The Physician Narrative Vs. The EMR Template
Or…How many clicks does it take to develop a narrative?
Or…Why the benefits of EMRs may be at the population level and not the individual level
How can you apply the highly desirable and perhaps necessary physician narrative using a template-based EMR? The short answer is that you don’t. Discreet data and a non-structured narrative don’t play well together yet. Discreet data is desired because you can easily mine and analyze pertinent information in order to address issues from a population perspective. Narratives are desired by caregivers who want to quickly assess or describe an individual patient’s current state. Some say the narrative even helps to humanize the practice of medicine. In other words, discreet data assists what known as Evidence-Based Medicine (EBM) while non-structured dictation aides a practice which has been in use for a long time, but is now being referred to as Narrative-Based Medicine (NBM) (Warning: .PDF). It remains to be seen as to which method is more effective in treatment. My guess would be that research will show EBM will have better results when looking at a specific patient population (i.e. patients with diabetes or hypertension) and NBM will have strong anecdotal cases and be preferred with physicians and patients.
In [a] Nuance survey, Dr. Hal Baker, the chief medical information officer at Wellspan Health, in York, Penn., offered a comparison of a narrative note dictated with Dragon Medical and another—with the same patient and conditions—compiled through a point-and-click EHR template. The narrative note read:
“The patient is a 74-year-old female who presents with a complaint of fall, 74-year-old female presents with complaint of neck pain, headache. She states that she had mechanical fall at home where she tripped and fell downstairs, approximately 9 steps and landed on her back. She complained of shortness of breath right after the event. She noted that she had pain in her left ankle and left knee. She is not sure whether she had loss of consciousness and the patient further complains of the pain in the right wrist.”
The note from the template read:
“The occurrence was one hour prior to arrival. The course of pain is constant. Location of pain: Head leg. Location of bleeding: None. Location of laceration: None. The degree of headache is mild. The other degree of pain is moderate. The degree of bleeding is negative. Mitigating factor is negative. Immobilization no backboard in place and no cervical collar in place. Fall description tripped. Intoxication: No alcohol intoxication. Location accident occurred was home.”
About 97 percent of survey respondents said they would consider the first note more valuable in treating the parent, according to Nuance.
Naturally, Nuance came up with a high number to state that physicians prefer good ol’ dictation. That’s Nuance’s livelihood. However, even without Nuance’s influence, these surveys still have strong numbers. Dictation proves faster to input data and the output is a much more “humanized” result than point-and-click. Unfortunately, I have not yet found any studies that captured the eye movements of a physician reading through a dictated note opposed to the movements on a note derived by template to determine which pieces of information they truly find relevant. This type of study has been done in other areas so it is possible. Physician preference is one thing, but what information they actually use may be another.
A recent article (which is quite brilliant) details the powerful influence of narratives to support or detract from the spread of information in the medical and health spheres. The author even suggests that narratives can override cold, hard facts, as could be the case in the recently released mammography recommendations which have suffered a terrible outcry from the public. Clearly, the answer to create narratives that support the facts and don’t contradict them.
In the office visit realm, a physician is attempting to document the facts as presented by the patient and compose a narrative that accurately reflects the patient state. It is at this point that two conflicting goals appear. The healthcare organization wants discreet data that it can pick out of a patient record. Admittedly, this is primarily for billing and compliance purposes, but some forward thinking organizations are actually using this data to study their patient population in order figure out more efficient and effective ways to treat them. The HITECH Act and it’s “Meaningful Use” requirements are also trumpeting this purpose. The physician on the other hand wants a compact summary of what a particular visit entailed so it can be easily referenced. The amount of spewed data on a progress note created by an EMR is astounding and downright difficult to sift through compared to a thoughtfully crafted and succinct snapshot. If flowing rhetoric, artistic embellishments or colloquialisms are used, it is OK because they can understand it. They also feel a time crunch to create this keystone of the visit because they need to see a certain number of patients per day in order to stay in business.
