A Note of Optimism on the Electronic Health Record
The first batch of our younger breed of interns has begun their ambulatory rotations after undergoing a week of global residency orientation and a full morning of introduction on the nuts and bolts of treating patients in the outpatient setting. Everyone seemed to be really eager to be here, ready to tackle healthcare and all of the problems that come with it as we fight the good fight to care for our patients.
They’ve all had extensive training using our electronic health record (EHR), and many of them have used the same one while working on the wards or in clinics as medical students at other institutions. We hope that as time goes on, we can instill in them a desire to build better medical records, to learn how to write a note that accurately depicts what transpired in our office, to precisely encompass our assessment, plan, and all the effort put into providing care for our patients.
Just this morning, we reviewed the procedures of pre-charting, checking old notes, looking at current labs and consult notes, evaluating admissions and discharge summaries, updating prescription lists, and so much more. One complicated patient we saw had a recent visit with a specialist after they were sent home from the hospital, and we looked over their note to see what they had to say and what action the patient should take. It spanned 37 pages.
I know, these aren’t actual pages, since we didn’t print out the note, but we went through 37 screenfuls of material from the patient’s hospital course and prior medical history on the computer monitor. It continued on and on, with screen after screen of laboratories, cut and pasted data from imaging and procedures, and earlier consult notes. We never really got a sense of what this provider was thinking or what they considered should happen next, even after reading it in depth. Even though, we were able to see that they integrated several previous notes that mentioned what other providers had opted to do, most likely in an attempt to compile and summarise all of the plans. Regrettably, each of them began with something along the lines of “So, for today’s visit…” As we read, we kept thinking we were getting close to the evaluation and proposal. However, as we came to the conclusion, we discovered we still didn’t know what the patient’s next actions should be. This Patient is just an example of what we go through every day and many of our colleagues have started moving the assessment and plan up to the top of their notes, in an attempt to speed up the process of reviewing notes.
However because of the January 2021 changes to the Medicare billing and coding compliance rules, a tremendous quantity of needless paperwork is no longer required in office notes, we are at a moment when a significant opportunity has presented itself. Transitioning to this new method has been difficult for providers, and I believe our impulses are still to copy forward, cut and paste, and include everything. I believe the moment has come for all this to become obsolete, for us to use the electronic medical record as a repository for each patient’s healthcare journey rather than for us to extract every old detail into every note we make. Given the popularity of the Open Notes movement and the fact that our patients will be reading and evaluating an increasing number of the notes we write about them, it’s only natural that we prioritize clarity, simplicity, honesty, and communication.