Documentation Sucks: How did we get here?!

Every clinician understands the pain of medical documentation in electronic medical records (EMRs). This system is outdated, contributing more to chaos than clarity.

The traditional documentation method is a carry-over from the era of paper records. Every patient-encounter is documented as a “note” – like how we would write it on a piece of paper. This note is then moved into the EMR for storage. Review of a patient’s medical history requires opening the patient’s chart (akin to opening a physical patient folder/file) and reading through prior notes. Documentation of patient’s presentation essentially requires creating a new blank page, which then needs to be populated with information from scratch. This paradigm is ill-suited for the current digital age.

Most patient visits/encounters require a physician to have some knowledge of patient’s medical history. As medical care becomes more complex and the population gets older, traditional EMRs don’t have the capacity to present prior contextually-appropriate medical information in a succinct manner to the clinician – this either increases workload of the clinician substantially OR introduces error. During encounters, documentation of a new note from scratch often results in unnecessary duplication of information, further increasing risk of errors and burnout.

This forces us into a constant battle with "information chaos," where duplicate, scattered, and often conflicting data bury the essential insights about a patient's health.

Diving deeper and conducting more research into information management made us realize that the culprit is the “note” – an outdated paradigm that organizes data by time, author, or data type, rather than by topic. In doing so, it fails to provide a holistic view of a patient's condition in a concise, error-free manner. It makes it difficult to track the evolution of a patient's health without sifting through redundant and scattered notes.

But we can change this. Imagine a world where medical documentation is organized such that a patient's condition is easily accessible, and the most current state of their health is clear at a glance. This isn't a pipe dream—it's a necessary evolution of our current system.

Stay tuned for our upcoming newsletters where we will delve deeper into this topic and discuss realistic solutions to this daunting problem.

Together, we can turn "Documentation Sucks" into "Documentation Rocks."