Back in the day—the “day” being only about 10-15 years ago—when a patient went to visit a doctor, the doctor probably scribbled down handwritten notes to capture the essence of the appointment. Those notes were added to the patient file and used as a reference for future appointments.
The advent of electronic medical records, led by companies like Madison’s own Epic Systems, has transformed how doctor’s notes are written and, more broadly, the field of medical informatics. Today, doctors use several different documentation aids to help them create patient notes. They might cut and paste text electronically from a prior note, or they might use a tool within a records system to auto-populate a specific field. It is also likely they will use note templates, a popular tool that creates boilerplate text with placeholders for the doctor to input information specific to the patient.
While electronic medical records clearly have a long list of benefits—they’re legible, portable, shareable and can contain real-time alerts for physicians—the field is still growing and evolving, and some challenges have emerged along the way.
Adam Rule, a new assistant professor in the Information School, studies the ways medical and clinical staff use electronic records to document patient care. One focus is on how moving notes to an electronic format has created a bias towards what is known as “structured data”—the segmenting of information into a specific format, rather than a cohesive narrative.
“Things that might have been written in a narrative form in a note now get scattered a little bit across forms with separate areas for medications and labs,” explains Rule. “Being able to synthesize that information becomes a challenge due to that structuring.”
The doctor’s note is used for a long list of things: It’s a memory aid for future patient visits. It's shared with other providers and used for administrative tasks like regulation and billing. Given those multiple uses, it is important to understand how notes are created and used.
“At the beginning, the doctor’s note is a very human document,” says Rule. “It's documenting what the physician observed--how they're thinking about your case, the kind of uncertainty in the diagnosis and what they're wanting to do next. Moving to some of these documentation aids, there was a concern: Will you lose some of that narrative? Will it get buried underneath a bunch of stuff that's just automatically imported?”
Before coming to UW-Madison, Rule worked at Oregon Health and Science University, where he researched a decade’s worth of medical notes, encountering a phenomenon that’s come to be known as “note bloat.” Rule’s research team found that doctor’s notes got 60% longer over the decade, and they also became increasingly redundant through constant cut-and-pasting. More than 50% of the note text was contributed by templates that pulled in boilerplate language and lab values, whereas less than a quarter came from a physician or other member of the care team dictating or typing it in.
“So many clinicians have had this feeling that notes just seem to keep getting longer,” says Rule. “Things like notes can easily get very long, so it's hard for someone to read afterwards because you can quickly generate a document that has a lot of text.”
To Rule, the real power of the doctor’s note is its ability to tell stories with data, to combine the patient narrative with data-driven decision-making tools. As data analysts develop tools that allow them to pair text blocks with code that can analyze data and generate graphs, the potential exists to make note templates even more powerful—and useful.
“I think that there's a lot of opportunity for these kinds of new writing tools to get more interactive, and to let physicians do more to manipulate and analyze data directly within the note writing interface,” says Rule.
In the future, instead of piling up auto-generated text blocks, notes could generate graphs that track, for instance, a patient’s blood pressure or kidney function over time, creating a visual aid that both patients and doctors could quickly grasp.
In addition to teaching classes in the Information School’s new Master’s degree program, Rule has begun collaborating with family and internal medicine physicians within the UW Health system, examining how efforts like a push to standardize note templates across UW Health impact how physicians use electronic medical records. He also hopes to partner with Epic Systems to help study how tools like note templates are used at health systems across the country.
“There is opportunity not only to do research to inform at the national level, but research that touches on quality improvement, something these organizations are already heavily involved in,” he says.