If actual clinical research can prove that the physician’s narratives not only provide a more human experience to medicine, but also enhance the physician’s ability to diagnose and treat then current EMRs will need to make the shift. Honestly, they could all benefit from an understanding of how people interact with technology and a sensitivity to who has to use their systems to achieve a purpose that is not their own. This would mean investing in technologies that sift through narratives to pull out discreet data. These technologies already exist, but I haven’t heard of a single EMR company that is paying much attention. However, if the information actually used in a narrative doesn’t delineate much from the information used in a template created note, why bother with the narrative at all? I’ve been considering how to use discreet data to create a visual snapshot of the encounter for reference and I’m sure others are investigating too. One artistic expression can be replaced with another to maintain the necessary human element in the practice of medicine. Regardless, more care needs to go into creating systems that obtain data through intelligent observation rather than intrusion.
Until that time though, when implementing an EMR with a template driven documentation feature, certain care can be given to streamlining the content of the template so the physician can move quickly within it and so it produces something legible. This is a matter of creating a few basic templates for Family Practice and Internal Medicine providers that encompass a wide range of areas and creating a larger number of speciality specific templates where the content of the visit will be fairly predictable. In addition to this, Practice Management needs to look at the complete bottom line after a template-driven EMR is implemented and take a look at the charges, adjustments and receipts, analyzing inefficiencies in the office to reduce costs and analyze procedure volumes and profits to eliminate unprofitable ones before knocking on the physician’s door to complain about patient volumes.
Aaron Berdofe, MHI - Health Informatics 
Apologies in advance for the length.
I am a consultant for a physician owned EMR software company. Over 30 years I have worked as a programmer, business analyst, computer and document solutions sales rep, and medical records solutions consultant.
As the article referenced (Narrative Based Medicine) mentions, the narrative text and template based structured data are best considered as complimentary rather than mutually exclusive. There are conflicting requirements for medical records – a conflict which has come to a head in the past 20 years. And neither of these requirements can be ignored.
Medical notes began as the physician’s own self-generated, self-reinforcing information source to help manage a patient’s ongoing health care. As such the doctor was the sole determinant of the requirements. Whatever worked for the doctor was okay.
But as insurers (both government and private) became the primary payers for medical services, they changed the role of the medical note into a means of oversight, and these institutions cared more for detail, structure and completeness than brevity or ease of use. Notes must serve dual purposes. Doctors still need notes, but can no longer write notes however he or she pleases. Notes must also meet stringent external requirements (or else!). He who holds the purse wields the power, as the saying goes. However you feel about this model, good or bad, it’s now a fact of life. And it means more information MUST be documented in greater detail than in the good old days.
Finally, the promise of obtaining vast amounts of standardized medical data and using it for population-wide research of all kinds has big government, big insurance and big medicine (pharmaceuticals, research companies, etc.), salivating. If they can collect mountains of data directly from the field without having to set up (and pay for) special studies, the benefits to all these entities could be enormous (and very profitable). And, oh, yes, patients could benefit too(!)
No doubt, the practical benefit of having a truly portable medical record accessible for any patient anywhere at any time would be a real benefit, assuming we can (and I think eventually we can) ever get there. If I have a car accident in Boston, it would really help the ER if my medical record from Dallas was instantly accessible.
Where the rubber meets the road is in the clinic, especially at the point of care for the physician. When medical note taking was “whatever works for you”, the doctor developed whatever method best suited him/her and it was not surprisingly, pretty quick, infinitely flexible, and efficient. Now the requirements are for lots more information in the form of structured data – not so easy to obtain and especially to input. Paper is a cheap, quick medium for data input. Not so great for storage, retrieval, transport, analysis or reporting, but great for input. Computers solutions are not so cheap and usually not as quick on the input side. It’s the storage, retrieval, etc. part that they do so well.
