The following is a guest blog note written by a very senior, academic internist and active clinician who wishes to remain anonymous. I will personally vouch for both his talent and long experience in delivering patient care.
Being an old-timer in practice,I have lived through at least two generations of EHRs in one form or another in my years of academic clinical practice. This experience has provided me with a perspective on the use of such systems. Let me begin by stating that an EHR provides many features that I like very much -- not just the ability to keep track of my patients but also the ability to to carry forward an “active” and updated problem list that is not just a cut-and-paste. Such a system also provides me with the means to generate prescriptions electronically, place patient orders, and use communication tools within the EHR that are convenient even if not as flexible email.
However, EHR also have a dark side. Let me point out just a few of the problems that I have encountered. I work in a relatively sophisticated and high-powered academic medical center with a major training role. Too often the way the EHR is used by physicians acts to obscure information and hinder communication as the responsibility for care is passed from one practitioner to another. Examples of EHR misuse that I have often seen include excessive use of the copy-and-paste feature and innumerable abbreviations as well as poor note organization. I also encounter the tendency to “document” and "fill up" physician notes, more for the purpose of billing and inclusiveness than for information clarity.
Demands for more billing information result in the inappropriate and excessive use of the “copy and paste” feature that only serves to fill the EHR with repetitive clutter that would be better referenced than re-copied and could easily be eliminated to shorten documents and make them more readable and useful. Examples of such instances include discharge summaries that can be nearly impossible to comprehend as well as inpatient or outpatient notes that have evolved into tomes. They often include cut-and-paste lab results, procedure reports, medication lists, and endless problem lists containing minor and unimportant items. Such documents are virtually useless if one is searching for pertinent and timely information about a patient. Because of this and during any chart review, the reviewing physician often ends up ignoring 90% of the record and proceeds to the final (or initial) “impression and recommendation” to obtain any useful information about the patient.
If the EHRs deployed in our medical centers are to accomplish what the advocates of such systems told us was initially intended (e.g., accurate data collation and availability, inter-episode communication, and the ability to search for and identify important information), a more judicious use of the EHR is necessary in order to avoid the endless "filling" of the electronic spaces. Those of us who want to use the EHR to foster more efficient information availability should demand a record closely aligned to the physicians' standard workflow and communication needs.
I believe that the EHR is theoretically flexible enough to allow this kind of workflow. In order to achieve this type of product, however, we can't mindlessly cram as much information into the record as is physically (electronically) possible simply because the EHR allows it or because we can bill more as a result. It remains to be seen whether we will realize the potential benefits of the EHR that were touted in the debate about its relevance for ACA and other new health care initiatives.