Unfortunately, the “note bloat” discussed above not only overwhelms the senses of a provider trying to locate clinically meaningful information from the past, the multiple episodes of healthcare contact make drilling down into the electronic records extremely laborious and time consuming. Often, hundreds of individual notations for dates-of-service document communications with the patient by multiple providers and staff members over time. Sorting out the clinically significant ones from the less meaningful diagnostic labels can be an overwhelming task with regard to the time and effort required.
After all is said and done, the conscientious practitioner should remember the old saying, “Don’t believe everything you read!” Rather than being lured to the path of least resistance to facilitate meeting patient expectations, as well as administrative demands, with regard to development of a diagnosis with a treatment plan, critical thinking and intellectual honesty must prevail—even if not appreciated by the patient or the various insurance and administrative requirements needed to allow testing, treatment and payment for services provided.
Many physicians have learned how to game the system by telling white lies that allow the healthcare provider to manipulate the system to get things done, as well as look good on paper.
Thoughtful consideration of a patient’s concerns & complaints, along with formulation of a diagnosis & treatment plan (not to mention examination), is undermined by the inflexible demands of the EHR program, which will not progress to the next task until all tasks required are completed.
Where We Are
In summary, the EMR promotes diagnostic labeling, which justifies the medical treatment provided rather than valid diagnoses. This flawed model of healthcare allows reasonable but unproven concepts regarding disease processes to be accepted over time as fact with resulting bad results purchased at a high cost both financially for society and personally for the patient.
The diagnostic label has become the modern equivalent of the deus ex machina (a god introduced by means of a crane in ancient Greek and Roman drama to decide a final outcome). If a healthcare provider needs an explanation or justification for services provided or requested, just come up with the needed “diagnosis.”
Also, this author believes that having a non-medical scribe in the room doesn’t help the doctor–patient relationship, although the physician is relieved of some of the documentation burden.
EMR documentation requirements are changing the diagnostic paradigm for all physicians, who have to fulfill burdensome documentation demands, as well as provide thoughtful, compassionate and competent patient care.
