The Electronic Medical Record and the Disappearance of Patients’ Stories

Below, a guest post by Christopher Johnson, a physician who has practiced pediatric critical care for more than three decades. For many years, Johnson served as the Director of the Pediatric Critical Care Service at the Mayo Clinic and Professor of Pediatrics at Mayo Medical School. Today, he devotes his time to practicing pediatric critical care as President of Pediatric Intensive Care Associates, P.C., i n St. Cloud, Minnesota, and as Medical Director of the PICU for CentraCare Health Systems.

In addition, Johnson writes about medicine for general readers, both on his blog  and in books such as HowYour Child Heals: An Inside Look at Common Childhood Ailments  and How to Talk To Your Child’s Doctor: A Handbook for Parents

Not a few doctors complain that, too often, electronic medical records seem designed to improve billing, rather than to improve care. Johnson suggests that today’s EMRs are trying to serve too many masters—not just doctors, but payers and lawyers who want to see information laid out in easy-to-read “templates.” 

With a single keystroke, one can “drag and drop” information from previous notes into these templates, Johnson observes. But when physicians use them to record their progress notes, something important is lost: the patient’s story. Traditionally, progress notes set out to “tell, from day to day, what physicians did to a patient and why,” Johnson explains. They are a narrative that fleshes out the patient’s history in a way that helps other doctors treating the same patient.

Johnson uses and appreciates the many ways that EMRS can help him. But when writing out his progress notes, he ignores those smart templates, and tells the story the old-fashioned way, typing out his progress notes, just the way he did when he used pen and paper. Not only does this help other doctors, but Johnson says, it gives him a chance to “think things through.”

Narrative connects the dots.


The Electronic Medical Record and the Disappearance of Patients’ Stories   

By Chris Johnson, M.D.

The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this represents progress: the EMR has the ability to greatly improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important information.

With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy.

                            The EMR–Serving Too Many Masters

I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. While overall, I am happy to have electronic records, there is a problem: The EMR is trying to serve too many masters. The needs of these various masters are different, and sometimes they are incompatible, even hostile to one another.  These masters include other caregivers, the agencies paying for the care, and those interested in medico-legal aspects of care

What can happen, and I have seen it many times, is that the needs of the caregivers take a back seat to the needs of the payers and the lawyers. The EMR is supposed to improve patient care, but sometimes it makes it worse. Physician progress notes illustrate how this happens.       

                                                  The Patient’s Story

Progress notes are the lifeblood of the medical record. They tell, from day to day, what physicians did to a patient and why. They are a narrative of the patient’s care. Three decades ago we sat down, pulled out a pen, and wrote out our daily progress notes. There were standard ways of doing this, but physicians were free to organize their notes however they liked. That was both a blessing and a curse. It was a blessing because not all patients fit the standard way of note writing, so you could modify how you recorded things; it was a curse because every physician was different, and some wrote very sketchy notes indeed, notes from which it was very difficult to figure out what happened.

I once did a research project for which I was reading physician notes from the nineteen twenties, thirties and forties. I recall one patient in particular who was clearly desperately ill. He had critically abnormal vital signs (which I could tell from the nurses’ graphic chart), needed several blood transfusions, and even stopped breathing once. His progress note for the day, written by a very famous and distinguished physician, was one line: “Mustard plaster didn’t work.”

Physician notes have evolved a great deal since 1930. Certainly in my medical career, which began in 1974, physicians were expected to make some reference to what they were thinking, why they did or did not do what they did. Sometimes the notes were cryptic jottings that made it very hard to follow what was happening. But most of the time you could understand what your colleagues were thinking.

                                   Payers and Lawyers: Different Needs

But while this worked reasonably well for physicians, other users of the medical record complained loudly. Payers, such as insurance companies and Medicare, based their reimbursement upon those notes. They were unwilling to pay for anything that was not clearly documented. They also increasingly based their payment structure on the complexity of the medical decision making; if physicians wanted to be paid at a higher rate for managing a complex and difficult patient they needed to show in their note just why that patient was complicated. They needed to show what they were thinking, and what information, such as laboratory data and the physical examination, they used to make their decisions.

