Friday, July 17, 2015

Which is better—an electronic or a paper progress note?

It depends on whom you ask.

A new study says internal medicine house staff generally feel that the quality of progress notes is unchanged or better since the implementation of an electronic medical record, but the attendings feel that progress note quality is unchanged or worse.

Over 400 interns, residents, and attending internists at four university hospitals were surveyed. The paper appears online in the Journal of Hospital Medicine.

Specifically, 50% of residents felt that the quality of notes was unchanged and 39% thought the quality was better or much better. Conversely, 39% of the attendings felt the note quality was unchanged, and another 39% felt that it was worse or much worse.

From the paper: Half of interns and residents rated their own progress notes as “very good” or “excellent.” A total of 44% percent of interns and 24% of residents rated their peers’ notes as “very good” or “excellent,” whereas only 15% of attending physicians rated housestaff notes as “very good” or “excellent.”

When the 9-item Physician Documentation Quality Instrument was used to evaluate notes, attending perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes, p < 0.001. One of the PDQI items asked for a rating of how succinct resident notes were. That feature was rated lowest by attendings and residents alike. I can think of a lot of words to describe electronic progress notes, but "succinct" isn't one of them.

In all, 16% of interns, 22% of residents, and 55% of attendings reported that copy forward [copy and paste] had a “somewhat negative” or “very negative” impact on critical thinking, p < 0.001. Auto population of fields in notes was judged similarly.

The authors felt that these differences could be explained because Attendings may expect notes to reflect synthesis and analysis, whereas trainees may be satisfied with the data gathering that an EHR facilitates. I agree.

Can all this be remedied?

Dr. Daniel Sexton, a Duke University internist, authored a three page guide [link is safe] on how to write effective progress notes. Here are just a few excerpts:


It is often good and useful to explain your thinking in the chart.

Do not mindlessly repeat yourself in daily notes. [That goes for "copy and paste" too (my extension of this recommendation)]


I have written about the pitfalls of electronic medical records several times. In my blog's search field to your upper right, insert "electronic medical record" or "EMR" and click "Search This Blog" to see my other posts.

It's early in the academic year. Start writing better notes now. And please don't copy and paste.


artiger said...

I guess the opinion on quality of the note depends on who is reading it.

frankbill said...

I have found that what the provider writes in my EMR isn't what I say but what the provider thinks I said. Sometimes I am never asked the question the provider answers.

artiger said...

Frankbill, that's because EMR's were designed to maximize billing, rather than to be efficient and improve care. Just yet another boondoggle, allowing another leech to suck $$$ out of health care.

Anonymous said...

In regards to frankbill, I think it would be good if providers and we went over the notes. I found so many things different from what this one doctor did, it took pages of corrections with research showing it was wrong. Another one put a dx code in there that wasn't supported by his notes.

frankbill said...

Anonymous One of the problems is providers spend more time writing in EMR during your visit then trying to DX you.

Skeptical Scalpel said...

I agree that sometimes what doctors write in the chart is not what the patients say they said. At times it is at odds with the facts.

And yes, the EMR is about billing.

frankbill said...

The danger is when you see a different provider many times they review what they think are true facts. They never check if the facts are true.

Anonymous said...

Sounds about right Frankbill. I see too much auto accept of another doctors' words vs. mine. I suspect a huge part of missed or delayed dx's.

Totally correct Skep.

Would a solution be to have the patient do some of the checkboxes in terms of what is wrong with them? At least a systems check and then a specifics check, and a box to give some clarification? Ie they could say upper or lower or mid back pain, and then clarify after working out in the yard or when dehydrated. That would give the doctor better clues on what to do next without having to gather that information themselves. That would shorten the time they have to dig, maybe less incorrect dx'es, and the doctor is spending less time on the PC than with the patient?

Skeptical Scalpel said...

Checkboxes are not the answer. The questions are often too vague and it is very easy to overlook something when multiple boxes are checked.

frankbill said...

There is Watson. Not that it will be much better then how Dx are now made.

What is needed is for provider to look at the whole body. They miss many things that could lead to DX by not looking at the whole body.

Today they don't even have you remove shirt to take blood pressure.

Emperor of Epidemiology said...

The copy forward mode has to be destroyed. I am seeing progress notes that are boiler plate - one almost wonders if the house officer even saw the patient, and I know from experiences that its rare that the attending will ever make the HO redo or clarify the note - the EMR was a device created to socialize medicine in the US and to ensure that the billing was correct. But, at least we can now read the imperfect record, and I guess that's an improvement.

Skeptical Scalpel said...

Frank, the physical exam is fast becoming a thin of the past.

