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.