The Metastasizing Complexity of Templated Exam Notes

The Metastasizing ComplexityThe problems associated with templated exam notes have been well documented. From the amount of time it takes to build the notes by entering every piece of data via pointing and clicking, to the sheer length of the output that makes it hard for physicians to find the information they need, to the challenges related to upcoding and cloning (factors that the government is actively investigating), templated notes have been tolerated as a necessary evil associated with EHRs. But there are better ways to capture, exchange, and analyze discrete clinical data with precision, and without adversely affecting physician productivity.

As government programs rapidly evolve, and the number of such programs increases, the need to capture and analyze data will change and grow—think: new stages of meaningful use, PQRS, and the impending switch to ICD-10. An interview with orthopaedic surgeon Scott W. Trenhaile, M.D. in AAOS Now illustrates the increasing template-related burdens associated with ICD-10, just as an example. “We’ve spent a considerable amount of time on templating and are adjusting our templates to address those issues. . . . We’re changing the EMR templates to ensure that ICD-10 issues are covered. Answering certain questions in certain ways opens other templates so we have the information needed for ICD-10 coding.”

Just this past week, the number of anti-template commentaries published in the media has exploded.

  • The problem was aptly described as “note bloat” in a recent presentation to attendees of CHIME’s CIO forum, where the problems associated with typical EHR documentation of a patient exam were lamented.
  • A recent survey conducted by the American Medical Association and reported by the RAND Corporation cited the prominent concern among physicians that EHR technology “requires physicians to spend too much time performing clerical work and degrades the accuracy of medical records by encouraging template-generated notes.”
  • Bill Cayley, Jr., M.D., a family-medicine physician, blogged, “With the increasing use of electronic medical records (EMRs) and their ever-so-helpful templates, smart sets, and forms for capturing information needed to support billing and guide protocols, I fear we are losing the narrative forest for the well-documented trees.” He goes on to say, “Far too often, doctors are being forced to re-gather the entire history with the patient themselves, because prior documentation fails to provide the nuance needed to understand what happened during the last visit.”

If physicians are struggling with templated notes now, their problems are bound to be exacerbated as EHRs layer more and more levels of complexity onto already bloated platforms to try to keep up with the government’s voracious appetite for data.

Physicians need nimble and flexible data platforms to support the data-capture needed to identify and reward quality of care while maintaining physician productivity. The metastasizing complexity of the templated exam note can only lead to its demise.

3 thoughts on “The Metastasizing Complexity of Templated Exam Notes

  1. When we’re paid for quantity over quality, you will continue to get lots of quantity. The only way to remove the incentives for superfluous charting is to radically truncate E&M coding by reducing all non global encounters to 1-2 codes that aren’t dependent on bullet points to establish their value. That would serve several functions including reducing time and cost of charting, billing and collections, largely eliminating the need for RACS of non institutional clients, and reducing overall friction in the system. I’d accept a universal E&M code equivalent to a level 3 encounter as we’d come out ahead with reduced costs

  2. When I used to get a chart for referral, the pertinent records were several pages with highlighted data regarding the problem for referral. Now I get literally 100’s of pages, many repeated repetitions of data designed to satisfy ‘meaningful use’ and of little value to the patient. How many times do I need to see that the patient smokes 1/2 ppd of cigarettes, or had a hernia operation in 1987, etc. etc. And every person who contacts that patient adds the same data and template: physician, nurse, LPN, podiatrist, admission clerk – each inserting virtually the same set of pages with the same information. Pity the poor trees. Can’t these brilliant programmers put in a summary page that combines these duplicate pages, avoiding repetition, and saving trees.

  3. The template based entries are far from being all bad because they lead to uniformed discrete data which can be much easier processed by computers. Richard brings an excellent example of such uniformity requirement to eliminate repetitive entries for patient smoking habits and hernia surgery. If the same entries are phrased in many different ways, how the computer will determine that they are the same in their nature to suppress the repetitive entries? There are certainly areas of the documentation where template restrictions may reduce the clinical value of the document and if so – the free form text entry (whether by typing or dictation) should be available. But as to amount of smoking, alcohol, street drug use, etc. as well as past history – these entries most of the time may (and probably should be) standardized across all the EMR/EHR not only the avoid duplications, but also for clinical analytics which unfortunately the current computer systems do not do.

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