Wednesday, June 09, 2010

Is EMR destroying “the narrative”?

Many ERs in my area recently transitioned to electronic medical records. And so far, this has been a terrible step backwards in physician documentation. Instead of getting a concise SOAP note that gives me a reasonable idea of what the ER doctor thought (or even did), I get a vomitus of essentially meaningless word-salad (which is generated, no doubt, from doctors checking off boxes on their computers). Here is a sample which I have transcribed almost verbatim (without the patient's actual name of course):
Have reviewed chart of JOHN DOE and it is ready for final disposition. Condition at discharge—stable. Patient discharged from department. Verbalized understanding of discharge instructions. Verbalized understanding of need for followup and how to access followup care. Verbalized understanding of signs and symptoms to return to ED. Patient discharged from department. Discharge home. Verbalized understanding of discharge instructions [haven’t we heard this already?]. Verbalized understanding of need for followup and how to access followup care. A disposition has been done for JOHN DOE.
What a complete waste of paper! All I want from the ER is something like this: “Johnny has a mild otitis externa. I have prescribed cortisporin otic drops for him. Follow up with Dr. Koo in 2-3 days.” Instead, I literally get five pages of tree-killing faxes that doesn’t even tell me what was prescribed! Nice!

Now I’m sure that some of the kinks of EMR will eventually get worked out. And to be fair, there have been some small improvements recently. However, because EMR relies on doctors typing and clicking on a computer rather than dictating into a voice recorder, I’m afraid that most of the “narrative” aspect of physician documentation will go by the way of the Dodo Bird. And I am saddened that I probably will no longer get something as simple as this from the ER:
“Mr. Johnson has some dizziness. I think this is probably just from some dehydration. I have instructed him to drink more fluids and to decrease his lisinopril from 20 mg to 10 mg a day. He was advised to followup with Dr. Koo in 3 days to recheck his blood pressure. Consider repeating a Chem 7 at that time to reassess his mild renal insufficiency.” 
Now that kind of dictation is HELPFUL, but will likely become increasingly rare in our new era of check-boxes and computer-based templates.


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