 Finally, for the lawyers, the operative phrase was “if it’s not documented, it didn’t happen.” In theory, the goals of all three users – caregivers, payers, and lawyers – should be in alignment. But with the EMR the needs of the caregivers, which should be paramount, are losing groun

 The EMR, since it is on a computer, can be manipulated in all the ways a computer allows. Hospitals are laying out millions to implement the EMR, and to ensure maximum payment they want to make sure it is easy for the payers to find in the EMR all the things the payers want there. This is accomplished, among other things, through the use of templates and “smart text” for progress notes. For example, a physician writing a progress note in Epic, a popular EMR system, can open a template that has many components of the evaluation already filled in. The program can bring into the note all the previous laboratory values. It has all the categories of the physical examination sitting on the screen for the physician to fill in.                                                                

                                                      Losing the Narrative    

It is easy to “drag and drop” information from previous notes with simple keystrokes. There’s nothing intrinsically wrong with all this. It can make producing a complete progress note quick and easy. But it also can destroy the original purpose of the progress note – to give a narrative of the patient’s progress. It can stifle the conversation between physicians embodied in traditional progress notes

Recently I saw an example of the problems this can cause. A couple of weeks ago I heard I was getting a patient into the pediatric intensive care unit with multiple problems, most acutely a blood problem. One of these lesser issues was a heart problem that required surgery. Because of the other serious problems, though, the surgery had been postponed for the future. I read about all this in the patient’s EMR before she even arrived in the PICU, which is one of the great aspects of the EMR. We no longer have to wait for a clerk pushing a cart around the hospital to deliver the paper chart. The patient had been seen just that morning by her hematologist for the blood issue and the progress note in the EMR told me the plan for her heart problem was surgery sometime in the future when the child’s other problems had improved. It said so right there on the screen. In fact, all the notes had been saying that for over a year.

 So imagine my surprise when I went in to see the child and saw an obvious and well-healed surgical scar on her chest, clearly from cardiac surgery. She had had her heart fixed two months before at another institution. I gave her hematologist the benefit of the doubt and assumed her doctor knew the surgery had been done, and that what had happened (I hope) was that the doctor had used the beguiling convenience of drag and drop on the progress note template to do the note. This particular incident was innocuous, but I think you can see the potential for mischief with this sort of thing.

 This is not an isolated event. I have seen many examples– so many that I now cast a suspicious eye on all those uniformly formatted progress notes. The ease with which mounds and mounds of verbiage and laboratory data can be stuffed into a progress note may give the payers what they want, but it often does not give me what I want– and that is some evidence that all this information was processed through a physician’s brain and led to a carefully considered decision about what to do. I want a human voice, and that is getting harder and harder to find in the EMR’s stereotypic and bloodless documentation.

Medicine is about stories – patients’ stories. I was taught forty years ago that most of the time the history gives us the diagnosis. Osler reputedly said: “Listen to the patient. He is telling you the diagnosis.” (That attribution has been questioned, but the spirit is definitely Osler’s.) 

Of course these days our wonderful scientific tools often give us the answer, and I certainly do not wish to toss all those things aside to go back to using only what Osler had. But medicine is not really a science. It is based on science, uses science, and is increasingly more scientific. But medicine also contains large measures of intuition, educated guessing, and blind luck. I do not think that aspect of medicine will ever completely disappear. When I read (or wade) through a patient’s record, I look for the story. When I cannot find a coherent story, I cannot give the best care.

 For myself, even though I of course use the EMR, I refuse to use all those handy smart text templates. It takes me longer, but I type out my progress notes, organized as I did when I used a pen and chart paper. It takes me a little longer, but it makes me think things through. No billing coder has ever complained. More than a few colleagues have told me, that when we share patients, that they search through the EMR to find one of my notes to understand what is happening with the patient.

