Bill Cayley, Jr,
MD MDiv
With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart-sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees. Especially in family medicine, we have a long tradition of teaching our learners to appreciate narrative and nuance, and the flow of meaning and story that comes from a patient’s history can give far more insight into what may be going on than one gets from simple documentation of location, quality, quantity, etc. Now, however, our use of EMRs is pushing us more and more to documentation of positives and negatives, rather than story.
Case in point #1: As emergency room documentation has moved toward templates and away from dictation, I have found ER notes growing in length, yet declining in their ability to convey meaningful information. Documentation of an ER visit that in the past was captured by a one- or two-page dictated note, now comes in a eight- or nine-page template document that gives no real clue as to what really brought the patient in or what really happened.
Case in point #2: As EMRs use templates to guide information gathering, how often do you find yourself responding to the template in an office visit, or ordering something “because it is there,” rather than listening to the patient’s story?
Case in point #3: How often do you see a patient and have to repeat the entire history yourself, because the information in prior documentation (whether from a colleague, from a learner you are supervising, or from a consultant) fails to provide the nuance needed to understand what happened in the last visit?
I fear that “template-based medicine” (or at least, template-based documentation) will lead to poorer care, because we focus on answering pre-specified questions rather than understanding the patient’s story. I also fear template-based documentation will, paradoxically, hamper efficiency, due to the loss of time entailed in re-obtaining a history that was previously obtained but inadequately documented due to the structure of the documentation system.
Most concerning, I fear that overuse of templates may lead our learners to focus more on completing check-offs, rather than understanding the patient story. In family medicine, and in STFM in particular, we have many who emphasize and teach the importance of understanding narrative. Yet, since we tend to respond to how we are reimbursed, if documentation, coding, and reimbursement are ultimately tied to the thorough use of templates and forms, in the end narrative may lose out to form completion.
EMRs are here to stay, and they do provide many benefits for information gathering and data management. However, as teachers and practitioners of family medicine, we need to be sure that our tools are not overwhelming our ideals and our understanding of what is important. We are not just “providers” who manage data points, we are physicians, and our fundamental task is to care for patients with real, meaningful, and nuanced stories. Even as data collection technology and systems become more pervasive in all areas of medicine, we must strive to promote clinical methods, ways of thinking and teaching, care processes, and above all, values that keep our patients and their stories to the fore.
STFM Blog 
Yes! 2 years of forcing my family medicine-mindset into an EMR template, doubling the time an office visit took while only documenting half the story, made me eventually stop caring about the story, and eventually, sadly, about my patients at all. The only thing that mattered if I wanted to get home before midnight was that I check the cluster of boxes required to “qualify” for Medicare incentives (whether or not they had any impact or meaning to the patient’s care/visit); like a robot scribe: check, check, import from last note, check, check, import, change order of problem list, check, check. No free text allowed: “it’s not captured for billing purposes…makes the notes too long.” Then, check 6 more boxes specific to Medicare that have nothing to do with the visit; do I really need to check a box to tell you I sent an electronic prescription – if I sent it electronically, shouldn’t “the system” document that somehow? Well, “The Story” (which never fits into a template), was always my favorite part of medicine; without it, I literally lost all the joy and fulfillment my job used to bring. Feeling trapped and depressed, and missing the QUALITY care I used to provide, I finally left this clinic (after 13 years and many tears) to work for another practice that, due to similar frustrations, had just gotten rid of their EMR (along with its meaningless “meaningful use” incentives), We can now CARE for patients, just as we were trained, and just as we are impassioned – be damned, Medicare incentives! The story is back, the joy is back, and we, along with our patients, could be no more content.
Excellent column, Dr. Cayley. For those who want to think about this topic as a specific case of a more generalized issue of how bureaucratic systems manage complex processes, the book “Seeing Like a State” by James Scott may prove interesting. This column reminds me of the first chapter – not medically-related, but potentially describing the same pathology, nonetheless. Most of the first chapter is available as a preview on Google Books: http://books.google.com/books/about/Seeing_Like_a_State.html?id=PqcPCgsr2u0C
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In the EMR early days this templating was a big selling point.
“You can save money by firing your transcriber!”
“You can save loads of time!”
It doesn’t take a rocket surgeon to understand templating is just not useful.
Besides, as lawyers get involved, each input will have an additional 3 to 5 pages of legal disclaiming I’m sure.
I also seem to remember templating being “outlawed” a few years back, yet I don’t have any proof.
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More detailed and concise documentation and less “storytelling” and we’d all be better off. You either diagnosed and/or treated something or you didn’t. Check. Note co-morbidities and be on your way. Check. Templates allow this without the fluff.
I certainly appreciate the semantic richness and freedom of expression afforded by narrative notes. But the fixation on this leads to practicing the “art” of medicine. Computers now enable us to bring much more science into healthcare. But computers require data, not free text. We should be able to mix codified data with a little narrative for color. If we don’t get data, we’ll never advance the science effectively. Healthcare will continue to be too expensive, with suboptimal quality. This critical issue is discussed in a brief opinion article posted at http://smartype.com/id11.html
The ultimate solution is actually to have a remote scribe handle all the documentation and also the encounter coordination. This approach, which dramatically improves physician productivity, is described in an article at http://www.fortherecordmag.com/archives/0913bonusp6.shtml
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