In Medicare, the law authorized a higher fee for service rates to “reward” those doctors who began to use them - which in actuality is a payment penalty for those who did not. The cost of the software programs is, by the way, exorbitant - almost prohibitively so for doctors in individual practices or small practice groups in relatively low-paying specialties like pediatrics and psychiatry.
I complained about some aspects about one EHR system I was using in a previous post. I must admit I had been wondering if I might be unusual in having noticed that there are significant problems.
In my previous post on this issue, I discussed the extraneous forms like treatment plans and symptom checklists that waste my time, as well as the difficulty in locating specific information in the overly-long patient record. In this post, rather than list the eight proposed "solutions," I will instead focus on a problem that was near the top of the concerns expressed in the above article:
Although physicians spend significant time navigating their EHR systems, many physicians say that the quality of the clinical narrative in paper charts is more succinct and reflective of the pertinent clinical information. A lack of context and overly structured data capture requirements, meanwhile, can make interpretation difficult.
EHRs need to support medical decision-making with concise, context-sensitive real-time data. To achieve this, IT developers may need to create sophisticated tools for reporting, analyzing data and supporting decisions. These tools should be customized for each practice environment."
Ah yes, the quality and the interpretability of the proverbial doctor’s progress notes has gone down the toilet.
So what makes a good progress note? A good progress note does not just describe what the patient looks like during a visit at that particular time coupled with a plan concerning what the doctor is going to do next. It should also indicate what the doctor is thinking about the patient, the patient's symptoms, and the diagnosis. Specifically, which of the patient’s symptoms have changed, and if so, what is the change due to? The medication prescribed? Side effects? A misdiagnosis? A placebo effect?
Does a change in the patient’s clinical picture suggest an alternate diagnosis? Are there any side effects from the medications that the doctor prescribed? How does the patient's clinical presentation relate to any treatment that has been rendered? Does any observed changes in the patient's condition mean the doctor should change the treatment or continue it as is? If a change in medication is planned, over which symptoms is the doctor trying to get better control? If there has been no response to treatment, to what does the doctor think this lack of improvement should be attributed?
In reading over a medical report, another doctor can fairly easily ascertain the answers to the above question from a relatively brief narrative. On the other hand, the answers to these questions cannot be ascertained from a simple checklist. No how, no way.
In the old days when I trained, we were instructed to use a so-called “S.O.A.P” note. The abbreviation stands for the different types of information that should be included in the note:
At the multispecialty clinic where I work part time, the useful S.O.A.P. progress note format is at risk of being abandoned. There are still good notes, but many of the progress notes contain almost no indication of what the doctor was thinking about the effects, let alone the pro’s and con’s, of the patient’s treatment.
Between scrolling through all of the the checklists and the extraneous notes and next to worthless notes, I find myself wasting an amazing amount of valuable time that I could be spending actually talking to my patient.
I certainly wish the AMA well in addressing these problems. I’m not holding my breath.