EHRs: Lots of Documentation But Little Communication

Greg A. Hood, MD


December 16, 2015

In This Article

Have We Come Too Far, Too Fast?

The US healthcare system has declared that data points are valuable. We've commoditized the details of people's lives. Checklists of metrics and measures of "quality" have become the focus. In Landmarks, Macfarlane quotes the American essayist and farmer Wendell Berry: "People exploit what they have merely concluded to be of value, but they defend what they love, and to defend what we love we need a particularising language, for we love what we particularly know."

Macfarlane invokes the memory of John Muir, whose writings inspired Theodore Roosevelt to create the national parks system. "It's the idea of hope in the dark." The time has more than come for US healthcare to decide where its values are, and who is to be defended. It is time to bring hope to the dark. When it's time to defend a person, or a value, the specifics of language become powerful instruments to evoke change and motivate supporters—in the profession, within the public, and in Congress.

In 2013, The RAND Corporation, in conjunction with the American Medical Association, reviewed factors affecting physicians' professional satisfaction.[1,5] They summarized doctors' relationship with EHRs:

First, our study does not suggest that physicians are Luddites, technophobes, or dinosaurs ... however, physicians noted important negative effects of current EHRs on their professional lives and, in some troubling ways, on patient care. They described poor EHR usability that did not match clinical workflows, time-consuming data entry, interference with face-to-face patient care.... Physicians also expressed concerns about potential misuse of template-based notes. Such notes, which contain pre-formatted, computer-generated text, can improve the efficiency of data entry when used appropriately. However, when used inappropriately, template-based notes were described as containing extraneous and inaccurate information about patients' clinical histories, with some physicians questioning the fundamental trustworthiness of a medical record containing such notes....

One could argue that the current state of EHRs is a transition period that is inevitable with any new technology.... However, no other industry, to our knowledge, has been under a universal mandate to adopt a new technology before its effects are fully understood, and before the technology has reached a level of usability that is acceptable to its core users. In addition, simply waiting for long-run fixes may prolong the current troubled state of EHRs, potentially exposing patients to unnecessary risk. For all these reasons, it seems vital that a more proactive approach be taken to address the problems physicians describe.

It's easy, if disingenuous, to ascribe this metaphor of language to an attempt to save the hundreds of eponyms for a variety of conditions. However, to do so would utterly miss the point. Such naming of conditions is an exclusionary activity. Only those "in the club" know the meaning of such phrases as "Bright's disease" and "Trousseau's sign." While it's interesting to note that medical students today scarcely know what were (in 1997) the most common eponyms for aspects of physical diagnosis or diseases, the point of this article is the exact reverse.

Through EHRs we risk losing the ability to communicate effectively because EHRs codify vast volumes of formulaic data in preference to meaningful communication. Ominously, we've now trained a generation of physicians in this "non-speak" of EHR documentation.

The chasm and vacuums that have been created by generic EHR note generation pose potential risks to patient outcomes. We can do better, but can the EHR reflect our efforts? Possibly, but I hope it won't take another 18 years, until 2033.


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