Nota Bene – or Not
Four years ago, the editor of Healthcare Informatics magazine wrote this sentence about the state of electronic health records (EHR) systems: “[Clinical] documentation is front and center when it comes to what’s frustrating [physicians] on a moment-to-moment basis.”
Sadly, that statement is just as true today. We have told doctors not to write on paper anymore – but now they are doing largely the same thing they were doing before, just on the computer. On the plus side, technology is yielding some cost saving; for example, at Mayo Clinic new technologies including voice recognition software have reduced the need for scribes. Generally speaking, however, computerization of clinical notes has had widespread, unintended negative consequences. Notes have become more cluttered (and therefore less helpful) as physicians now routinely include more than the last 24 hours of labs in their notes, for “defensive” rather than clinical reasons, and because it’s easy to do with a mouse click. The note has expanded to encompass many pages that regurgitate information contained in the EHR instead of being a concise, curated document that highlights the critical aspects of a patient’s care and what the clinician is thinking.
Take a step back and consider what the original purpose of a physician’s note was: to advance patient care. The note would be updated on a visit-to-visit basis by the same physician or perhaps another physician in the same group covering a weekend. Then shift-based medicine came into play, and the note became a vital mechanism to facilitate care transitions. Then, as malpractice suits became more commonplace, lawyers began requiring physician documentation to support their legal case. From there, we saw the note transform from a clinical and legal document to a billing document and a check for RAC audits. With Meaningful Use (recently renamed “promoting interoperability”), the federal government added to the documentation dilemma.
Clearly the clinical note is no longer what it once was, so we must drastically rethink the process to fit the new framework. To date, however, no one is helping doctors take advantage of the computer to write better notes. Ideas abound: some think the APSO format will make all the difference; while researchers at UCLA found that physicians produced shorter, higher-quality notes within a short period of time when they limited use of tools such as copying-forward and autofill.
Effective patient care and clinician communication demand comprehensible physician notes. But today’s prevalent electronic notes process isn’t cutting it; it disrespects the clinicians who must read and write notes daily. We can and must (and, I believe, will) do better.