Iris Gorfinkel is a General Practitioner, and Founder and Principal Investigator at PrimeHealth Clinical Research in Toronto, Ontario.
Medical documentation in primary care is a balancing act between promoting timely connection with patients and reducing clerical demands placed on physicians. Clinical notes contain increasingly less by way of narrative. They are often made up of time-saving digitized checklists of symptoms, physical findings, and treatments. Or the progress note may be a copy-and-pasted template. Both checklists and templates lessen the need for clinician typing and offer detailed notes within a few clicks.
Prior to the electronic medical record (EMR), hand-written or dictated notes would often relate a patient’s experience by quoting patients' descriptions of their symptoms. With the arrival of the EMR, doctors, most of whom had little typing experience, were abruptly confronted with having to type detailed patient encounters. The degree to which a clinician must type has since been correlated with physician burnout, which has risen sharply in conjunction with EMR utilization.
It is not without reason that digitized check lists have quite literally become a mark of modern medicine. The increasing use of surgical checklists, a now widely employed strategy, has been shown to increase patient safety by a significant margin.
Yet it remains concerning that 80% of clinical notes are simply copied and pasted. While templates give time-strapped doctors relief from the burden of manually typing a patient’s history, there is a concerning flip side to this approach to note-taking. Both checklists and templates do little to capture a patient in the moment of their visit, let alone the patient as an individual. This is because EMRs cause physicians to face a computer screen rather than the patient.
Perhaps Alduous Huxley understood when he penned that “technological progress has merely provided us with more efficient means for going backwards.”
A recent study of primary care physicians showed that over half the time (52%) of the average (16-minute) patient visit was spent with physicians looking at the electronic health record, leaving less time for direct communication with patients. However, less direct communication time decreases the chance that patients will adhere to their doctor’s advice. It also lessens time that physicians have to educate patients, to use humor and to encourage patients to express their opinions.
The relevance of documenting the patient’s personal perspective depends in part on who is reading the EMR. If the reader is a representative from a provincial college or insurance plan, a digital template may suffice. The added scrutiny of litigation may be more challenging should uniquely defining aspects of a patient’s clinical encounter go undocumented. Piecing together exactly what had occurred in a clinic visit from generic checklists or templates may later prove challenging.
Increasingly however, it is the patient who is most commonly reading the primary care record, including physicians’ progress notes, as noted in a recently published CMAJ Analysis article.
The authors of the first large-scale study conducted in the U.S. examining patient experiences with ongoing access to their clinicians’ outpatient visit notes, found that patients rated reading their notes as very important for their health management and shared their notes frequently with others. Of note, those patients who are traditionally under-served reported particular benefit.
Increased access to primary care records allows patients to directly collaborate with their physician. A step forward would be to enable patients to type their agenda into their clinic note prior to a visit. Patients could be provided with a laptop computer with the clinic’s EMR interface and have the option to type a maximum number of 60 words to describe their personal agenda prior to seeing their physician. The benefits of such an initiative would include improving documentation of a visit, increasing physician understanding of patient expectations, and helping to reduce the already high clerical burden on physicians. Physicians be provided with an understanding of patients’ concerns prior to a visit, which might allow for an improved allocation of limited clinic time to better match patient expectations. Such collaborative agenda-setting could then become an important component of the progress note. This could individualize and complement existing checklists, templates and physicians’ notes. It also signals to patients that their concerns are respected and validated through integration into their clinical records.
Collaborative agenda setting has been studied and is evidence-based. An assessment of the feasibility, acceptability, and utility of patients who were attending a large primary care clinic typing their agendas into the electronic visit note before seeing their clinicians found that well over 70% of patients and clinicians agreed that the agendas improved communication. Moreover, 73% of patients and 82% of clinicians wanted to continue having patients type their agendas in the future. The authors concluded that enabling patients to type their own agendas gave clinicians an efficient way to prioritize patients’ concerns.
Calls to mandate patient access to primary care records have been made, but at the time of this writing most Canadians continue to lack access to their primary care records. There continues to be considerable progress in expanding patient portals in Alberta, Quebec and Ontario. Examples include Alberta’s eClinician MyChart, Quebec’s Health Booklet, and Ontario’s hospital access through Sunnybrook Hospital’s MyChart, Sick Kids MyChart and the UHN patient portal MyUHN.
Patient portals currently provide information that flows from health care providers to patients. Enabling patients to type concerns into progress notes would create a novel direction that allows for the flow of information from patients to their health care providers.
There are many potential barriers to this concept. These include the costs of development, implementation, and security; the added perceived burden to physicians’ workload and physician acceptance; and patients’ ability to cooperate due to limited personal financial, electronic, physical or emotional resources.
There remains tremendous untapped potential for technology to enhance humanity. Integrating a patient’s own words into progress notes may reduce clerical burden on clinicians and serve as an adjunct to checklists, templates and physician notes. Patients would have the benefit of seeing their concerns validated through a platform that invites personal perspective and captures individual experiences. Documentation would be enhanced while patient and clinician expectations of a clinic visit become better aligned with more optimal use of limited office time.