EHRs: Lots of Documentation But Little Communication

Greg A. Hood, MD


December 16, 2015

In This Article

Thick Charts Stuffed With "Note Bloat"

In his book Landmarks,[4] Macfarlane makes an appeal for "a glossary of enchantment for the whole earth, which would allow nature to talk back and would help us to listen." Could there be more of a clarion call in healthcare than to appeal for a more natural method of communication between physicians, and between physicians and the rest of the world?

Macfarlane insists that his mission isn't merely to stoically preserve esoteric or arcane terminology. "The book," he says, "is about all of us finding ways to celebrate and enrich the language that we have for landscape and nature."

As the BBC article summarizes, "In Landmarks, Macfarlane pulls together nine glossaries of terms taken from 30 languages, dialects and sub-dialects around Britain and Ireland. They all describe aspects of weather, nature and terrain—and many of them are dying out, slipping out of conversation and off the tongues of those who once spoke them. They have been lost. Macfarlane wants them to be found." How much conversational wisdom is slipping off the tongues and from the (increasingly nonexistent) conversations between physicians? An eight-page specialty consultation note that contains seven-and-a-half pages of "note bloat" and one-and-a-half lines of physician-(or nonphysician provider-) generated italic print hardly qualifies as a "conversation."

In the BBC piece, Macfarlane described two of his favorite terms: "One is this lovely Cornish word 'zawn,' which means a wave-smashed chasm in a sea cliff—it's so evocative of that gaping mouth, and the power of those places," he says. It also seems to be an apropos analogy for the current state of healthcare delivery in the United States, "a wave-smashed chasm in a sea cliff" indeed.

"Another," Macfarlane continues, "is this soft, Gaelic phrase 'rionnach maoim,' the shadows that clouds cast on moorland on a windy day. There's something about the poetry of that, the precision and the need to compress that phenomenon down into that gorgeous soft phrase." How often is a physician's EHR note describing a typical patient encounter compressed into such a precise, well-phrased description? The gloomy reality of what actually winds up in our EHR systems may justly cause doctors to feel as if clouds are casting shadows across the medical landscape.

The writer of the BBC article, Fiona Macdonald, proceeds to summarize that "Macfarlane delights in the language." As Macfarlane himself describes it, "There's just the sheer joy of exactitude; I see it as a form of beautiful elegance. These lovely poems that fold up inside these words and spring out of them like jack-in-the-boxes—they're gorgeous forms of precision." Reading this led me to ask myself: Shouldn't the professionals in whom we all entrust our mortality and our vitality be able to delight in elegant exactitude when creating the historical notations upon which each successive medical decision will be based? Why instead does the profession accept the lowest common denominator of communication as provided by the lowest bidder?

There are a delicious plethora of additional terms that, by themselves, make Macfarlane's book well worth the read. However, the point of his tome is the transformational potential that language has to enrich the landscape of our lives. In the BBC interview, he said:

We increasingly make do with an impoverished language for nature, a generic language: "field," and "wood," and "hill," and "countryside." It's a very basic way of denoting, and that's fine, and sometimes we need to speak generally. We can't always speak absolutely precisely. But I'm fascinated by details and by the specifics of nature, and its particularities—and language helps us to see those. If we just see a landscape as some kind of waste space and devoid of detail, it becomes more vulnerable to dismissal or disinterest or improper use.

If words can be so for the natural world, then what would be more natural than to be able to do so in the realm of health?


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