The EHR has become increasingly important when it comes to documenting the care that we give to patients each day in our practices and hospitals. The tools available to healthcare providers in this day and age have dramatically improved as has the breadth of data available to support decision making.
For the first time since we began documenting the delivery of healthcare, we have significant and sophisticated tools to record patient care. Macros, templates, and other tools speed the process of chart documentation. However, we must be cautious about these conveniences. Previously, I’ve discussed the significant hazards of electronic charting. They include cloning and cut-and-paste, among other methods.
In the early iterations of our EHR, the chart note was highly dependent on templates for physical examination and review of systems. While this speeds up the process of charting, it also makes every history and physical, consult note and progress note look identical. Cloning is a particularly bad idea. It may speed charting, but it also propagates erroneous data by bringing it forward. When the provider is not savvy enough to carefully review all of the data in his notes, it is easy to overlook questionable facts, diagnostic information and other ratty data in the EHR.
One unanticipated negative trend of the EHR is the issue of “note bloat.” This is where notes seem to get longer and longer as people become more adept at using the EHR. When I started in the inpatient environment, the progress note was handwritten, and the history and physical exam was dictated. We had to be concise due to time constraints, and my progress notes would only take half of a page many times. Before the latest iteration of our EHR, the template-based charting turned half-page progress notes into two pages. This improved somewhat when I learn how to be more discriminating and learned to “deselect” automatically propagating data in the templates note to focus on what was really important.
Now, as the EHR has turned a corner and started to focus on the needs of the providers, the charting tools have become much more customizable and user-friendly. I have to say that the modern charting component of our inpatient EHR is very clean, concise and uncluttered.
Here are my rules for the inpatient chart note. When I am working with medical and PA students, I make it a point to have them understand this information intimately while they’re on our service.
No EHR should allow chart cloning in total. This means the ability to copy an entire previous chart. The caveat to this rule is that I do appreciate the ability to propagate previous medications, allergies, past medical and surgical histories, and other data that remains static as it relates to a patient. However, it is up to the provider to verify that all of this propagated data is accurate at every visit.
• Cut and pasting of EHR data is to be strongly discouraged. This also can be very hazardous and can bring forward unverified and inaccurate data about the patient. Like everything in charting, there is a caveat. I do use cut and paste to bring forward things such as a radiologist’s assessment of a study into the current chart note. By working closely with the IT support staff, I have discovered a very useful functionality of our EHR that rapidly speeds charting and includes pertinent data. We have the ability to use “.” macros such as .labs, .CT, .X-ray, etc. that bring forward the most current diagnostic assessments and labs into the note with simply the appropriate command.
• Avoid using the templated review of systems and physical examinations. These are ridiculously easy to spot with in someone else’s record, and all it says to me is that the documented history and physical exam was not performed.
• Integrated dictation is essential to the EHR in this day and age. Providers in the inpatient environment have much better things to do with their time than typing out chart notes in the EHR.
Healthcare facilities and hospitals have invested billions in EHR technology. We must make sure we continue to invest in the providers and other staff who use this technology. A key way we can make our current system stronger is to bolster training for providers and other staff to help them understand the complexities and functionalities of the evolving modern EHR.
Date: April 8, 2016