My general internal medicine practice is equidistant from the three academic institutions and a Veterans Administration facility, and thus I have patients who receive primary, secondary and tertiary care at each of these institutions.
The notes I receive back from one of these organizations are hands down the best of the four institutions. These notes are personal, concise, precise and clear. If the patient had a complicated outpatient work-up the communicating physician will send a problem-oriented summary of the patient’s symptoms, the work-up, the conclusion and the recommended next steps. There is a clinical narrative with clear communication of the patient’s unique story and the medical decision-making. Furthermore if the patient saw more than one physician, the note I receive integrates the impressions of all of the physicians.
For my patients hospitalized at this institution I especially value the discharge medication list, which is broken down into fields for continued medications, modified medications, new medications and discontinued medications. In most circumstances the patient has also received a copy of the inpatient and outpatient notes and the medication list.
From the other organizations the communication is rather more like a “ransom note,” a multi-font collection of structured text entries, pieced together with imported labs and x-ray results into a hard-to-read document, typically 6 pages of structured text, with an emphasis on billing justification and compliance language. Scanning through these lengthy documents for the “meat” of the note I struggle to find a coherent story (but I readily see what type of learner the patient is, and what part of the visit the attending was present for and other billing and compliance information.) Three different EHRs are represented. Here is a typical emergency room note:
The patient presents with palpitations. The onset was just prior to arrival. The course/duration of symptoms is resolved. Character of symptoms skipping beats. The degree at present is none. The exacerbating factors is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: near syncope
Transcriptionists are being replaced by physicians for cost reduction, a calculus that doesn’t consider reductions in patient safety and quality, or lost physician productivity and well-being.
This “savings” in transcription costs also comes at a cost to the clinicians who subsequently read through multiple pages of low value text to find the kernel of useful information. And because the person documenting the care spent considerable time processing through the drop down boxes, less effort has been applied to the assessment and plan, often leaving the receiving physician in the dark when trying to pick up the thread of care.
I have always appreciated the care my patients receive at the first institution, not just for the care itself, but for the systematic, reliable communication I receive back about my patients. I recognize that having one physician summarize complicated care across many specialties, and having dictated notes is an expense, but it is an expense that makes a difference in the care of patients. Replacing transcriptionists with physicians is a fool’s bargain.