Emperor, I'm not entirely sure about the socialized medicine part, but otherwise, my sentiments exactly.

connmannic said...


I am a biomedical engineer now, going to medical school next year. Really drawn to surgery. So many people have complained to me how their GPs sat on the computer during their whole checkup. Would a really responsive tablet with pen input provide a better platform than a computer, so they aren't tied to a keyboard and mouse and are closer to the patient? Or is it really the pen and paper that are the best?

My thoughts are that pen and paper have no latency compared to screens. There is just something organic and natural with writing that is difficult to replicate on the computer.There is always consistency with where things are on the page contrasted with the constant scrolling on the computer. The physician is away from a desk and closer to the patient. It takes less mental effort to not deal with a complicated UI.

Until tablets and electronics get closer to the feeling and responsiveness of pen and paper, I am not convinced they are a net benefit.

(I think they are getting there, Microsoft Surface and Sony Digital paper come to mind)

I think I have a novel solution to this this problem. I think about this a lot because it bothers me to think of how wide spread the issue of distraction with technology is. The patient doctor relationship seems vital to the overall health of the patient. Very easy to feel ignored or unimportant. I love technology but so often I feel true personal contact gets thrown away over the goal of efficiency and data collection.

Any thoughts? Sorry if my thoughts are scattered. Thank you for your site. Really enjoy your work.

Anonymous said...

Click-mark EMR notes are readable but soulless. Take that pen, put some thought in it and write a note that covers your clinical impressions. Now that is something worth reading.

Les said...

"trainees may be satisfied with the data gathering that an EHR facilitates. I agree." Oh ditto! I was referred to physical therapy 2 weeks ago and the poor PT looked alarmed as he skimmed over the chart my doctor had sent over. The PT asked if I was taking "ALL of these medications?" I looked over and the office had sent a list of every med I had taken for the past 5 years as if I were still taking all of it. The residents were tacking on the info without updating the record even after I told them I had stopped taking all of the meds. Other prescriptions were for antibiotics or corticosteroids that were limited to 1-2 weeks. How did this occur? My current health status was lost in a list.

Les said...

I forgot to mention, my clinic switched to EHR. I feel for the docs, surely they would rather spend time examining that typing on the computer they are forced to lug around from appointment to appointment.

frankbill said...

Is it good or bad the physical exam is fast becoming a thin of the past?

My research of what one can learn just by looking ones hands seems like very useful information.

Skeptical Scalpel said...

connmannic, I think a tablet that converts handwriting to text would be interesting to try. Why don't you do a study on it? I would love to see the results.

Anon, I agree.

Les, I have had similar experiences. The med list is rarely updated and often incorrect.

Frank, I think it's bad.

The Doctor Isn't In said...

We don't have the ability to copy and paste in our software byt we do have the ability to use Dragon Dictate. I see no difference in what I dictated into the old manually typed process then what I dictate into Dragon. To me a note is a note I say what I did what I expect and what I order and move on. No difference then when we used to grab a telephone in the doctor's lounge and do the same thing there.
The problem isn't the progress note it is the endless nonsense that the EMR requires just to complete one patient visit. Between the Rx and the Dx and the verification of Hx plus having to make sure the Rx is part of that formulary for that plan. When we first implemented it I had a secretary tag along and let her do ALL the EMR nonsense but the Esq's put an end to that 2 years ago.
The only real difference is now the PCP's thoughts are written out IN VOLUMES where I used to get a quick bullet now I get Moby Dick or Anna Karenina. WAY too much junk in notes and all it is going to do is hang them once there is a law suit.
No doubt the purpose was to better track fraud and make it easier to allocate blame surely not to increase care quality.
Dr D

Skeptical Scalpel said...

Dr. D, amen. At least Dragon can be fun when it types something outrageously wrong. Yes, the notes are way too long. I got to the point where I just read the Impression and Plan.

Anonymous said...

Dragon is not funny if it causes your notes to be unreadable. Some things in there are problems because you can't tell what is right and wrong and in my case it makes a huge difference.

Skeptical Scalpel said...

Of course you are right, but I'm not sure how much it matters. I am beginning to believe that almost no one reads progress notes anyway.

artiger said...

Amen to that, Scalpel. I never get calls from PCP's at this point. If I am lucky, they'll have office staff send over a progress note. Yet, for inpatients, it doesn't matter if I write a book of a progress note, it will go unread.

I'll admit that my observations are probably unique to my region. Somewhat, anyway.

Skeptical Scalpel said...

Progress notes were once a way of communicating one's thoughts to other docs and ancillary staff. Now they seem to be rehashes of everything that can be found elsewhere in the chart.

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