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Intelligent Healthcare Information Integration 8/1/10

July 31, 2010 News 3 Comments

EHR Speak

Recently, I learned that a friend, someone whom I admire and highly respect, was dealing with the impending loss of a parent. Combining that with some of my own recent life difficulties, both at home and in the workplace, it got me to thinking about the one truism I have noted when it comes to the really tough life experiences we all endure: there are no magical words of wisdom, no empathizing phrases that really help.

Indeed, most of those often well-intentioned clichés usually sound trite and often even minimize the emotional suffering of the sufferee. They may be the expressee’s way of trying to show support, but beyond “That really sucks” and “I’m here for you,” nothing much else conveys the meaning which may have been intended. They may make the expressee feel as if they’re trying to help, but they often result in making the sufferee feel worse. (I’m betting that any of you who have experienced loss or major life trauma know just the phrases of which I speak, so I’ll forego examples.)

My perverse, geekoid, HIT brain, of course, took this melancholic consideration and immediately made a connection with the world of EHRs. (This is actually sort of sad to admit, that I find HIT-ness even in the face of human suffering…I really need a vacation!)

Here’s sort of how the neuronal path went: 

  • Saying what we mean and having what we say actually provide the information – and especially the intended meaning behind it – is often quite the challenge.
  • I notice the same difficulty in the electronic medical record reports I receive from other providers.
  • From one particular emergency room, I used to get five-page EMR-generated reports to tell me that a patient was seen for an ear infection, prescribed amoxicillin, and told to follow up with me in two weeks.
  • From that same ER, I now get two-page EMR-generated reports about a child who presented with skull fracture, cerebral contusion, and seizure-like activity who was admitted to the hospital and the amount of info is about as limited as what is in this sentence.
  • Formatted, templated, pre-made medical descriptives seem about as adequate as the pre-made clichés so many people try in trying times to convey their sympathies over someone’s personal loss or other tribulations.

So, what does work? (For medical info conveyance, not personal sympathies.)

Thinking back, the best descriptive, by far — by leaps-and-bounds far — which I ever receive about patient-provider interactions come from the dictated narratives, most typically from consulting specialists. They may have basic formatting, often following SOAP note style or some variant thereof, and they provide a colorful picture, a conceptualization complete with supporting details and even the thought patterns which led to the diagnoses and/or treatment decisions.

If there is vagary (which is still so frequently unavoidable in medical evaluation and diagnosis,) that is also conveyed with the reasoning which makes the vagaries necessary. These dictated notes, most often with a lower page count than even the best EHR-generated document, paint a picture which is easy for my brain to understand and which conveys the complete, pertinent patient encounter information, subtleties and all.

I’m not saying I think every EMR/EHR system and user should use some form of dictation or speech recognition. But, perhaps system designers could start focusing more on “EHR speak,” on how they can enable capturing and relaying the subtleties, the nuances of medical descriptives. These so often provide the real “color” of a patient’s situation rather than just clichéd, templated, rowed-and-columned, formatted data. It’s sort of a Van Gogh versus a paint-by-numbers thing.

To my friend: It really does just suck and my thoughts and prayers are with you.

From the trenches…

“Never does one feel oneself so utterly helpless as in trying to speak comfort for great bereavement. I will not try it. Time is the only comforter.” – Jane Welsh Carlyle


Dr. Gregg Alexander, a grunt in the trenches pediatrician, directs the “Pediatric Office of the Future” exhibit for the
American Academy of Pediatrics and is a member of the Professional Advisory Council for ModernMedicine.com. More of his blather…er, writings…can be found at his blog, practice web site or directly from doc@madisonpediatric.com.

Comments 3
  • Those 5 page notes are generated with a templated style called “documentation by exception” (DBE)– fill the chart with 5 pages of normals and then delete that which was not asked, was not checked. Another style, called “documentation by findings” (DBF) places into the chart those items which were asked and examined.

    The problem with speech recognition, when combined with Documentation by Exception is that the reader will still have to find within those 5 pages the nuggets of useful information, barely improving on the dominant style. Readers will quickly tire of the search.

    Speech recognition is best when combined with Documentation by Findings. That is, include briefly those pertinent positives and negatives which apply, but add a narrative that provide the color.

  • Dr. Alexander,

    I so enjoy reading your articles on HISTalk – I am not sure how you have the time – you are involved in so many groups, etc. and a great caring Doctor at the same time. Love your website.

    Anyway….. just letting you know (of the many thousands of fans you have) I am very appreciative of your time and the sharing of your wisdom.

  • This succinctly states my major complaint about EMR. I do not use an EMR system in my clinic, but suffer from the same inflated ER reports.

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