Tech

What Do I Do If I Don’t Have a Template?

Screen Shot 2014-11-03 at 11.49.29 AMElectronic medical records (EMRs) now play a part in the daily documentation routine for most physicians. While improvements in access to patient data, legibility of notes, and ease of order entry are welcome enhancements, there is a significant downside to EMRs as well. Although I’ve blogged about my frustrations with nonsensical, auto-populated notes and error carry-forward, there is a more insidious problem with reliance on EMRs: digital dependency.

The idea of digital dependency first occurred to me during a conversation with a young medical resident at a hospital where we share patients. I was bemoaning the fact that I was being forced to use hospital-designed templates for admission notes, rather than a dictation system or carefully crafted note of my own choosing. She looked at me, wide-eyed and said:

“You’ve worked without templates? How do you even know where to begin? Can you really dictate an entire note off the top of your head? I couldn’t live without templates.”

As I stared back at her with an equal amount of bewilderment, I slowly realized that her thinking had been honed for drop-down menus and check boxes.

Over time, she had lost the ability to construct narratives, create a cohesive case for her diagnostic impressions, and justify her patient plan of action. To this bright, highly trained mind, clinical reasoning was an exercise in multiple choice selection. Her brain had been optimized for the demands of an EMR template, and mine was a relic of the pre-EMR era. I was witnessing a fundamental cognitive shift in the way that medicine was practiced.

The problem with “drop-down medicine” is that the advantages of the human mind are muted in favor of data entry. Physicians in this model essentially provide little benefit over a computer algorithm. Intuition, clinical experience, sensory input (the smell of pseudomonas, the sound of pulmonary edema, the pulsatile mass of an aneurysm) are largely untapped.  We lose our need for team communication because “refer to my EMR note” is the way of the future. Verbal sign-outs are a thing of the past it seems, as those caring for the same patient rely on their digital documentation to serve in place of human interaction.

My advice to the next generation of physicians is to limit your dependency on digital data. Like alcohol, a little is harmless or possibly healthy, but a lot can ruin you. Leverage the convenience of the EMR but do not let it take over your brain or your patient relationships. Pay attention to what your senses tell you during your physical exam, take a careful history, listen to family members, discuss diagnostic conundrums with your peers, and always take the time for verbal sign outs. Otherwise, what advantage do you provide to patients over a computer algorithm?

Am I a curmudgeon who is bristling against forward progress, or do I have a reasonable point? Judging from the fact that my young peers copy and paste my assessment and plans into their progress notes with impressive regularity, I’d say that templatized medicine still can’t hold a candle to thoughtful prose. Even the digitally dependent know this.

Val Jones MD  blogs at Get Better Health, where this post first appeared. 

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Curly Harrison, MDDr. MikeHans Duvefelt, MDRetired MDWhatsen Williams Recent comment authors
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Curly Harrison, MD
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Curly Harrison, MD

Hey, Booby,

You finally said something and/or posted something aligned with the thoughts of many commenters on this blog:

Paper medical records have advantages over the gibberish of EHRs.

Dr. Mike
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Dr. Mike

Is it not ironic that the EHR, which has been touted as a way of increasing communication, may be responsible for an inability to communicate? Each new physician seeing the patient for the first time essentially has to start over as the content of the EHR gibberish takes so long to decipher that starting over is simply faster.

Hans Duvefelt, MD
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A frightening vignette of the new generation of doctors: “can you really dictate an entire note off the top of your head?”

Retired MD
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Retired MD

I agree wholeheartedly with this analysis. I would not use templates for this reason. Those who use templates spend more time paying attention to the items in the drop down menu then they spend paying attention to the patients use of words and nonverbal cues. There is a flow to a history that cannot be duplicated with a template. For those who feel that a computer will be able to come up with a better diagnosis, remember “garbage in, garbage out”.

Whatsen Williams
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Whatsen Williams

“The problem with “drop-down medicine” is that ” that it is drop dead medicine. Ask the family of the late Thomas Eric Duncan who died from the Eoic EHR facilitated delay in diagnosis in the EHR run ER at the Dallas hospital wherevthere was a complete H and P defaulted to normal.

@BobbyGvegas
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See Nicholas Carr’s “The Glass Cage” — e.g., __ “…THE INTRODUCTION of automation into medicine, as with its introduction into aviation and other professions, has effects that go beyond efficiency and cost. We’ve already seen how software-generated highlights on mammograms alter, sometimes for better and sometimes for worse, the way radiologists read images. As physicians come to rely on computers to aid them in more facets of their everyday work, the technology is influencing the way they learn, the way they make decisions, and even their bedside manner. EMR systems are used for more than taking and sharing notes. Most… Read more »