In a recent Ideas and Opinions piece entitled, Restoring the Story and Creating a Valuable Clinical Note in the Annals of Internal Medicine, Gantzer et al call for clinicians to, “…reclaim the clinical note as a means of showing the cognitive processing involved in turning medical information into a thoughtful assessment and plan.” They point out that, “There is a critical distinction between documentation and communication: Communication can document, but documentation alone rarely communicates what matters most.” 

They identify two key changes: 1) Curtail “note bloat” and 2) restoring the story. 

This is a recurring theme I’ve heard from physician colleagues since the big push for EHR implementation and use with the implementation of the HITECH Act in 2009.

In 2010, I wrote an editorial for the Annals of Internal Medicine entitled, “The Clinical Record: A 200-Year-Od 21st-Century Challenge” about The Evolving Medical Record by Eugenia Siegler. Siegler reflected on what we could learn from medical records in the 1800s. At that time, physicians were forced to move from free-form, highly stylistic notes reflecting unique writing to very structured notes designed to capture data. She wrote: 

“Changes in record format, designed to manage increasing volumes of data, and physicians’ responses to those changes parallel some of the contemporary threats to documentation posed by the electronic health record.” 

Eugenia Siegler

I encourage you to review Siegler’s article as it includes great images of clinical records from the 1800s illustrating the evolution of record-keeping.  

My editorial closed with the following: 

“Electronic health records should be used as a tool to support clinical curiosity and critical thinking rather than simply to expedite clinically meaningless documentation in order to bill higher codes. We are in danger of repeating history by once again overstructuring the clinical record and overloading it with extraneous data. Physicians must learn to leverage the enormous and growing capabilities of EHR technology without diminishing or devaluing the importance of narrative entries. Failure to do so will inevitably influence the way we think and teach—to the detriment of patient care.” 

Michael S. Barr

The American College of Physicians published a policy paper in 2015 entitled, “Clinical Documentation in the 21st Century” which included several recommendations that also highlight concerns about electronic health records and loss of the rich narrative and story. This statement captures the key sentiment: 

“The primary goal of EHR-generated documentation should be concise, history-rich notes that reflect the information gathered and are used to develop an impression, a diagnostic and/or treatment plan, and recommended follow-up. Technology should facilitate attainment of these goals in the most efficient manner possible without losing the humanistic elements of the record that support ongoing relationships between patients and their physicians.” 

American College of Physicians

What needs to be done to improve existing EHR systems to help retain the clinical narrative and reduce unnecessary note bloat and documentation? 

Is this all related to documentation to support billing requirements – or have clinicians lost the art of storytelling in current training? 

What are you doing in your practice/institution to ensure clinical team members are not deluged by excessive notes and information? 

This post was originally published on my personal blog in November 2020.