The electronic medical record doesn’t tell you the story

28th April, 2012

This column was featured on the Association of American Medical Colleges’ blog “Wing of Zock” on May 7, 2012, and on KevinMD on May 10, 2012.

One morning recently, I found another physician standing morosely at one of the mobile computer terminals we refer to as “cows”—computers on wheels—that are everywhere now in our hospital. I asked what was the matter.  “Oh nothing, really,” she said.  “It’s just that I don’t feel I know the patients as well as I used to.”

I knew exactly what she meant.  Things are different now that we have the EMR—the electronic medical record.  After two months of use, we’ve learned to our sorrow that these records don’t tell us stories that make cognitive sense.  Instead they offer data in endless lists.

Before the written word, people told stories.  In every culture, around hearths and on journeys, they remembered and retold tales of great deeds, romance, and tragedy.  When we were medical students, we learned to present each case on rounds by telling the patient’s story.  The story had well-defined elements:  the current complaint, the background of genetics or misfortune that led up to the present, the investigation that might clinch the diagnosis, and the plan of action.

The best stories almost told themselves.  The business executive fresh from a transatlantic flight presented with shortness of breath; VQ scan revealed a pulmonary embolism.  The young woman with Marfan’s syndrome began exercising one morning and developed severe chest pain radiating to her back; the echo demonstrated aortic dissection.

Now, however, we have lists.

One list will give us the medical history.  In no particular order of priority, it includes one-word problems such as osteoarthritis or hypertension that have nothing to do with the patient’s current admission for acute pancreatitis. The relevant history of alcohol abuse may be found elsewhere, in the list under “social history”.  Our “social history” includes a field that will tell you whether or not the patient chews tobacco, which is so seldom helpful in southern California.  The complaint of abdominal pain won’t be found anywhere near the list of laboratory values with the important amylase and lipase levels.

If you’re a consultant trying to make sense of the patient’s case, you can find yourself frustrated and stymied at the difficulty of getting the big picture.  If you’re lucky, you can find a human who knows something about the patient, and get him or her to tell you the story.  You can bet that this won’t be the resident, who has just come on the service, didn’t admit the patient, won’t be following the patient, and will have to lie down for a nap soon.  But with perseverance you may find an attending physician who has no duty hour restrictions and actually knows what’s going on with the patient.

If finding a human fails, your second hope is to find a narrative note by a physician who is in the old-school habit of dictating an organized history and physical.  This is the pot of gold in the EMR, but you may have to sift through pages of notes on the computer before you find one.  Sometimes, just for fun, I print it out so I can refer back to it without logging on to anything.

The use of all the “smart fields” in the EMR looks appealing at first, until you figure out that it is fraught with peril.  Not long ago, I was reviewing the computerized record of an aged patient with a hip fracture before I went in to examine him.  The orthopedic surgeon’s note (not surprisingly) contained the standard “smart field” notation that the patient’s heart sounds were normal.  So did the emergency room note.  The renal consultant, however, took the trouble to type in a free text notation of a harsh systolic murmur.  This led me to click through more drop-down lists and screens until I turned up an echo report that documented critical aortic stenosis.  Nowhere in the patient’s medical history or “problem list” was aortic stenosis even mentioned.  And no one had linked the family’s account of the patient’s dizziness and recurrent falls to his heart sounds.  The classic symptom of late-stage aortic stenosis after all is syncope, or fainting spells, which in all likelihood caused his hip fracture.  We had a lot of disconnected data, but no real story.

In my own customized templates for writing notes, I’ve deleted most of the “smart fields”.  If they aren’t there, I can’t click “normal” just because I’m in a hurry.  Whatever I type in is what I actually saw or heard or palpated.  If I ever have to refer back to that record, I’ll know that it contains no default entries.  There could be future medicolegal risk for all of us because it’s so easy to enter “normal”.  In the past, if part of a physical exam hadn’t been performed (such as a neck exam by the colorectal surgeon), we would leave that field blank or write “deferred”.  Years from now, how will we be sure which findings were really and truly normal in all these computerized notes?

Still another hazard of the “smart fields” is that they propagate themselves endlessly, like tribbles.  The same “past medical history” will appear as an identical list in note after note, because it’s so easy to type “.pmh” instead of summarizing the patient’s problems as a narrative.  If an error of any kind is made, it will continue until someone notices and takes the trouble to delete it.  If “Lasix” instead of “latex” is entered as an allergy, it may be listed that way indefinitely.  You’re much more likely to click on the wrong line of a list than you are to write down the wrong information in a handwritten note.

With the billions of dollars that are being spent on EMRs, and the Obama administration’s keen interest in their implementation, no one wants to hear about the problems they cause.  But the truth is that it’s much harder for physicians and everyone else in the hospital to learn and remember what they need to know about their patients from reading electronic records.  Human beings don’t learn best by memorizing disconnected lists.  From fairy tales to patients’ histories, we’re hard-wired to remember stories.

         Author’s note:  Thanks to Robert Dickman, executive coach and author of The Elements of Persuasion, whose focus on narrative strategies in communication helped me articulate what bothers me most about the EMR.

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