Ideas and Opinions
14 July 2020

Restoring the Story and Creating a Valuable Clinical Note

Publication: Annals of Internal Medicine
Volume 173, Number 5
Today's clinical notes don't serve anyone particularly well. Cogent summaries are few and far between, having been replaced by templates that emphasize billability over interpretability. These long, overly detailed documents—with dozens of imported values ranging from test results to problem lists—manage to simultaneously over- and underwhelm. On the one hand, generating and reading such a note are time-consuming tasks that require substantial cognitive load and contribute to burnout (1, 2). Yet, the final product still fails to communicate much useful information (3), and much of what it does include may not even be accurate (4).
There …

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References

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Erickson SMRockwern BKoltov Met alMedical Practice and Quality Committee of the American College of Physicians. Putting patients first by reducing administrative tasks in health care. A position paper of the American College of Physicians. Ann Intern Med. 2017;166:659-661. [PMID: 28346948].  doi: 10.7326/M16-2697
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Morgan M. Matt Morgan: when bullet points miss the heart. BMJ. 2019;366:l5500. [PMID: 31530546]  doi: 10.1136/bmj.l5500
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Overhage JMMcCallie D Jr. Physician time spent using the electronic health record during outpatient encounters. A descriptive study. Ann Intern Med. 2020;172:169-174. [PMID: 31931523].  doi: 10.7326/M18-3684
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Berdahl CTMoran GJMcBride Oet al. Concordance between electronic clinical documentation and physicians' observed behavior. JAMA Netw Open. 2019;2:e1911390. [PMID: 31532513]  doi: 10.1001/jamanetworkopen.2019.11390
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Hendrickson MAMelton GBPitt MB. The review of systems, the electronic health record, and billing. JAMA. 2019;322:115-116. [PMID: 31173055]  doi: 10.1001/jama.2019.5667
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Centers for Medicare & Medicaid Services. 2019 Medicare Physician Fee Schedule. 22 November 2018. Accessed at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1693-F.html on 1 May 2020.

Comments

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Roger J Beneitone. MD 14 July 2020
Comment

I could not agree with the author more. Having grown up in the pre EMR era I long for the narrative note. I never could fully embrace the templated note or the idea of documenting to justify my charges. We need to end the tyranny of overdocumentation.

Disclosures:

No Conflict of Interest

Greg T. Lehman, MD 14 July 2020
Comment

This is such an important article an issue for all of us who care for patients. The authors point out the shortcomings of the cut and paste notes that were designed to fulfill billing requirements, but don’t include the patient’s voice or  preferences and critical integration of data to formulate a diagnosis and plan. There have been numerous examples of diagnostic error that resulted from misleading or erroneous information that was copied and pasted from visits that no longer apply to the patient’s current status. My gratitude to the authors of this article for spearheading this important initiative that we need to incorporate into our daily practice.

Thomas E. Finucane, MD 15 July 2020
Adverse consequences of the modern note.

One further harm from modern notes is that in signing them we accept, and model to learners, the tacit acceptance of casual fraud. This is mentioned in passing by the authors who observe that, although a note may state that cranial nerves II-XII are normal, there’s no reason to believe these were tested (especially for a progress note, especially when cut-and-pasted). Acknowledging that olfaction was not evaluated seems to suggest a fig leaf’s worth of virtue.  The same is true, I’m pretty sure, for the “12-system review of symptoms” that may be recorded daily. My guess is that most authors couldn’t name 12 systems.

Sunil K Sahai, MD, FAAP, FACP, SFHM 27 July 2020
Missing the Forest for the Trees

The amount of note bloat leads to a missing the forest for the trees mentality.  Personally, I have found that when dictating an assessment & plan, I much more effusive and provide a better narrative than when I am typing in a problem list. Many of us are not expert keyboarders, and as such, we tend to take shortcuts about a patient’s narrative.   Using an APSO note format, also allows both the reader and the author to focus on the assessment and plan, and then draw a line and state: Everything below this line is for billing purposes only.

Disclosures:

Royalties from UptoDate.com for Perioperative Medicine in the Cancer patient chapter

Sangeeta Joshi 7 September 2020
Suggestions

I appluade the authors for adressing this important aspect of patient care and creating an exaple of a note that represents better communication. May I please suggest a few points as below that can be added to capture the patient status better 1) Daily activity: It helps a great deal to understand if they are able to and motivated to stay active so that interevntion can be planned  if needed 2)Medications: In  addition to the list of medications, what helps is if patients affords those meds? Are they really using those daily? What is the co-pay? Does the patient  need assistance to buy medications?

