The Fault in our EHRs

“The fault, dear Brutus, is not in our stars,

But in ourselves, that we are underlings.”

-Cassius, Julius Caesar (I, ii, 140-141)

There is no shortage of reasons to feel frustrated with EHRs—tedious data entry, finding the right diagnosis codes, and a blur of pop-up reminders. For me, the greatest disappointment is the way that documentation in the EHR depersonalizes a patient’s story.

The EHR template

The EHR template is based on the way we are taught to present and document patient histories from the very beginning of our training—chief complaint, present illness, past medical history, lab data, and so on. It is a series of short narratives, and mostly lists. What we end up with is a dull depiction of a person. Communicating this way, whether verbally or by charting, not only dehumanizes patients, it also feels dehumanizing to the clinician. Perhaps our impersonal electronic documentation is less due to the limits of the EHR, and more a symptom of the fundamental problem—the way we are taught to deconstruct and present patient stories.

World champion poker player

Earlier this year, I had the privilege of hosting a medical student, S, during her family medicine rotation. When she presented patients after her evaluations, she began with something unique and personal about them. In one particular case, I recall her saying, “Mr. C is sixty-seven years old, and is getting ready to leave for Las Vegas later this week. He is a world champion poker player and has an important tournament coming right up.”

In all the years I have known Mr. C, I never knew this about him. He was suffering from a recalcitrant sinus infection that impaired his concentration, and made him reconsider his plans. This provided some context for his medical concerns, and helped us personalize his evaluation and treatment plan. My student made many other similar discoveries during her month at our office.

Why don’t we present this way all of the time? The so-called “social history” is usually relegated to the end of the history, and is often reduced to details about alcohol, smoking, and substance use.

Sewing together setting, characters, and plot

As Colleen Farrell, MD, pointed out in her recent essay, “Social History as Story,” the social history is much more meaningful when its components—setting, characters, and plot—are sewn together in a narrative that shows the patient’s unique life context.

Perhaps the social history should be the very first thing presented. It may not be the first information obtained; it is best to preserve open-ended interviewing with refinement as needed for problem solving, and to understand the patient’s priorities. When conveying a patient story to colleagues, however, a thorough social prelude humanizes in a way that a standard presentation cannot.

It feels inadequate that we typically reduce our introductory remarks in clinical presentations or write-ups to age, ethnicity, and gender. “A fifty-seven-year-old white male,” does little to convey who I am as a person. Even Amazon, knowing my address, demographic, and previous purchases, begins a commercial transaction with a more robust social profile of me than a physician’s standard documented clinical history.

The history template in the EHR could be constructed such that human and social descriptions get first heading, even before chief complaint or history of the present illness. Better yet, perhaps a personal “snapshot” prepared with firsthand input from patients and further curated by the provider, could be imported into the visit note, much in the way that many of us currently do with labs and other pertinent data. There are many creative options here, all of which begin with recognizing and underscoring the value of this information in forming a full picture of the person with are caring for. From there, we are better positioned to partner and create a care plan that consists of thoughtful, shared decisions.

S and I worked with Mr. C and came up with an aggressive symptom treatment regimen to help salvage his poker tournament plans. He may have offered this concern on his own, but S made sure this personal element of his visit was not overlooked. Further, we both felt satisfied that perhaps we did something for him beyond what “a sixty-seven-year-old African American male with sinus congestion,” would have inspired. S made a point of highlighting Mr. C’s poker skills first in her progress note, but she had to go outside what was prompted in the EHR template in order to do so.

This medical student’s creative case presentations inspired me to reexamine my struggle with the impersonal aspect of EHR documentation. The record is shining a mirror and exposing a methodologic blind spot which, when resolved, is humanizing for patients and clinicians alike. The fault here lies not in the software, but in ourselves.