Electronic Health Records (EHRs) are not the cause of inferior notes

By | October 17, 2017

Recent discussions within the industry have placed blame on EHRs for repetitive or ineffectual notes. Some say the reason is the required documentation that must be completed in order to justify reimbursement. We also have seen the proliferation of information in the EHR that has very little impact on the reason for the visit.

EHRs do not cause us to create meaningless notes; we are merely using technology to replicate an inefficient structure of communication. Back in the day, when we either hand wrote or dictated notes, we still had this controversy, either there was irrelevant information or words that were meaningless. In recollection, I remember reading numerous notes that documented, “No change from previous note, or everything is within normal limits.” Not helpful at all for the delivery of care. Therefore, we had the same issues, just a different medium.

Historically, notes were written after seeing the patient, as a way to convey the health care provider’s impressions and thought process, as a way to remind themselves during the next encounter, or relay the information to others seeing the patient at a different time. In keeping a longitudinal story, their purpose was delineating care delivered. Over time, notes evolved as a justification of payment. We were required to document certain information as a proxy for services provided. Notes also became legal documents as we all have heard “if it wasn’t documented, it never happened.” The value notes shifted, no longer were they a way to communicate with oneself or others. Instead, they became a way to communicate with the payer of our services and the court system.

EHRs are best suited for collecting pertinent information on our patients that enhances patient care. They provide information in ways that enhance differential diagnosis, treatment options, and the monitoring of results. They are a medium to collect data for improved learnings, and communicate the relevant information needed to generate appropriate decisions. I remember when I first used an EHR in the late 1990s, I found myself just looking at the true data rather than my last note. When needing to send my patient to a specialist, I would share the relevant facts by sending the information from the EHR. The specialists appreciated obtaining the pertinent information they required without having to sort through reams of information. As contextual information is also important, EHRs must have fields to capture such documentation including the ability to share as needed.

If we covet value-based models, it is imperative we consider how to utilize our technology in ways that help in delivering value, not just replicating imperfect models electronically. Remember as payment forms shift, the necessity of using notes for payment will lessen. Capturing our thought processes and the pertinent data remains critical and is paramount in any EHR functionality.

Let us not use technology to make an inadequate model easier to replicate, but accordingly, let us apply it in a way that enhances the care we deliver and how we communicate what is needed to others on the care team.