Editor's Corner | The Electronic Health Record: 4 Years Later

By Alfred A. Bove, MD, PhD

Like many of you, I have been immersed in the world of the electronic health record (EHR) for the past 4 years. I am reminded daily to digitally close an encounter, to be sure electronic prescriptions are signed, to click on a box to swear that I reviewed a lab or imaging report, and to be sure to give the patient a summary of their visit before he or she leaves the office. I receive constant reminders of drug interactions, the need for flu shots, and whether I am at par with my peers in e-prescribing, closing encounters, etc. 

Our EHR is available through a secure web browser, so I can access the information from home or when travelling to keep up with my patients and clear the never-ending new items from my inbox. 

Having worked with computers for most of my professional life, I welcome the opportunity to review patient records at my desk or at home, and to have the relevant laboratory and images all available in one place for review. Because the information from our practice is stored in a single database, I look forward to the opportunity to search the database to measure my performance, and to have the opportunity to do research studies on our patient population.

For the past decade or more, there have been efforts to create standard nomenclatures for our clinical data. These efforts have resulted in several systems of nomenclature that, when incorporated into a database structure such as an EHR, allow searchers to examine patient populations for practice performance measures, standards of care, and research.  

So, I am quite comfortable using the EHR when I see a patient in the office. Our examining rooms are arranged so that we can face the patient while accessing the data record on the computer screen. This set-up allows us to enter data while taking the patient’s history, review symptoms, and check the medication list. Then, after examining the patient, I can quickly enter the important physical findings into the electronic record. When I am finished with the encounter, I spend 3 to 4 additional minutes completing the diagnosis, patient assessment and treatment plan, and letters to referring physicians. 

When I dismiss the patient and leave the room, the record is closed, the meds are e-prescribed, and the referral letter is on its way. Assessments and plans are brief and telegraphic. The record is stored as a collection of standard objects that can be found in a later search.

Unfortunately, EHR users have separated into two groups: “clickers” and “dictators.” Clickers check off findings in check boxes from a list of symptoms or physical findings. These are assembled into a narrative report by the EHR software, so a letter or note documenting the encounter has all the necessary details. Dictators, on the other hand, dictate a text report that becomes a single entity in the record. It contains the information about the patient encounter, but cannot be searched for individual terms. Dictated narratives cannot be used for assessing performance or for retrospective research as the dictated text contains no standard terms.

Let me put in a word of support for the clickers among us. The electronic record becomes infinitely more valuable when data are stored as individual fields that follow a standard nomenclature. The information can be used for assessment of practice performance, for research, and for comparison with national data. In the future, we are likely to be held to some performance standards in order to be paid for our efforts. Dictators, please think about joining us “clickers” when you use your electronic record.

Alfred A. Bove, MD, PhD, is professor emeritus of medicine at Temple University School of Medicine in Philadelphia, and former president of the ACC.

Keywords: Electronic Health Records, Drug Interactions, Referral and Consultation, Medical Records Systems, Computerized, Standard of Care, Electronic Prescribing

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