 My advice to other doctors is this: don’t let the templates get in your way. Tell the story.


12 thoughts on “The Electronic Medical Record and the Disappearance of Patients’ Stories

  1. Nice article indeed. The problem is that the majority of physicians are not towing that agenda. How many EMR’s reflect complete physical examinations, when none or very little were actually done?; moreover, how many ‘operators’ populate the record with ‘just enough’ inputs, thus allowing opportunities for upcoding and overbilling. The narrative/history that is captured frequently contains many errors.
    Sometimes, these professionals confront a patient who, unbeknownst to them, are also doctors.
    Given enough time in practice, the probability of ‘stepping in it’ goes up quite a bit, imho. I hope a lot of that occurs, because good health care is a right that must be secured, above all else. It’s going to be a long, tough road back from 37th in the world (NEJM, Jan 2010).

  2. Dr. Johnson’s comments are right on target. Our practice has resisted adopting an EMR for the very problem he addresses. We receive many reports from practices with EMRs illustrating his point. The records are quite obviously oriented to hitting the “bullets” required to charge the maximum, not to convey medicial information the best. We see voluminous records containing documentation of exams that were not done and insignificant items such as “chest rises and falls with respiration”. Records from emergency departments are especially and critically delinquent in this regard.
    The push to move to EMR from the fed, etc. seems to disregard all this.
    EMR certainly has potential to improve medical care, but with the shortcomings described here, I’m not sure that the overall effect is positive.

    Evan Ballard, MD family doc

  3. Evan, Ruth

    Evan– Thanks for your comment.
    I also have heard that too many EMRs seem designed to facilitate billing, not patient care.
    But when EMRs are created by physicians (not software folks) that tend to be much more useful.
    I think of the IT at VA system, which was set up within the VA.
    I wish the government had set up clear standards for EMRs (devised by phsyicians and nurses), rather than :”letting the market decide” which IT will be widely adopted.
    As Chris Johnson points out, EMRs can make patient care better–and safer–providing a clear record , for instance, of what medications patients are taking. Also, in an emergency, a doctor who has never seen the patient before can quickly get a picture of his or her condition.
    But from what I have heard, it is hard for small practices to find affordable health IT that serves their needs. When physicians work for a large organization that has set up its own IT, there is a much better chance that it will facilitate patient care.

    I’m sure that there is some “gaming” of EMRs in order to maximize bills. But again, as more and more doctors work for larger organizations where someone is looking over their shoulder, this is likely to be less common.
    It’s something that Medicare and other large payers will have to keep an eye on.

  4. Maggie,
    Commenting on your reply.
    It’s interesting that you and others hold up the EMR that is used by the VA as a model. I and my partners have many patients who visit the VA to get their free or cheap medicines.
    When, on the seldom occasion, we are able to get copies of the VA EMR notes we find those notes to be among the worst from which to glean useful information.
    I’d suggest that the EMR used by the VA should not be a model to copy.

    • You are confusing the content of the progress notes with the medical software. The notes written using the VA’s EMR software do not reflect the program itself as you may think. Poor documentation can happen anywhere. Detailed documentation can be done using any EMR. It all depends on the end user. What I like about EMRs are the clear and easily read progress notes, medication orders, medication administration logs, appointment reminders, clinical warnings and much more. I think that when some people use EMRs, they get a little lazy and start to click more than they type. Granted, that is still no excuse for poor documentation. However, lets not write EMRs off or give them a bad rap because of the notes written using them. I strongly urge you to try one out first before you form your opinion.

