A PIECE OF MY MIND

John Lennons Elbow

HE ELECTRONIC MEDICAL RECORD (EMR) HAS TRANSformed the nature and purpose of hospital progress notes. While copy-and-paste has played a dominant role in this transformation, other less conspicuous elements have also contributed. These elements are characterized by George Harrisons Long, Long, Long. Student/ resident EMR notes are long. The time required to write them is long. Most important, the time span between note initiation and note signature is long. Note time span is a new phenomenon in the EMR era. It manipulates time and transforms the traditional linear timeline of medical storytelling into a nonlinear one. In the cinematic and literary arts, time manipulation and nonlinear narratives serve to heighten dramatic impact. In EMR notes, they heighten confusion. The impact of EMR notes was presaged almost five decades ago by another Beatle, John Lennon or, more specifically, his elbow. More on that later. This essay explores long notes and long note time span in the EMR era.

ough, and unreadable. Unreadability is a problem only if readability is a goal. But these notes are not constructed to be read. They are constructed to warehouse data. All the key information is contained within but as hard to find as a radial pulse beneath multiple color-coded wristbands. Residents and students expend a great deal of time and energy constructing EMR progress notes. Indeed, residents spend more time each day writing notes than they do seeing patients.1 A residents daily progress is measured by her daily progress notes. They are her daily measure, her sed rate. When asked by a fellow resident, Hows your day going? the response is likely to be Great, only two more notes to write. Signing the last note of the day signals the end of the workday.
Strange Interlude: Note Time Span

Long Days Journey Into Note

When notes were written with pen and paper, writers cramp kept entries succinct, eg, Chest radiograph shows apical cavitary infiltrate; likely consumption or 14 grain morphine q4h. In EMR, my notes remain short because hunt-and-peck keyboarding encourages brevity. For students and residents, one would think their familiarity with 140-character NNT (number needed to tweet) would yield short notes as well. Not so. Their fingers fly across the keyboard at more than 100 words per minute (land sakes!). The speed and stamina of these young whippersnappers transcend physical limitations to note length. Furthermore, young authors are hoarders. Their notes retain everything that has transpired during the hospitalization. The initial physical examination appears daily. Every CT and MRI done during the current hospitalization, if not the past 2 years, is recorded every day. The echo of the echo never fades. During a recent 2-week stint as inpatient teaching attending, I read every EMR note on every patient written by everybody(residents,interns,students,nurses,therapists,socialworkers, dieticians). That this endeavor was time-consuming was not surprising. That it was unrewarding was. The length of the notes served to obscure any key facts or insights. I once asked an intern why his successively longer daily progress notes retained old or irrelevant test results. His response was revealing: This way, my final progress note is also the discharge summary. This Twelve Days of Christmas approachbuilding a final supernote by successive daily additionyields a discharge summary that is long, thor2012 American Medical Association. All rights reserved.

EMR automatically marks every note with a time of initiation (usually early morning) and time of completion (usually mid-afternoon), thus documenting note time span. EMR note time span can be quite long because, in contrast to paper notes, EMR resident/student notes are not constructed in a single sitting. Rather, they are built sequentially throughout the day. With long time span notes, data are entered at multiple time points, leading to muddled narratives. EMR note construction is a five-step process, the first three of which are completed before the patient is seen: (1) copyand-paste yesterdays note (the computer places a time/ date stamp), (2) import todays vital signs and lab results, (3) keep old/irrelevant CT/MRI reports and consultants recommendations. Steps 4 and 5 are performed later in the day after the patient has been seen: (4) update a few items (this step is optional), (5) sign the note. At step 5, EMR places a second time-stamp. The time span between the initial timestamp and the signature time-stamp may be measured in hours for resident notes and days for student notes because students frequently delay signing their notes until completion of team rounds the next day. I maintain an ongoing internal soliloquy about this particular student behavior. My optimistic voice contends that students read about their patients diagnoses that first night in order to write a more thoughtful assessment the following day. My realistic voice insists that students delay note completion until they gauge the prevailing diagnostic sentiments of the attending physician and resident. Whatever the reason, a time span of 24 to 30 hours between note initiation and note signature is not unusual in student notes.
A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor. JAMA, August 1, 2012Vol 308, No. 5 463

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A PIECE OF MY MIND

A lot can happen to patients during a 30-hour time span. They can be admitted, treated, and discharged. They can be pre-opped, opped, and post-opped. The cardiac rhythm might change from normal sinus to ventricular tachycardia followed by cardioversion back to sinus again, with an attendant round trip to intensive care. Pre-EMR progress notes covered a 24-hour period as look-back summaries of the preceding 24 hours, written at a single point in time after the fact. From that vantage point, it was possible to order and prioritize events in the patients course. By contrast, EMR notes are built sequentially at multiple points in real time. Regarding a cardioverted patient, a pre-EMR note would begin, Mr ONeill felt well until 10 AM at which time he experienced palpitations and lightheadedness. An EMR note would begin, Mr ONeill feels well and has no complaints. Not until later in the note would the reader be informed that Mr ONeill had almost died. One would think that real-time narratives, as in televisions 24, would be capable of accurately reflecting patient fluctuations (eg, 0900 bibasilar crackles heard, 0915 IV Lasix given, 1300 lungs clear). But EMR notes are not realtime notes in a linear sense. Some portions of these notes are written before, some during, and some after the events they describe. The resulting timeline and clarity are more akin to Lost. Furthermore, a daily 30-hour time span note stretches and distorts time. Time spills over from one days note to the next. At the end of the day, there is no end of the day. And, owing to sloppy-and-paste,2 it may not be clear which 30-hour period is being described. I happen to have a lawyer acquaintance who sees great potential for litigious mischief in these long time span notes, particularly with regard to what one knew and when one knew it. (Now, Doctor, when exactly during the time you began your note at 7 AM and signed it at 2 PM did Mrs Rittenhouse fall? Was it before or after the examination documented in your note?) EMR places notes in chronological order of note initiation, giving rise to some interesting time paradoxes as demonstrated by the following example: A student begins his

note at 8 PM Monday and leaves it unsigned. The attending makes rounds with the team Tuesday morning and writes and signs her note that same morning. The student amends the assessment in his Monday note to reflect the attendings thoughts, then signs his note. The students note is displayed before the attendings note making it appear that the attending borrowed heavily from the students assessment rather than vice versa. I once fell through this particular wormhole and, based on the order of note initiation, criticized a student for copy-and-pasting an interns note. The student was able to exonerate himself with a bravura demonstration of signature times. It was the intern who was in fact the copy-and-paste perp.
Conclusions

The long and winding road of EMR progress note construction results in notes that are read by few and appreciated by fewer. This state of affairs brings us back to John Lennons elbow. During Beatles concerts, crowd screaming became such that no one could hear the music. While performing Im Down before 50 000 screamers at Shea Stadium, Lennon figured what the hell and proceeded to play the organ with his elbow. The result was almost certainly awful, but since nobody could hear, nobody seemed to mind. EMR progress notes are like music from John Lennons elbow. They are created by individuals with great talent, the results are awful, and nobody seems to mind.
Robert E. Hirschtick, MD
Author Affiliation: Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois (rober@northwestern.edu). Additional Contributions: I am indebted to David Neely, MD, for his helpful suggestions regarding this essay. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

1. Oxentenko AS, West CP, Popkave C, Weinberger SE, Kolars JC. Time spent on clinical documentation: a survey of internal medicine residents and program directors. Arch Intern Med. 2010;170(4):377-380. 2. Hirschtick RE. Sloppy-and-paste. http://www.webmm.ahrq.gov/case.aspx ?caseID=274.

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