Physician Progress Notes

The ability to gather, analyze, and distribute information broadly is one of the great strengths of digital health, perhaps the most significant short-term opportunity to positively impact medical practice. Yet, the exact same technology also carries a set of intimately-associated liabilities, dangers we must recognize and respect if we are to do more good than harm.

Consider these three examples:

  • Last week, a study from Case Western reported that at least 20% of the information in most physician progress notes was copy-and-pasted from previous notes. As recently discussed at kevinmd.com and elsewhere, this process can adversely affect patient care in a number of ways, and there’s actually an emerging literature devoted to the study of “copy-paste” errors in EMRs. The ease with which information can be transferred can lead to the rapid propagation of erroneous information – a phenomenon we used to call a “chart virus.” In essence, this is simply another example of consecrating information without first appropriately analyzing it (e.g. by asking the patient, when this is possible).
  • At a recent health conference, a speaker noted that a key flaw with most electronic medical record (EMR) platforms is that they are “automating broken processes.” Rather than use the arrival of new technology to think carefully, and from the ground up, about the problems that need to be solved, most EMRs simply digitally reify what already exists. Not only does this perpetuate (and usual exacerbate) notoriously byzantine operational practices and leave many users explicitly complaining they are worse off than before, but it also misses the chance to offer conceptually original approaches that profoundly improve workflow and enhance user experience.

Continue reading “The Chart-Eating Virus, Me Too Software and Other Emerging Digital Threats”

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The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy.

There is a Problem

I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. While overall, I am happy to have electronic records, there is a problem: The EMR is trying to serve too many masters. The needs of these various masters are different, and sometimes they are incompatible, even hostile to one another.  These masters include other caregivers, the agencies paying for the care, and those interested in medico-legal aspects of care.  What can happen, and I have seen it many times, is that the needs of the caregivers take a back seat to the needs of the payers and the lawyers. The EMR is supposed to improve patient care, but sometimes it makes it worse. Physician progress notes illustrate how this happens.

Continue reading “The EMR and the Case of the Disappearing Patient”

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