As North Americans were preparing to view the total solar eclipse at nearly this time last year, I was preparing for the eclipse of my clinical career; I had made the decision to close my 20-year-old practice to move on to other pursuits in medicine. Sitting in lawn chairs in the hospital parking lot with eclipse glasses on, I chatted with a friend from my medical school class whose office was one floor down from mine in our medical office building. She, like most of my colleagues, expressed two emotions upon hearing of my impending retirement from clinical medicine: disappointment that I would no longer be a practicing colleague, and jealousy that I was “getting out while there was still time.” She lamented at the long hours seeing ever more patients, only to be followed by more long hours charting in the Electronic Medical Record after the patients were gone. There was no argument from me, as frustration with EMR was one of the final nails in the coffin of my practice. To illustrate her point, she described the EMR training she and her practice partners were being required to do in order to maintain privileges at one of their hospitals: two eight-hour days of hands-on screen time in a computer lab on-site, followed by six two-hour modules of off-site training, none of which was to be compensated or rewarded CME hours.
The SOAP note is the backbone of medical documentation, and one of the first skills mastered in clinical training in medical school.
“S” describes the patient’s subjective complaints— “My stomach hurts and I’ve been vomiting since last night. I also feel tired and achy all over.”
“O” is what can be objectively measured regarding the patient—temperature, blood pressure, pulse and respiration rates, as well as the details of your physical exam of her or him.
“A” details the clinical assessment of what is wrong with the patient—your diagnosis of the problem, in addition to any differential diagnoses that should be considered.
“P” sets out your plan of action—how you will treat the patient in order to return them to health.
By the end of their second clinical rotation, any third-year medical student worth their salt can throw off a well-constructed and thought-out SOAP note in five to seven minutes (assuming, of course, that they have taken proper time and care with the history and physical exam of their patient). Taking a simple five-minute task and turning it into more than three days of training on a computer is the height of inefficiency and waste. The mire of EMR has flipped the importance of the daily tasks of practicing medicine. A half-hour-long H&P should take 5 minutes to document; however, it is not unusual to find that a now ten-minute H&P is taking 30 minutes to document for new EMR users. Although documentation is crucial to the process of medical practice, what sense does it make that such documentation has become the end-all be-all? Shouldn’t the greatest time and care be devoted to the history and physical, and not to the documentation thereof? Isn’t the interaction with the patient of paramount importance, not jotting down its details?
Most EMR systems link documentation to billing, so if certain and specific details are not captured, charges are not billed, and physicians don’t get paid. In order to meet the bottom line, the beast of the EMR must be fed– properly and with care. If one’s livelihood depends upon clicking all of the right boxes, then the 24 hours in a day demand that something must give, and usually that is the time spent with patients. A 2016 study published in the Annals of Internal Medicine showed that physicians spent almost twice as much time on EMR documentation and desk work as they did seeing and interacting with patients. This is not the way to provide the best care for patients, but without revenue, the clinic doors don’t stay open.
EMR systems were built for the convenience of those who do coding and billing, not for the good of patients and physicians. The patient-physician relationship is the linchpin upon which all of healthcare turns; without it, the wheels fall off. We are dangerously close to having that happen. This must change, and it is possible for it to do so. The time to return patients and physicians to the heart of medicine is now, and those of us who advocate for intuitive EHR systems must lead the way. Making those systems serve physicians and not billing personnel is the first step in the right direction; it is the way physicians will best be positioned to serve their patients in turn.