The loss of eloquence in EMR notes

Much has been made of the downside of the increasing use of EMR systems by physicians. But I am not going to  dwell on those pervasive complaints concerning the cost and complexity of setting up the systems. Nor shall I rehash the well known issue of what I call “doc blocking” … wherein a computer (or other entity) stands between the patient and physician, slowing the exchange of information to however many words can be typed per minute. No there’s another more pressing issue to me personally that is rarely discussed in regards to use of the EMR. The loss of eloquence.

First, allow me declare my unabashed love of the EMR in my office. It has become part of my routine and there are lots of things that I cherish about it. Such as the fact that when I log off and walk out of the room, the encounter is complete. The physician letter and prescriptions are off into the ether at the speed of light. Yes, the whole encounter probably takes longer than a traditional interaction. But afterwards, there is no walking around the office between patient encounters with  a  dictaphone,   no calling in presriptions, no faxing of letters and reports. I know what you’re thinking. Call me what you will, dictaphobe, electrophile, I’ve heard them all.  I still abhor our hospitals dictation system, with its old timey keypad and user ID numbers and dictation types and patient ID numbers and voice prompts and passwords and typos and confirmation numbers and the need to sign, and correct, and sign again. Ugh, press 7 to shoot me.

Yet with the fast, often shorthanded typing that’s needed to keep up with the patients story, I admit that somethings do not make it onto the screen. For example, here’s a short exerpt from an imaginary history as well as  part of the assessment & plan  that might follow of someone with asthma.

Thank you Dr. Soandso for referring Mrs. Jones for dyspnea. As you know, Mrs. Jones is a 65 year old female who has been having trouble breathing and wheezing from asthma  for the past 2 and a half years. She tells me that her symptoms are typically worse in the spring and fall and made worse by strong perfumes and odors such as perfumes and cleaning agents. She also notices that her wheezing seems to be more pronounced at night. She is not certain what other things make her breathing worse, as she has not really given them much thought. Incidentally she got a new cat about a month before her symptoms got worse and she reports that the cat has been sleeping in bed with her. She has been tested for allergies in the past and was indeed told that she is allergic to cats. She bristles at the mere idea that her cat may be contributing to her symptoms. Mrs. Jones tells me that she has no children and that the cat is practically a member of her family. In fact she even stated that “the last doctor told me to get rid of the cat, so I got rid of him instead!”. . .

Assessment and Plan: … I had a long discussion with Mrs Jones today, regarding her allergic asthma. Her asthma might be better controlled by starting on a inhaled steroid. In addition, I discussed her cat allergy and I suggested  that keeping her cat of the bedroom might help her night time symptoms. She seems agreeable to this plan, though she tells me “he aint gonna like that!” …

Here’s what the same exerpt might look like in EMR.

Mrs. Jones is a 65 yo female referred by Dr. Soandso for dyspnea.  She has been having wheezing from asthma  for 2.5 years, worse in spring, fall and at night.                                                      

Triggers: scents, strong odors (like cleaning agents).  She wheezes more at night. No other known triggers. Symptoms came on a month after she got a cat, and the cat is sleeping in the bed with her. She’s very close with cat, not sure she would consider removing it from bed …

Assessment and Plan: … Allergic asthma, will start inhaled steroid. Recommended removing cat from bedoom, she is agreeable …

As you can see, the EMR version does limit ones desire to  express subtle patient dynamics such as the strange bizarre love/hate triangle between  the patient, her cat, and her physician(s). And while one might argue that the dictated version is more verbose, the EMR version relays essentially the same information in a more succinct way and thus takes less of the readers time. In any case, I’ll stick with my beloved EMR, maybe someday soon, I’ll be proficient enough of a typist so as to have my cake and wax poetic about it too.

Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.

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