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Daybook, Medicine, Quotage

On handwriting and medicos.

We know that handwriting lecture notes improves retention. I collect (and use) fountain pens — including at work: Noodlers make good and cheap pens.

But then one has to dictate and upload. The problem with handwritten notes is that they get filed in rooms you cannot enter due to chemicals that were historically stored there, or Asbestos. The worst note is one that is not available.

But I hate the tick box mentality of many of our systems.

Why, then, do I remain so ambivalent about the EHR’s place in my life and the lives of my patients? Because repetitively typing EHR notes on my patient interactions is, for me, a soul-sapping exercise in data entry; reviewing the novella-length EHR notes of other clinicians has become a tiring and cynical hunt for meaningful observations, interpretations, or conclusions. This is not the fault of the EHR. The EHR was never designed to facilitate a human narrative, which was what my great-grandfather’s documentation was all about. Like him, when I wrote my notes, I was forced to think about how best to describe my patient’s idiosyncrasies, heart sounds, or skin lesions. It forced me to think about how best to state my conclusions and concerns, and how best to justify my plan of action. In the writing of these things, I learned them, remembered them, and they became important to me. Now, with a single click, I can populate an entire physical examination, add reams of diagnostic tests, or even generate a complete, comprehensive note. I can click to add impressive phrases such as: “Extensive differential diagnosis generated and considered,” “Laboratory and radiology results reviewed,” or “Diagnosis and care plan discussed at length with patient and all questions answered.” From a time-management standpoint, this is miraculous, and I use these tools to survive every day, but at what cost?

By its very nature, the EHR can offer no guarantees that I performed the examination that is so thoroughly documented, that I reviewed the pages of diagnostics pasted in, or that I actually took the time to have a discussion with the patient. It can be easy, and tempting, to pad an electronic note with everything “on the menu” to make it look impressively thorough or to justify an “upcoded” billing level. I see this with physicians-in-training who approach EHR documentation with the “more is better” method. More is not better.

A good note should offer insights into the thought processes, intuitions, and recommendations of the clinician. It should provide an assessment of the myriad psychosocial factors that may affect each patient’s care. It should be an honest and accurate reflection of both the clinician’s thoughts and the patient’s condition. Although voice recognition technology offers much promise, most current EHR platforms make it very difficult to efficiently achieve these goals. We click on the buttons that we have been told to click and hope it all somehow fits together. Sometimes, at the end of a long day when I have finally finished pointing, clicking, and pasting together my last note, I know in my heart that some of my documentation falls short of what my patients truly deserve.

Tomorrow, or 80 years from now, will someone be able to read through a bundle of my EHR-generated notes and develop any meaningful insights into how I cared for my patients or who those patients were? Will they sense any of the human aspect of patient care? Will they be able to discern what was truly important? What was real? The EHR may well prove to be “safer” and “more efficient,” but until it can more easily allow us to choose our own words, set our own priorities, and craft notes that better assist patients and colleagues, I doubt that my great-grandfather would say that it is “better.”

Curtis G. Kommer, MD
JAMA. 2018;320(9):875-876. doi:10.1001/jama.2018.11781

There is one other thing: you can emphasize easier on paper. Underline. Write big. Put boxes around things. Annotate. Adjust. An EHR system often hides, as does a poor paper based system, the important information under the mandatory information. Which is why I flip files upside down and read from the back.

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