EMR companies, contrary to your comment, ARE paying a lot of attention to mining structured data out of unstructured narrative text – only the methods and technology to make it really work are very complex and expensive and to date they’re not dependable enough to support life and death decision making. Unstructured text can’t meet all the requirements.
As such, it makes sense to use a template based approach to generate the highly standardized structured text mandated by today’s regulatory and financial requirements because selecting items on forms is still faster than typing them into database fields. The problem isn’t (entirely) that template based EMR’s are terrible software (okay, some of it is), but that the increasing requirements being imposed on medical records can’t be met as quickly or easily as writing your own notes on a scratchpad used to be. That’s just a fact. There is no point in wishing that unstructured data could do the job because we still like it better.
Additionally, if you want the patient to input information directly, a simple blank box may be okay for those patients who are medically articulate and naturally expressive, but a well-designed template that guides them through a series of possible problems elicits a more complete and reliable response across all patients than a simple open ended question might. Once again, the two approaches must be complimentary, not mutually exclusive as each has its advantages and pitfalls.
The challenge today is to create a method of documentation that captures structured data, is flexible, customizable, easy to learn and easy to use. If, in addition, it can facilitate direct patient input, that’s even better. If doctors and other medical professionals prefer medical narrative to serve the original purpose of medical notes (and that’s altogether valid), then we have to find a way to do both without taking 30 minutes per patient to do so.
Currently, a mixed method relying heavily on well-designed customizable templates for 90% of the information but allowing for some unstructured narrative as needed is probably the best approach.
Patrick J. Casey
Marketing for AvivaEMR.com
Thank you, Patrick for your comments. You’ve reiterated a number of my points and brought to light some new topics of discussion. I think we both agree that the ideal solution is one that allows for high speed input and also defines relevant information in a discreet and structured way. I forsee the next industry phase we will (or perhaps should) see is the reconfiguring of data output that can be used in a more visually informative way. The input side needs more intelligence (artifical and otherwise) before it assists in the process instead of being a nuisance. We need to redesign the process that takes into account the new external demands instead of creating systems to duplicate the paper methods. Good design enhances a process, bad design gets in the way.
I would say that there are some features of paper that we absolutely DO want to duplicate, or at least emulate.
I continue to be puzzled by a connundrum. Technologists have for decades predicted a paperless society, yet, at last check, we continue to use more paper, not less. We routinely denigrate paper for all it’s bad qualities, yet it persists, even thrives. Why? Because not everything about it is bad. And when it comes to certain things, it’s still better than computers.
I would say that we will successfully replace paper only when we recognize and replicate the qualities it has, instead of concentrating only on eliminating it’s disadvantages. The 5 qualities it has which I have not seen replicated yet are:
1. Dirt cheap: It is very cheap, and therefore, it’s also relatively ubiquitous. I haven’t even a cheap netbook that costs 2 cents. When half the world lives on less than $5 a day, we won’t see computers in everyone’s hands any time soon.
2. Durable: It is pretty durable (i.e., doesn’t get ruined by water, dirt, etc.) and can last for hundreds of years. I have CD’s that, contrary to their advertisements, haven’t survived a decade. We’ve all been through data formats changing whereby “poof” all my data is “gone” for all practical purposes. But we can still read the Gutenberg Bible almost 500 years hence.
3. Flexible: It is infinitely flexible – I can write, draw or scribble anything I am literate or artistic enough to produce. Mice and keyboards are good in some ways, but limiting.
4. Input: It is fast and easy to use for INPUTTING data. This may actually be the primary advantage over other data capture tools. As an input medium, paper is still quick and easy.
5. Review: I can easily flip a page or lay 10 pages on a table top or floor. Screen size is still a limitation for computers. When laptops can project on any flat surface, we’ll be getting somewhere.
All it’s downsides are on the retrieval, portability, aggregation, analysis, and reporting side, and those, I agree, have become practically intolerable.
But the positive features must be replicated in the digital realm if we are to get where we really want to go with electronic medical records.