Perspective: Template Charts and the EMR: The Good, The Bad And The Ugly

In January WSMA Reports contained an excellent article by Elizabeth Leedom, JD, on the risks and benefits of the electronic medical record (EMR). I hereby add my comments to the discussion.

More and more emergency departments and physician offices are using template charts or electronic medical records (EMRs) to record patient encounters. They are being promoted by specialty organizations, vendors, governments, insurers, hospitals, etc. EMRs do have some benefits. But if a practitioner is sued for malpractice and has only an electronic medical record with which to defend oneself, it can be an uphill climb out of a dark pit to prove what one did or did not do or say.

I recently was involved in a case involving sketchy handwritten medical records. The chart contained little information, although the defendant physician claimed to have “charted by exception.” This means that whatever was not written down was, by definition, normal. In a perfect world, that would be wonderful, but in a busy office or ER, that implies that every patient was asked about a history of brucellosis and every thyroid gland was examined, regardless of the presenting complaint. This is simply not the way the world works.

During the course of the case, the defendant physician switched to an EMR. For the next 17 months, every entry in the plaintiff’s chart, amounting to approximately 50+ lines of text for visits that occurred at least monthly, was word-for-word identical to the original note, with less than a dozen words changed during the entire period of followup

The appearance of the electronic chart made this reviewer wonder how much of a history and how much of an exam was actually done. Was the patient really identical on every presentation? If so, why was he continuing to see the physician? Was this lack of diligence? Laziness? Chart padding? Whatever, it did not help the defense.

EMRs and template charts, even when used diligently, provide the reader with none of the “flavor” of a patient encounter. There are usually lots of boxes to check “yes” or “no” and even room for comment. There is also an opportunity to check things that one would normally do during a patient encounter, but which one might have skipped or forgotten on a specific encounter, e.g., over-documentation of negative findings. This makes it easy to make a chart look more complete than it might otherwise be. Most EMR programs have background definitions for “negative,” the classic example being the statement “cranial nerves II-XII intact.” I can’t recall ever in my career examining cranial nerve IX or XI.

With an EMR or template chart, rarely are there handwritten notes that indicate the physician and patient interacted in real time. Mistakes made on a prior visit can be perpetuated in the record, such as misdating the patient’s last tetanus shot or overlooking a crucial medication that might result in a drug interaction. Such charts appear to carry more weight than they deserve, for the phrase “garbage in, garbage out” applies. And such a chart is usually longer than necessary, full or irrelevant boilerplate, and dull.

When I look at a medical record, I’m looking for a caring physician trying to do the best he or she can for a patient. Most of the time that is reflected in handwritten notes (no matter how difficult to read) that indicate an honest interpersonal communication between physician and patient.

Sure things can get missed in both records, and there are real advantages to an EMR if one can assure that “garbage” does not go into the record, and all the “good stuff” does. On the other hand, while an EMR can flag abnormal results and remind a physician of screenings due for a patient, a downside is that failure to acknowledge or follow up on those results or reminders poses a serious risk. It’s sort of like landing a plane on autopilot in the fog. Sure it can work, but only if the computers on the plane and ground both operate to perfection. A programming error can result in disaster. Remember Korean Airlines Flight 007?

Perhaps the best approach is the record that includes background data, stable information, and chronic care templates (diabetes and CHF management being good examples), but with a personal note from a caring physician indicating a real face-to-face encounter on each patient visit.

Bottom line:
Don’t expect an EMR by itself to help or hinder a defendant physician. It can go both ways.

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