Are EMRs Killing the Clinical Narrative?

Scott Mace, for HealthLeaders Media , March 20, 2012

"The doctors in the ER were trying to figure out whether the shortness of breath in this woman was due exclusively to her failing heart, or was there a problem with pneumonia," Resnik says. "People who have pneumonia do not respond promptly to [BiPAP] treatment. But she responded promptly. This gave them information."

Resnik bets that few point-and-click EMRs have a check box or slider control for how quickly a patient responded to a treatment.

Text fields in EMRs can capture this information, but in a busy exam room, with doctors trying to point, click, and enter EMR data during the exam, while also trying to maintain eye contact with the patient, how much time will be left for text entry?

The dilemma compounds when you realize that any data entered in text fields will resist analysis. Database analysis works best with discrete numbers. So even if we get doctors to enter the portions of their narrative that don't fit in discrete data fields, we've lost the ability to really analyze that data.

As an experiment, Resnik and some other researchers took 20 cardiology dictations and went through them manually, highlighting the info that could be placed in discrete fields, without having to type into a text box.

"Then we took two cardiology experts and said, 'Let's pretend this clinical record is somebody a doctor across the country referred to you as a case,'" Resnik says. Researchers had highlighted info that couldn't be placed in the discrete fields, and they asked the cardiologists to rate how severe a gap in the record the highlighted information was.

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11 comments on "Are EMRs Killing the Clinical Narrative?"

S. Silverstein MD (3/28/2012 at 12:21 PM)
I remind that the goal of the medical informatics pioneers was lexical and semantic clarity, not ambiguation. They intended that computational linguistics-based analysis of free text would accomplish this. The commercial sector, however, saw fit to ignore this work and try to make EHR's a "medicine by template" affair - much faster to market, and much more profitable. Imagine lawyers trying to practice "template law." Their briefs would be impaired beyond use. I note that it is possible to prevent EMR's from producing "legible gibberish." An example is here:

Beth Friedman (3/26/2012 at 2:10 PM)
Yes. Anyone who uses the doctors narrative reports day in and day out, such as coders, CDI, researchers, and auditors, is aware of this problem. EMRs make cutting and pasting, shortcuts and over-documenting way too easy. While I understand that physician documentation should be there for patient care - not necessarily all the various downstream functions - that's not the reality in the U.S. Physician documentation is the basis for so many downstream functions and reports. The onus is really on the physicians and the vendors to make the process of documenting a by-product of care. Until then, it will be a difficult balancing act between ease of use for MDs and enough information for downstream functions and quality reporting.

Steve Wilkins (3/22/2012 at 6:16 PM)
Scott, Add to the issues you articulated so well in your post the issue of EMRs and physician de-skilling. As physicians switch over to filling out the EMR, they are not documenting so much of what they used to capture in their notes before. Check out a piece on physician de-skilling at Steve Wilkins




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