Is the quality of documentation better using EMRs or paper? Readers of this blog will be very interested in receiving feedback from physicians and office staff who have been using an EMR for their clinical documentation for a couple of years or more. If you have never used a paper chart, it may be difficult to make the comparison, for example new graduates who have been trained in facilities and practices that only use electronic record systems. However the majority of physicians in clinical practice today will still remember the paper record — some with a sense of nostalgia and others a sense of relief.
There is something elegant about a well-crafted clinical note that tells the story of the patient (whether it be electronic or on paper), particularly if that note can be crafted into a patient summary or referral/consultation letter that accurately describes the patient's clinical problem in a manner that is helpful to the treating physician. Earlier this year, while working in Singapore on a medication project, a colleague lamented to me about the state of clinical documentation. He described a time pre-EMR when physicians would take the utmost care to think about the clinical status of their patients and would painstakingly document their findings including a summary and plan and would integrate lab and diagnostic information into the narrative. In contrast, he felt that the prevalence of electronic clinical documentation systems had made physicians lazy — it was easier to generate a report by selecting checkboxes and date ranges for clinical encounters than ensuring the summary was accurate, logical and clear. It’s all about the building blocks. If you are not inputting quality information, it is difficult to get decent information out of the chart.
Back to the original question. Is the quality of documentation better in one medium vs. the other? From a legibility perspective, EMR wins hands down as typed trumps handwritten notes in the vast majority of cases. In fact, as we become more comfortable using technology, I believe that the quality of penmanship further deteriorates. Narrative vs. structured data recorded in the EMR? While I fully understand the need for discrete data in the EMR in order to graph, search, and analyze, I much prefer reading a narrative note, particularly if it is detailed. Trying to reconstruct a clinical encounter from a series of bullet points may work for common conditions such as UTIs or Hypertension monitoring, but it is extremely difficult for mental health problems or multi-system disease. Some of the patient summaries and printouts generated by EMRs are dreadful both in terms of format and content. Sifting through reams of discrete lab results, each on a separate line, or encounters that do not make any logical sense is very frustrating.
An article on AmericanEHR.com titled, “Are You Proud of Your Documentation Using an EHR?” drew some insightful feedback. Personally, I do not believe that technology is the problem. It is more related to how that technology is being used, whether the templates and clinical encounters have been optimized for data entry, the ease of use of the EMR regarding data entry, and whether the system can generate a record that is as good, if not better, than a well-written narrative note.
What is your experience? Are you satisfied with the documentation in your EMR? If not, what would you change to make it better?
Click on the “Comments” link below to share your feedback.