What’s In A Note?: The Use of Electronic Health Records

Americans love excess. When it comes to eating, driving, watching television, or sending text messages, we take (and eat) the cake. According to the Centers for Disease Control and Prevention, more than one-third of Americans are obese, an incidence that is 2.5 times the rate in France. Americans use text messaging four times as often as those in Great Britain. The average American television stays on for nearly 8 hours per day. What a life! No wonder there is so little time to exercise.

Our quest for excess extends into other domains as well. Consider the Standardized Aptitude Test, better known by its acronym, the SAT. In a fascinating study comparing the length of the SAT writing essay and the grade received, Les Perelman, PhD, the director of undergraduate writing at the Massachusetts Institute of Technology in Boston, observed a strong correlation between the two variables. The shortest essays, typically 100 words, received the lowest grade of one. The longest, about 400 words, usually were scored with the top grade of six. The correlation between length of essay and grade was also noted for essays with an intermediate number of words. In a New York Times article, he concluded: “I have never found a quantifiable predictor in 25 years of grading that was anywhere near as strong as this one. If you just graded them based on length without ever reading them, you’d be right over 90% of the time.” He was also struck by all the factual errors in even the top essays. Dr. Perelman contacted the College Board, the overseers of the SAT, and was surprised to learn that on this writing exam, students were not penalized for including incorrect facts. The official guide for scorers stated: “Writers may make errors in facts or information that do not affect the quality of their essays.” When asked how he would advise students to prepare for such an essay, Dr. Perelman responded: “I would advise writing as long as possible and include lots of facts, even if they’re made up.”

Are We Any Better?

I don’t mean to be cynical but the dictum, “to write as long as possible” has become the norm for some physicians, as well as for college applicants. The movement toward the use of electronic medical records (EMRs) has opened the floodgates for verbal excess. Nowadays, it is common to scroll through records that go on and on and on. Sometimes the content sounds eerily familiar. Wasn’t that history in the follow-up note the same as the history in the admission note from six months ago? A careful reading may identify some of these notes to be, in the frank words of Robert Hirschtick, MD, associate professor of medicine at Northwestern University in Chicago, “recombinant versions of previous notes.”