Among the many complaints about electronic medical records (EMRs), the death of the useful medical note ranks very high.

Notes are too long, too complex, and filled with unhelpful words. It’s often impossible to glean what the clinician thinks is going on, or what’s planned.

Ever get a note from an urgent care clinic on a patient who went there with a viral syndrome? Or a discharge summary? The note contains pages of indecipherable gobbledygook, ICD10 codes, irrelevant review of systems, stock phrases — the medical words are there, but where is the content? Give a click on this note for a particularly egregious example (all identifying information removed). Then come on back here. I’ll wait.*

(*Good chance these notes are faxed to your office, then scanned into your EMR’s “media manager,” or whatever your EMR calls it. My wife, a primary care pediatrician, calls this part of the EMR “the place where information goes to die.” Yep.)

It hasn’t always been this way. I’ve worked with EMRs of various sorts for decades. One of them, designed for outpatient care, had two ways to file notes — the clinician either dictated a narrative (for complex cases) or, more often, wrote a brief handwritten note in a 3-line section that was immediately typed in by clerical staff.

Both types of notes were infinitely more useful than today’s behemoths. The long dictated notes told a logical story, the short ones highlighted only the most relevant information. Example of the latter:

New painful rash on back. PE: vesicles in T10 dermatome on L, otherwise neg. Dx zoster, Rx Valacylovir 1 gm TID for 7d. Discussed possible complications, reasons to return or call for f/u.

That’s it! Today, this would be unimaginable. In a paper published in the Annals of Internal Medicine, three experts in EMR optimization compared the length of notes in the USA vs other countries:

In other countries, [a note] tends to be far briefer, containing only essential clinical information; it omits much of the compliance and reimbursement documentation that commonly bloats the American clinical note. In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries

So how did we get here? What caused the note to shift from being the primary means of communicating medical information to this gargantuan beast? Three primary reasons:

1. Money. Some might call this “billing” or “regulatory” or “compliance,” but let’s call it by its root source — money. Based on quirks of our strange American healthcare system, certain words or phrases or diagnoses yield higher reimbursement than others. This hierarchy has nothing to do with delivering good patient care or communicating with other clinicians.

It’s not just individual words — entire sections of notes owe their very existence to maximizing revenue from clinical services. Dr. Mark Reid, author of the entertaining Medical Axioms, complained last week about being forced to include certain words in his notes.

He received this painful response from a Cardiology fellow, who recently had his notes reviewed by a “Cardiology Coder”:

I got this message in my epic inbox. As a FIT, it was hard to look at this in any positive way. What can I do to help? pic.twitter.com/7oJ34DOUdF — Ali A. Azeem (@aliahsanazeem) December 29, 2018

Not only did poor Dr. Azeem include a Review of Systems to satisfy the Insatiable Billing Monster, but someone reviewed his Review of Symptoms to ensure he used the correct words! Could there be a better example of what’s wrong with medical documentation than this anecdote?*

(*And could you imagine having that reviewer’s job? Shudder.)

2. Copy/paste. Some EMRs have a feature where you can highlight only the original — not the copied or imported — content of a note. If you do this, you instantly understand why “ID consulted, awaiting input” appears several days after you’ve done your consult and have been communicating regularly with the primary team. They’re not ignoring your beautiful consult, they just haven’t gone back to update the text.

Other symptoms of copy/paste madness are the gobs of laboratory and radiology data appearing in every note, copied from the actual reports and then pasted into the “Results” section, or imported via macros (see #3 below).

How bad is the copy/paste phenomenon in medical documentation? Researchers at UCSF reviewed the source of text from medical notes over an 8-month period, and their findings were not pretty:

We analyzed 23, 630 notes written by 460 clinicians. In a typical note, 18% of the text was manually entered; 46%, copied; and 36%, imported.

3. Text expanders. Call them what you like — “smart text” or “auto text” or “templates” or “dot phrases” — but these tricks of the trade, once mastered, are simply irresistible to most of us, for better or worse. Dr. Grace Farris captures our ambivalent relationship with this strategy perfectly in the cartoon that led off this post.

It works like this — we enter a magic little short string of characters, press return, and voila! Everything from a complex (but commonly used) sentence to a full medical note appears on the screen. Take a bow and admire your work!

From a Reddit thread on this strategy:

.NICU: As a peds resident, I made this dot phrase. Took me about 2 full days of work to get it together, but I basically created it to pull all the info I needed to preround on a patient. All the numbers from all systems, weight change, ecmo/ventilator settings, even the number of desaturations they had overnight. Approximately 6-8 pages worth of data, arranged in order of systems that we would present on rounds.

Impressive! But do we clinicians really learn, or interpret, material that “autopopulates” a note? And how can these one-size-fits-all notes apply to the infinite diversity of patient care?

Full disclosure: After once receiving feedback that my notes didn’t have sufficient documentation about the time spent on counseling and patient education, how did I respond? By creating “.saxcounsel”, of course — which when typed, expanded into a thorough description of time spent on counseling and patient education! That will show them!

So is there any hope for the medical note?

I do think there is a way to improve them, at least a bit, that won’t require a complete overhaul of billing regulations — but that will be a topic for a different post. In the meantime, I very much welcome your suggestions in the comments!