  5. Evan–

    The VA’s EMR system, VisTa is pretty old– develped in the late 1990s, and by current EMR standards somewhat out of date.
    Though today it is being adapted for use in private hospitals.
    And it was one of the first truly successful examples of Health IT in the country. Today, it’s still far better than what some vendors are selling.
    You and your colleages will no doubt need to find good EMR
    eventually. Patients will demand it– as will Medicare and private insurers.
    I realize that is is time-consuming and frustrating trying to find good EMR –and then learning how to use it.
    But note: Chris Johnson is not saying “don’t use it.” He says he wouldn’t be without it. (He learned to use EMR while at the Mayo Clinic) But he is saying “don’t try to use templates for progress notes.”
    As for the VA– There are thousands of VA hospitals in the country. Some are better run than others, though over all, reserach published in the NEJM, JAMA, etc. shows patient outcomes are better than in private sector hospitals.
    (See the book, The Best Care Anywhere.)
    The VA has very low rates of preventable errors (medication mix-ups, etc.) in part because of its EMR.
    My brother-in-law lives in Manhattan and uses both the VA and doctors in private practice. (He is on Medicare, and in Manhattan, even the vast majority of Park Avenue specialists take Medicare, but he doesn’t just go to the VA for “cheap medications.”
    For years he has had serious hearing problems: the best specialists in private practice in Manhattan recommended hearing aids that were almost impossible to use in many situations (too much background noise.)
    Then his primary care doctor at the VA recommended a
    particular type of implant that has worked beautifully.
    Since many VA docs are academic doctors (teaching at
    major academic medical centers) they tend to be on the cutting edge of things. They’re reading and talking about the latest research.
    And since they cannot take money (or dinner, or lunch) from anyone (device-manufactuers, drug makers) etc. or any consulting fees (because they work for the government) they are less likely to recommend a hearing aid made by someone they consult for.
    Finally, Gawande and others see the VA as a model for the
    “integrated healthcare” of the future.
    EMRS are key to that integration. No more faxes.

  6. Maggie,
    thanks for your time.
    Congratulations to your brother-in-law. He has found a good doctor. Hold on to him. There are certainly good doctors in the VA system.
    My experience with many patients for many years teaches me that there are lots of problems in that system. The EMR is a major one, from the perspective of a physician on the receiving end of medical information trying to coordinate my care with that of the VA.
    There are more problems I see from this perspective, which is a perspective I don’t see articulated elsewhere.
    I’d love to have an extended conversation with a proponent of the VA as a model of health care delivery.

  7. Evan–

    Thanks for responding. I appreciate the fact that you recognize that there are good doctors in the VA.

    If you would like to talk to a proponent of the VA system, you might want to contact the author of the oobk The Best Care Anywhere (Philip Longwood–he’s at Washington Monthly).
    I’ve also written about the VA both on this blog and in my book Money-Driven Medicine where I make the case for the VA system;..
    But my book was published in 2006 ( I wrote it from 2003 through 2005) & after 2000 the VA was seriously underfunded.
    G.W. Bush felt that government should be smaller (“Stave the Beast’) and this meant that the VA wasn’t getting adquate funding at a time when Vietnam Vets were getting older, and many soldier were returning from Iraq with serious physical problems.
    In the past, they would have been killed. Now, we are able to save many more soldiers on the field–but just barely. I don’t mean to suggest that getting better at saving soldiers isn’t a g oood thing. Of course, it is, (Though a better thing would be to avoid wars.) But soldiers have been coming back from the Middle East horribly wounded, putting more pressure on the VA.
    Finally, the wars in the Middle East have led to sendng soldiers back for two or three tours . Many are coming home with severe psychological problems that the VA isn’t staffed to deal with.
    So all of this may help explain your frustration when dealing with the VA hospital in your area..

  8. As a nurse who has worked with both paper charting and an EMR, I must say this really hits home. I absolutely love the organization and flexibility of the EMR. As Chris Johnson states in the article, with the EMR I can view a patient’s records before he or she ever gets to me and anticipate his or her immediate needs. I can also view what we have been doing throughout the hospitalization and have a more complete understanding of our plan of care. Well written EMR progress notes absolutely improve patient care in this way. On the other hand, I have also come across the template that was referenced in which each note says the exact same thing in an obvious cut and paste manner. This is extremely frustrating to me as a healthcare provider because it tells me very little about the course of care. While these templates may be faster and easier, our focus is shifting form quantity to quality and these notes should follow suit.