Electronic medical records (EMRs) have a bad reputation among many physicians for generating progress notes that are so verbose and filled with standard phrases that they are nearly useless to other physicians, and even to the physician who produced the note in the first place. This is in part because rather than engineering the EMR to produce a note intentionally efficient and effective for users looking at the note on a computer monitor, many EMR users choose to create a record familiar to them from years of use of paper charts. A note documenting a patient visit really serves only 3 purposes. First it is a clinical note documenting the patient’s history, findings on exam, and the assessment and plan of care. This is ideally efficient to generate, easy to review, and have the information needed in future visits in an easy to see and understand format. Secondly the note is a legal document, providing documentation of care and advice provided, and needs to be useful in case of a legal challenge. Third it needs to document the care done to justify billing and assure payment by third party payers. A good note does all of these things. In many EMR systems the last two are done well, but the clinical usefulness of the note is very poor.
Most EMR notes do a great job of documentation to assure payment. The ability to easily enter the information needed to justify a level of billing is sometimes too easy, and EMR users have been criticized for overbilling as a result. From a physician’s point of view, being easily able to enter the information required by payers without doing a long and costly dictation is a big plus of EMRs.
EMRs also can easily make a document that does a good job of producing a document that can stand up to legal scrutiny. Although there is little data to prove it, some experts believe use of an EMR can reduce liability.
When a physician reviews a prior progress note, the information they usually want to see the assessment and plan. Much less often they need to know the details of the patient’s history, examination, review of systems, etc. In a paper chart it is just a movement of the eyes to find the desired part of the note, and it makes little difference whether the needed information is on the first few lines, or at the end of the note. The traditional progress note format is the SOAP note: Subjective history first, Objective information like vital signs, physical exam and test results next, Assessment including the diagnosis and documentation of the thought process and decision making third, and the Plan of treatment last. This reads in a logical fashion, and has become the standard format in most paper patient charts. In an EMR note reviewed on a computer monitor, the traditional SOAP note simply does not work. The history of present illness, past medical history, family, and social history, and review of systems, and physical exam more than take up the available space on a monitor. To see the needed information, the assessment and plan, requires scrolling to areas hidden on first glance. This is exacerbated by the ease of documenting repeated information like past medical history and family history, which might be stated very briefly in a dictated note, but are often included in much more detail in EMR notes. The information is also usually in a format that requires more screen space than a dictated note. In EMR templates that simply try to reproduce the end product of a dictated note, i.e. a SOAP note, the product is a note where all of the key information is a long scroll away.
Consultants have known for years that their referring physicians do not want to look through the entire history and physical exam documentation to get to the assessment and plan. Most consultants make notes to their referring physicians with the Impression and Plan/Recommendations at the top. This allows the referring physician to quickly see the key information they need, and then choose to review what other information they need. As physicians making notes primarily for our own and our associate’s future use, we need to give ourselves this same ability.
Simply making an APSO note instead of a SOAP note, i.e. putting the Assessment and Plan first, and the Subjective history and Objective information later can make reviewing notes much more efficient. This simple change can be done easily in most EMRs, and just requires thinking about the different work process using a computer monitor to look at information.
We need to modify our work processes to make our technology work for us, not try use the technology to electronically reproduce previous workflows.
Ed Pullen, MD, is a board certified family physician practicing in Puyallup, WA. Dr. Pullen shares his viewpoints on medical news and policy from a primary care physician’s perspective at his blog, DrPullen.com.