Death of the physician progress note

I am not sure of the date or time of death. However, I am reasonably certain of the cause. Death was by electronic data and formatting. The victim was the time-honored physician’s progress note. To be sure, these notes, even the now “ancient” written ones, were far from perfect. And they were often illegible. Shortcuts such as “as above” or AVSS (all vital signs stable) littered the pages of the now nearly extinct hospital chart.

Yet, what replaces it sometimes resembles a random collection of information and numbers more than anything readable or coherent. The EHR is drowning in data excess where the truly pertinent information is at best lost is a sea of cut and paste gobbledygook, and at worst, repetitive false information.

The designers of the EHR sowed the seeds of this mess. Initially, computerized health records were created to more accurately bill medical procedures, CPT codes, and hospital services. Clinical information was added out of necessity, but layered on a framework of billing and coding, making a very imperfect marriage as the final product. I have used our office EHR now for ten years, and learned four different hospital systems over the past three to four. Thus, I have seen more than my share of this landscape, and trust me, it is far from pretty.

I have worked with IT personnel to try and make my notes more readable and coherent, using everything from larger fonts, to SOAP formats. But in order to comply with coding requirements for mid-level and higher coding, I am forced by Medicare to throw in stuff that is redundant and clinically useless.

For example, “No change in PMH/FH/SH/ROS.” (Translation: past medical history, family history, social history and review of systems.) Since it is unlikely that my patient with CHF will remember a new symptom, or discover a family member had a stroke, between day one and two of his hospitalization, this exercise is a waste of time, but required by CMS if you want to be reimbursed for a complex visit.

I review my patients’ medication administration record (MAR), daily. However, if I document those medications in the record, the end result may be a morass of unorganized and scattered drugs. The worse offender here is the system used by a well-known large hospital corporation. When integrated into the progress note, the list is neither alphabetical, nor chronological, or by route of administration. In other words, it is a jumbled mess. This quirk has been pointed out to the hospital IT staff, and they say they have forwarded the doctors’ “concerns” to the programmers, who say they are “working on it.”

The other issue with the electronic progress notes is the “carry forward” features. The aforementioned EHR system’s physical exam auto-fills from the previous day, unless you specifically change it. This is nice for the time pressed doctor, but leads to false and inaccurate documentation. I have seen patients who days following extubation still have noted an ETT in the mouth.

In order to keep the physician honest, you must fill in “general appearance” daily, but the rest can be all too easily repeated. Ditto for the impression and plan. Again I have noted plans like, “for bypass surgery” a day before hospital discharge. In its defense, you can free text anywhere, but that takes work and typing skills, and many older doctors simply are lacking here. And the local large corporation hospitals have refused to install voice recognition software to make the docs’ jobs easier.

Other hospital systems force the doctor to refill the H&P daily, but there are auto-click buttons, which when repeated daily are obvious cookbook catch phrases. You can free text for sure, but again that takes more time. Another large local hospital system has thankfully installed proprietary voice recognition software to accommodate the keyboard-challenged physicians.

The end result is often a misleading and unhelpful recording of the day-to-day patient’s progress. There seems to be more than enough information in the notes, it’s just that the forest is lost inside all of the trees.

I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.

There must be better information systems around. Unless we can free ourselves from being reimbursed by the number of words in a note, I fear the valuable physician progress note will continue to drown in mountains of data and illiteracy.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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  • John C. Key MD

    Well said. When I started medical school the Weed System “SOAP” format was new and all the rage. I still think it is a pretty darn good system, at least the important data generally got written down and you could follow a thought process. In today’s notes the check boxes don’t allow me to read what other “team members” are thinking.

    My supervisor constantly chides me for writing brief notes–you get more plaudits for cutting-and-pasting tons of boilerplate into your entry. Personally I hate having to wade through pages of boilerplate.

    I stick with SOAP and let the chips fall where they may. But then again I gave up on using mid- and upper level codes a long time ago.

  • lord acton

    So true. We physicians let this all happen. I predict more system dysfunction and more physician whining. We can turn this around if we would care to lift our faces out of the (rapidly draining) trough. I don’t see that happening. Bon appetite.

  • Chip Lohmiller

    Nobody likes EMR. Much about EMR is a pain.

