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Embrace the EHR. But Never Lose the Soul of the Note Card

by Scott Moore, MD

Shakespeare said that brevity is the soul of wit. I say brevity is the soul of a good note.

As a resident back in the early 90’s I would look at office notes written by older, near-retiring physicians. I’d read these one or two lines written on 3 ½-inch note cards, turn to my fellow residents and ask, “How can someone possibly document this way?” Years later, I realize the genius, beauty and efficiency of this type of record, and it seems I’m not the only one. There is a crisis in medicine and, in many cases, the introduction of electronic health records (EHRs) has made it worse. Providers have too much to read at the end of the day, much of it adding little value to the care of our patients.

My health records from my own pediatrician, Dr. Patrick Brucoli (who continues to be an inspiration), span nine years and about ten visits, with a total page count of less than two. Granted, I was a relatively healthy kid… but recording ten visits in just 1 ¾ pages? That’s unheard of today. When I have a new patient that has transferred from elsewhere—and in particular, when an EHR is involved, I groan. The amount of time and concentration it takes to get through that chart, and its pages and pages of verbal diarrhea is daunting. The endless nonrelevant Review of Symptoms (ROS), Family, Social, Enviromental, extensively documented physical, etc. disguises the essential information that is buried within. It is amazing how much of today’s documentation is clearly just automated jibber-jabber.

I compare this to my childhood chart from the 1970s, Dr. Brucoli taking notes in which every word matters. I can truly review the pertinent aspects of the chart in just a fraction of the time that it takes to understand the record from one of my own incoming patients. The beauty is in the brevity, in how clearly those shorter notes communicate what a visit was about. There is much less chance that something will get lost in the weeds of minutia.

Today, in any correspondence I receive from a physician, I trust that he or she has done a comprehensive history and ROS, has asked about smokers in the house and did the appropriate anticipatory guidance. I don’t need to read about it; this is only a distraction and I would contend that it’s potentially detrimental to the care of the patient. We are overloading physicians with reams of notes that are important – but not at all relevant when trying to communicate the crux of a visit. If within the three-page emergency department discharge summary, nestled in the extensively documented physical exam, you mention that you heard a concerning murmur, that finding shouldn’t get the same press as a Chest-Clear to auscultation and percussion, no rhonchi rales or wheeze, no increased respiratory effort, and no grunting flaring or retractions.

I realize that at this point you may be thinking, “Well, there is stuff that needs to be asked, screened and documented.” And I agree. Clearly our roles in health care have changed based on regulations and mandates, and what we need to discuss with patients has changed along with it. We now screen for mental health issues, domestic violence, substance abuse and home/life safety issues, all of which are important. And insurance companies are auditing charts with a closer eye than ever, looking for everything that was covered during the patient exam to justify what was billed. And while I realize I’m a bit of a hypocrite in what I’m about to say, this is exactly where we need to take advantage of electronic health record technology. When an EHR really works, we have the ability to produce both a brief note and a full patient record. Note the emphasis on really.

With a significant part of our job relying on the communication we receive from fellow physicians, we need the ability to easily produce a lean, readable document that communicates three things: 1) what the doctor believes to be the diagnosis, 2) how he/she came to that conclusion and 3) what we are going to do about it. (Sounds a lot like a 3 ½-inch note card…) Then, in a separate section of the EHR would be all the information that is, essentially, irrelevant for me, but can be made accessible for those requiring the minutia, e.g. insurance companies, lawyers, etc. I do believe that is something my EHR vendor, athenahealth, is striving for and is the reason I decided to go with them back in 2011. I remember watching a video clip of their CEO Jonathan Bush and just thinking this guy gets it, not to mention has an entire team devoted solely to the physician usability of their EHR.

So, while we don’t have an option to turn a blind eye to the adoption of electronic records, we can, and should, demand from ourselves and all in our referral networks to produce clear concise communication. And we should continue to push on our EHR vendors for this ability. Let us hold onto the simplicity and clarity- the soul - that a 3 ½-inch note card gave us.

Dr. Moore is a pediatrician and founder of Moore Pediatrics & Associates in Chelsea, Michigan.

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