How can we make the EMR note more legible? Here are some ideas.

Despite the well-known rollout problems for hospitals and clinics across the nation, there are many palpable and welcome advantages to using electronic health records.

Chief among these are the ability to access the chart from anywhere, rapidly search for information needed, and reducing the centuries-old problem of illegible doctors’ handwriting. But with the good comes the bad, and in these still relatively early stages of health care information technology adoption — the current IT solutions remain slow and cumbersome, ultimately taking time away from doctors and their patients.

I’ve written a lot about these problems and will continue to do so until we get this right. However, another less talked about disadvantage is that if they are not optimized carefully, use of IT significantly reduces the quality of physician documentation in the medical records.

Let’s take the example of a history and physical, which is the core document the physician produces when he or she first sees the patient. In the traditional way of doing things, the doctor would dictate (using a transcription service) the medical history, physical exam findings, and then their overall assessment of what’s wrong with their patient and the treatment plan. The final product is a letter-like record that appears in the chart, carefully sub-headed and in flowing paragraphs that look like they have been written by a human being.

Thankfully this remains the process for lots (if not most) doctors. However, it may not be for much longer. In the new health care IT world, where capturing data is paramount and many EMRs make the doctor into type and click bots — the new up-and-coming way to do a history and physical is to go through a checklist and series of tick boxes on the computer. Typing and use of voice-recognition software are encouraged for the other parts. The end result is a ream of information, often incoherent, and a final assessment that is robotic and frequently lacks clarity of thought. Unfortunately from what I’ve seen, medical students and residents are increasingly adopting this new method of doing things, with the result being a vastly inferior product that is displeasing to the eye and whose content lacks downstream thought. A problem of both style and substance.

I would challenge anybody, including the IT gurus who promote its use so much, to look at a history and physical produced by the two methods and honestly assess which one is more coherent: the traditional one or the new computer generated report? Ditto for progress notes and discharge summaries, where the same problem exists.

So what can be done apart from going back to the bad old days of no information technology? Actually, an awful lot, if we optimize the information technology correctly. Remember IT is not the enemy here — it’s the design and implementation. Here are some solutions:

Decide what is and isn’t useful information to put in the main physician documentation sections. Should there be a gold-standard definition from a leading authority?
Make the final computerized document more eye-friendly and avoid reams of data in favor of intelligent looking descriptions and paragraphs. If tick boxes must be used, make the output a better one.
Seek feedback and guidance from other institutions who already do things better with their own electronic medical records.
Put tremendous resources into developing better voice recognition software. The particular one I’ve seen used the most (no name mentioned) is painfully slow and I feel a bit sorry when I watch colleagues talking slower than a 5-year old as they dictate their notes, correcting mistakes every few seconds with the keyboard.
Create a national task force to address this issue for the future.
A good start would be for hospitals to establish committees involving senior physicians, IT staff, and administrators. Because every hospital has their own electronic medical record, the work to do will be unique to each institution.

The world of health care needs to quickly correct course before this problem gets too far away from us. With information technology, health care will reap what it sows. If it encourages new doctors to become thoughtless type and click bots — just see what that doctor generation will look like in 10 years time.