Electronic Health Records: A Slippery S.(L) O.A.P.

In the last few years, the federal government has been pushing doctors to adopt software for recording medical records electronically on computer, and in response several companies climbed all over one another trying to sell Electronic Health Record (EHR) systems. 

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.

The EHR’s were supposed to increase efficiency and produce cost savings. Lab results from all of the patient’s doctors would be instantly available so that tests would not be repeated needlessly. Doctors would have instant access to prior records without having to mail away for them, and every current doctor would be able to see what the patient’s other current doctors were doing.

Those are admirable goals. Unfortunately, there are some problems with the currently available software that actually have had the effect of negatively impacting patient care. 

Whether these problems were foreseen or unforeseen is a debatable proposition.  George Dawson in his blog Real Psychiatry certainly makes the case that some of the “changes” we have seen in recent practice patterns that were caused by the use of EHR’s are highly consistent with the goals of the money-grubbing, profiteering-at-the-expense-of-patient-health managed care insurance industry. Or as we like to call it, mangled care.

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.

Well, the American Medical Association (AMA) has noticed them, and they have had enough! According to the AMA Wire on 9/16/14, the AMA has belatedly pointed out the obvious and has taken some action. Well, sort of. Of course, it will probably go absolutely nowhere.

It’s no secret that many physicians are unhappy with their electronic health record (EHR) systems, thanks in large part to cumbersome processes and limited features that get in the way of patient care. Now a panel of experts has called for EHR overhaul, outlining the eight top challenges and solutions for improving EHR usability for physicians and their patients.

This new framework (log in) for EHR usability—developed by the AMA and an external advisory committee of practicing physicians and health IT experts, researchers and executives—focuses on leveraging the potential of EHRs to enhance patient care, improve productivity and reduce administrative costs. Here are the eight solutions this group identified to address the biggest challenges.

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:

Poor EHR design gets in the way of face-to-face interaction with patients because physicians are forced to spend more time documenting required information of questionable value. Features such as pop-up reminders, cumbersome menus and poor user interfaces can make EHRs far more time consuming than paper charts.

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:

Subjective: A description of the report from the patient regarding his or her own symptoms and overall improvement or lack thereof, as well as any reports of side effects. In the case of antidepressants, the timing of any changes in symptoms should also be ascertained and described, to help rule out a placebo effect.

Objective: What does the doctor observe when looking at the patient? Are there any changes in the patient's physical examination? What changes in the patient’s outward mental status have transpired since the last visit? What are the results of any lab tests that have been ordered?

Assessment: What does the doctor think these results mean regarding the patient’s diagnosis and treatment?

Plan:  What is the doctor going to do next to handle any problematic side effects of treatment, or to handle any failure of the patient to improve?

In psychiatry, a good progress note should also contain information about any changes in the patient's psychosocial situation - particularly any stressors: job changes, divorce, major family battles, deaths, children getting into trouble and the like. This information is important in determining whether any changes in the patient's clinical picture are due to environmental stressors or psychological reactions, and not due to the medication or its failure.

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.