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. 

6 replies »

  1. 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.

  2. 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.

  3. 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”.

  4. “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.

  5. 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 of them incorporate decision-support software that, through on-screen checklists and prompts, provides guidance and suggestions to doctors during the course of consultations and examinations….

    A study of primary-care physicians who adopted electronic records, conducted by Timothy Hoff, a professor at SUNY’s University at Albany School of Public Health, reveals evidence of what Hoff terms “deskilling outcomes,” including “decreased clinical knowledge” and “increased stereotyping of patients.” In 2007 and 2008, Hoff interviewed seventy-eight physicians from primary-care practices of various sizes in upstate New York. Three-fourths of the doctors were routinely using EMR systems, and most of them said they feared computerization was leading to less thorough, less personalized care. The physicians using computers told Hoff that they would regularly “cut-and-paste” boilerplate text into their reports on patient visits, whereas when they dictated notes or wrote them by hand they “gave greater consideration to the quality and uniqueness of the information being read into the record.” Indeed, said the doctors, the very process of writing and dictation had served as a kind of “red flag” that forced them to slow down and “consider what they wanted to say.” The doctors complained to Hoff that the homogenized text of electronic records can diminish the richness of their understanding of patients, undercutting their “ability to make informed decisions around diagnosis and treatment.”…

    Although flipping through the pages of a traditional medical chart may seem archaic and inefficient these days, it can provide a doctor with a quick but meaningful sense of a patient’s health history, spanning many years. The more rigid way that computers present information actually tends to foreclose the long view. “In the computer,” Ofri writes, “all visits look the same from the outside, so it is impossible to tell which were thorough visits with extensive evaluation and which were only brief visits for medication refills.” Faced with the computer’s relatively inflexible interface, doctors often end up scanning a patient’s records for “only the last two or three visits; everything before that is effectively consigned to the electronic dust heap.”…

    …With paper records, doctors could use the “characteristic penmanship” of different specialists to quickly home in on critical information. Electronic records, with their homogenized format, erase such subtle distinctions. Beyond the navigational issues, Ofri worries that the organization of electronic records will alter the way physicians think: “The system encourages fragmented documentation, with different aspects of a patient’s condition secreted in unconnected fields, so it’s much harder to keep a global synthesis of the patient in mind.” The automation of note taking also introduces what Harvard Medical School professor Beth Lown calls a “third party” into the exam room… More than 90 percent of the Israeli doctors interviewed in the study said that electronic record keeping “disturbed communication with their patients.” Such a loss of focus is consistent with what psychologists have learned about how distracting it can be to operate a computer while performing some other task. “Paying attention to the computer and to the patient requires multitasking,” observes Lown, and multitasking “is the opposite of mindful presence.”

    …Studies show that primary-care physicians routinely dismiss about nine out of ten of the alerts they receive. That breeds a condition known as alert fatigue. Treating the software as an electronic boy-who-cried-wolf, doctors begin to tune out the alerts altogether. They dismiss them so quickly when they pop up that even the occasional valid warning ends up being ignored. Not only do the alerts intrude on the doctor-patient relationship; they’re served up in a way that can defeat their purpose.

    A medical exam or consultation involves an extraordinarily intricate and intimate form of personal communication. It requires, on the doctor’s part, both an empathic sensitivity to words and body language and a coldly rational analysis of evidence. To decipher a complicated medical problem or complaint, a clinician has to listen carefully to a patient’s story while at the same time guiding and filtering that story through established diagnostic frameworks. The The key is to strike the right balance between grasping the specifics of the patient’s situation and inferring general patterns and probabilities derived from reading and experience…

    Being led by the screen rather than the patient is particularly perilous for young practitioners, Lown suggests, as it forecloses opportunities to learn the most subtle and human aspects of the art of medicine— the tacit knowledge that can’t be garnered from textbooks or software. It may also, in the long run, hinder doctors from developing the intuition that enables them to respond to emergencies and other unexpected events, when a patient’s fate can be sealed in a matter of minutes. At such moments, doctors can’t be methodical or deliberative; they can’t spend time gathering and analyzing information or working through templates. A computer is of little help. Doctors have to make near-instantaneous decisions about diagnosis and treatment. They have to act. Cognitive scientists who have studied physicians’ thought processes argue that expert clinicians don’t use conscious reasoning, or formal sets of rules, in emergencies. Drawing on their knowledge and experience, they simply “see” what’s wrong— oftentimes making a working diagnosis in a matter of seconds— and proceed to do what needs to be done. “The key cues to a patient’s condition,” explains Jerome Groopman in his book How Doctors Think, “coalesce into a pattern that the physician identifies as a specific disease or condition.” This is talent of a very high order, where, Groopman says, “thinking is inseparable from acting.”

    Like other forms of mental automaticity, it develops only through continuing practice with direct, immediate feedback. Put a screen between doctor and patient, and you put distance between them. You make it much harder for automaticity and intuition to develop.”

    Carr, Nicholas (2014-09-29). The Glass Cage: Automation and Us (Kindle Locations 1380-1581). W. W. Norton & Company. Kindle Edition.