Discussions on the EMR

Is the electronic medical record, at its present state of development, better than paper? It depends. It depends on how it’s developed, how it’s implemented and how it’s used. Right now we don’t have an evidence based answer but there are plenty of opinions. We have a generous sampling this week.

The Dinosaur, writing in Medscape, says his paper records are legible and well organized and he’s doing just fine, thank you. Many docs are not as legible or well organized as the Dinosaur. For those who struggle with paper record chaos one of my colleagues in Northwest Arkansas has developed the problem-integrated charting (PIC) system:

Utilizing the system ameliorates many of the limitations of the human mind when dealing with multiple comorbidities and reduces undesirable redundancy. The system could lessen the impact of technologic impoverishment for practitioners still using paper records and has the potential to be utilized in electronic medical records.

Joseph J. Fins, an internist writing in the Hastings Center Report about his introduction to the EMR, laments the decline of the old fashioned narrative history:

When we were residents in the late 1980s, we would pride ourselves on how our charts read and looked. The chart was a place to tell a patient's story from our point of view. Although we had all been trained in the architecture of the medical note and the progression from Chief Complaint (CC) to History of Present Illness (HPI) on down to Assessment and Plan (A/P), each of us did it a bit differently. Each of us had our own voice. I recall marveling at the charting styles of my colleagues and professors: the long, obsessively complete note of the intern versus the almost aphoristic musings of the attending—the former chock full of unorganized information, and the latter synthetic in its encapsulation of the problem and plan of action. And in that transition, through our writings in the medical record, we all learned how to think as doctors.

One of the benefits of the old fashioned narrative history is that it tells the patient’s story and presents a time line. Electronic medical record templates are not conducive to this. DB, although he defends the EMR, realizes the importance of the timeline in the patient’s history. In a recent post he illustrates how construction of a timeline can provide the critical data necessary to understand a patient’s problem. Although electronic medical record templates can’t force how we think they can influence how we think and distract us from important patient data if we are not careful.

Dr. Fins will miss the paper based narrative, but at the end of his training he concludes that the advantages of the EMR outweigh the disadvantages.