes simply because it’s easy to do so with a mouse click. Dumping large amounts of clinical information into notes provides little value for the next clinician who reads them. Quite the opposite, in fact – physicians are spending more time sifting through lengthy clinical notes trying to discern the vital nuggets of information necessary to inform the care they’ll deliver to their patients.
To date, no one is helping doctors take advantage of the computer to write better notes. And whether in SOAP or APSO (or any other) format, the notes taken about a patient’s visit – and, by extension, the system a doctor uses to take them – can impact the patient’s healthcare experience.
Of course moving to the computer is a logical first step – it’s important that American healthcare has taken it – but computerization can be awkward and, in and of itself, doesn’t necessarily yield positive change. Healthcare should take a lesson from Uber and reinvent the process so it’s optimized for and native to the technology that enables it. That’s where significant benefits will be realized, including (and most importantly) improvements in patient care.