James J Stark MD, FACP 14 September 2020
The loss of critical thinking.

A teacher of Internal Medicine and Medical Oncology for forty years, I have been alarmed at the loss of narrative in the medical record.  More to the point, copy and paste have threatened to destroy what underlies the narrative: critical thinking.  A recent role I have assumed as an unpaid Professor is tutoring those medical residents thought at highest risk of failing the internal medicine board exam. Perhaps my sample is skewed but I have observed an appalling lack of critical thinking when approaching clinical problems.  So what came first: the loss of teaching of critical thinking or the copy-and-paste electronic health record?   Will the restoration of the "story" solve the underlying problem?  Time will tell. 

S.Kirk, MD 30 September 2020
Blame the Vicitm

Another "blame the victim" EMR article

Clinical MDs have had very little input into EMR design. Most MD's have had EMRs foisted upon them without any say in the matter.

The result are EMR designs tailored not just to billing, but in a "database" format that is familiar to software programmers, not MDs.

With endless data fields that need to be filled individually, even dictation can be difficult. Add to that data that is not pulled into a note, but has to be manually obtained and reviewed, and "fatigue" is inevitable. Most doctors quickly develop the "just get it over with" attitude for good reason.

Untlil EMRs are altered to cater to MDs, the goals noted in the article will never happen.

Ellis M Knight 11 October 2020
Wonderful piece

I don't think I've read a better article in a long time.  Improvement in clinical documentation has the power to really change healthcare delivery for the better.  As a clinically retired internist / hospitalist I now do a lot of expert witness work.  I can say without a shadow of doubt that my 40 plus years of knowledge and experience are of little value when trying to wade through a 1500 page hospital record for a three day admission.  Figuring out what happened to the patient and why is like searching for a needle in the haystack.  The only thing I would add to this excellenct article is a recommendation that nursing notes and those of other clinical providers be scrutinized similarly so that they add to the story recorded in the medical record and don't simply add to the verbiage / data dump.  

Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 173Number 51 September 2020
Pages: 380 - 382

History

Published online: 14 July 2020
Published in issue: 1 September 2020

Keywords

Authors

Affiliations

Park Nicollet Clinic, Methodist Hospital, St. Louis Park, Minnesota (H.E.G.)
University of California, San Francisco, San Francisco, California (B.L.B.)
Lacy C. Hobgood, MD
Brody School of Medicine, East Carolina University, Greenville, North Carolina (L.C.H.)
Janice Tufte
Hassanah Consulting, Seattle, Washington (J.T.)
Note: Dr. Gantzer currently serves as the Chair of the Board of Regents of the American College of Physicians.
Acknowledgment: The authors thank the members of the American College of Physicians Restoring the Story Task Force for their contributions and thoughtful perspectives in discussion of this topic.
Corresponding Author: Heather E. Gantzer, MD, Park Nicollet Clinic, 3800 Park Nicollet Boulevard, St. Louis Park, MN 55416; e-mail, [email protected].
Correction: This article was corrected on 15 September 2020 to revise one of the abbreviations defined in the figure legend.
Current Author Addresses: Dr. Gantzer: Park Nicollet Clinic, 3800 Park Nicollet Boulevard, St. Louis Park, MN 55416.
Dr. Block: Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, 513 Parnassus Avenue, Room 1314, San Francisco, CA 94143.
Dr. Hobgood: Division of Internal Medicine–Pediatrics, Brody School of Medicine, East Carolina University, 517 Moye Boulevard, 2nd Floor, Greenville, NC 27834.
Ms. Tufte: 412 Eleventh Avenue, No. 106, Seattle, WA 98122.
Author Contributions: Conception and design: H.E. Gantzer, B.L. Block, L.C. Hobgood.
Drafting of the article: H.E. Gantzer, B.L. Block, J. Tufte.
Critical revision of the article for important intellectual content: H.E. Gantzer, B.L. Block, L.C. Hobgood, J. Tufte.
Final approval of the article: H.E. Gantzer, B.L. Block, L.C. Hobgood, J. Tufte.
Administrative, technical, or logistic support: H.E. Gantzer.
Collection and assembly of data: L.C. Hobgood.
This article was published at Annals.org on 14 July 2020.

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Heather E. Gantzer, Brian L. Block, Lacy C. Hobgood, et al. Restoring the Story and Creating a Valuable Clinical Note. Ann Intern Med.2020;173:380-382. [Epub 14 July 2020]. doi:10.7326/M20-0934

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