Hitting A Nerve

The ‘monster note’ in EHR systems rarely helps


Recently, the hospital I take call at switched to Epic as its electronic health record system.

Overall, I don’t have too many complaints about it. It does some things better and some things worse than other systems I’ve used. That’s to be expected.

But with Epic has come an alarming new trend: the monster note.

Dr. Allan M. Block

Dr. Allan M. Block

The feature that automatically pastes radiology and lab results in a note has become horribly misused. I’m sure it looks good for legal purposes (“Hey, of course I read it. It’s in my note”). But what it really does is fill up a note with drivel: test results that take up space, followed by an exam that’s likely been cut and pasted from the previous day, and an impression that’s usually almost meaningless. Typically the last is along the lines of “continue current treatment” or “cardiology to see.”

Rarely does it ever give you a hint into the thought process or what’s going on that (at least to me) is so critical to medicine.

In a recent example of the insanity, one of my office patients was in the hospital overnight for a transient ischemic attack. When I went to get the discharge summary, it was 97 pages long! (Really, it was.) All of it was auto-filled in with test results, vital signs, MRI screening forms, medication administration records, and nurse, therapy, and respiratory notes. Most of it was far from the stuff that discharge summaries are supposed to contain. What part of “summary” are people not understanding anymore?

Of course, this isn’t Epic’s fault. It’s just a tool. It’s how humans use it that becomes the problem. This misuse of the system has made routine notes, as Shakespeare’s Macbeth said, “a tale told by an idiot, full of sound and fury, signifying nothing.”

For better or worse, I deliberately don’t do this. I let Epic put in the patient’s name, birthday, and most recent vital signs ... and nothing else. I’ll fill in the test results when needed, in a concise form that I can grasp. (It’s my note, after all.) To me, writing (or typing) the note is part of the thought process. As I enter results, I turn over what they mean, in a way that just seeing five paragraphs auto-pasted in doesn’t do. It also allows me to boil them down to one or two sentences.

After all, brevity is the soul of wit. And while I’m not trying to be witty in my notes, I am trying solve the problem in front of me. Taking the time write it out in my own words is essential to my thought process and letting others understand how I came to my plan. And, as a result, it is what’s best for the patient.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

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