    But I certainly read other physicians notes more than with paper. If you spend a little time typing, and have reasonable templates, I would argue that my notes have never been better. I can efficiently communicate game plans before even seeing a patient – ie surgical scheduling, etc. People know what my plan is. I know what theirs is. Other consultants can give clear recommendations. Those that are moderately savvy will put the plan either way above or below all the boilerplate.

    There is a way to not “let it happen.” Learn to utilize EMR, encourage your colleagues to do the same. And stop whining.

    • guest

      I am not sure that pointing out the ways in which EMR could be better is the same as “whining.”

      I find it quite irksome, when I speak up in staff meetings to suggest some modification to EPIC that could make our system more efficient, or more user-friendly, or just less screw-up prone, and receive the inevitable response “But a PROGRAMMER would have to do that!” As though programmers were some rare and delicate creature whose time is more valuable than ours…

      • rbthe4th2

        My stomach just churned when you said EPIC … for some reason that falls in the area of death and taxes.

    • Deceased MD

      what EHR are you using? It is very dependent on the system in use.

      • David Mokotoff

        Meditech and Beacon (Cerner) at the hospitals. GE Centricity at the office.

        • heartdoc345

          Cerner totally blows!

    • David Mokotoff

      I am not whining. I am reflecting what I see on a daily basis. Many older physicians are just not tech savy and these systems make concise and effective communications difficult. I type reasonably fast and don’t have a problem with EMR’s in general. As stated it the blog, it is CMS et al. that has created a monumental cascade of recorded crap.

  • Thomas D Guastavino

    Yes, but did you meet the criteria for stage 2 meaningfull use.? That is, of course, the real reason for all of this, isnt it?

  • guest

    What I dois to document my conversation with and exam of the patient in a narrative at the top of all the boilerplate check-boxes. My plan I outline in a problem-oriented list at the bottom of the boilerplate.

    It takes more time that way, but on the other hand I think UM has an easier time getting authorization based on the material they see in my notes, and the nurses have a clearer idea of what’s going on with my patients.

  • David Gelber MD

    I have experience with three different EMR’s and none of them functions well. i spend lots of time wading through mountains of repetitive and unnecessary documentation to find out if any of the consultants on the case are thinking, what their treatment plan might be or if any intervention is planned. At least I can read the notes, but I’ve discovered that the notes don;t say anything worth reading.

  • DeanBarnett

    I’ve been reading physician progress notes since the 1970s. Certainly there are formatting issues to be resolved, but I think the average information content today is much higher – and more useful.

    • David Mokotoff

      Yes, I agree with you to some degree. It’s gone however from the sublime to the absurd. Old: short, often illegible notes to NEW: mountains of data with poor formatting and only 20% or less is clinically relevant.

      • heartdoc345

        The EMR we use reverses all paragraph indentation and randomly changes fonts inside the note – makes it look like a 5th grader wrote it!

  • guest

    This, right here, is a brilliant illustration of exactly what’s wrong with progress notes as done in an EMR.

  • Joe

    “I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.”
    Aww, come on, man. It’s all about giving better care to the patient. Don’t you know that?

  • http://www.chrisjohnsonmd.com/ Chris Johnson

    We had a discussion about this a while back over at Maggie Mahar’s HealthBeat blog. Interested people can find it here.

    http://www.healthbeatblog.com/2012/10/the-electronic-medical-record-and-the-disappearance-of-patients-stories/

    The bottom line to me is that the current EMR boilerplate system buries the patient’s actual story in a pile of verbiage. It’s very hard to tell what’s happening day to day or what people are actually thinking about the case.

  • narayanachar Murali

    You have a choice. Don’t use that garbage called EMR. Pick up Dragon and say what you want in a few sentences. File chronologically using PDF, I am about three times more productive than the best power EMR users!

    • David Mokotoff

      I type pretty fast so for me Dragon isn’t much better.

    • FEDUP MD

      Dragon, even after practice, does not pick me up well, nor some of the other docs in my practice. I have a bit of a strong Northeastern accent so that may be why.

  • Noni

    I get zero information from contemporary progress notes in the EHR. As the author noted they are not informative and often full of errors.

  • Chris Porter MD

    I work as a night surg hospitalist. The daily progress notes written by interns are between useless and misleading, in terms of creating a narrative I can follow.

    Who advocates for the providers, in creating an EHR that aids our workflow?

    http://www.youtube.com/watch?v=ZHq6bLCE6L4&list=PLeY2I_OziOH5eBSUugXhyDF8WtHBfmAM9&feature=c4-overview-vl