Are EMR Templates Really That Bad?

Recently, I read an interesting blog item by healthcare veteran Bobby Gladd, kicking around the notion of whether structured EMR data is killing medical practice. In the item, Gladd makes as good of a case as I’ve seen that while open text has its place, the lack of same is NOT single-handedly killing medicine.

In the blog item, Gladd ribs critics of template-driven medicine such as Margalit Gur-Arie, who has called structured data “the one foundational problem plaguing current EHR designs.” Gur-Arie argues that templated data controls clinical interviews, a phenomenon she calls “Bingo Medicine”:

“When your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say.”

Gladd does concede that templates for Meaningful Use can be “simply stupid,” for example in the case of the MU Core 9 measure of smoking status. But do free-written EMR entries support the care process better?  Maybe we do actually need “open-ended analytical narrative in the progress note, replete with evocative, dx-illuminating metaphors and analogies and elegant turns of phrase in lieu of blunt instrument categorical and ordinal ‘structured data,'” Gladd notes wryly.

Ultimately, perhaps critics of templates have gone overboard, the blog contends. Gladd suggests that Gur-Arie’s “bingo medicine” argument is more sound than substance: “I have to be a bit skeptical that (it) is anything more than a motivated-reasoning assertion of opinion lacking evidentiary underpinning comprised of adequate psychometrically valid studies of physicians’ cognitive processes while at work, perhaps using docs on paper charts as the differential ‘control’ group.”

As Gladd sees things, the real issue with templates isn’t their existence, as such. For one thing, as readers are likely to know, EMRs almost always come with free-text narrative options from many different points in the workflow. So it’s not that there’s no opportunity for clinicians to write detailed prose about their patient encounters.

Also, the issue isn’t necessarily that doctors are having templates forced upon them, either. As Gladd rightfully points out, at least the Meaningful Use-related data gathering requirements have been extensively vetted by the public, with each stage generating thousands of recommendations from physicians. And both CMS and ONC incorporated as much as possible from that flood of commentary.

Ultimately, the problem isn’t that physicians are being asked to adhere to digital documentation styles at times, Gladd contends. The true problem is the “productivity treadmill” requirements that push doctors to see 25-30 patients a day. “If the typical physician only had to see an average of one patient per hour…adequate documentation would be way less onerous,” Gladd concludes.

And there you have it. Overwork is the bane of any profession requiring brain work, and turning back to all narrative-style documentation does little to remedy the problem. (In fact, it could make things worse — for if doctors don’t have time to use templates, how good are their long-form notes going to be?)

Maybe templates have some downsides. In fact, if someone tried to get me to practice blogging with word templates I’d probably object. But it’s worth bearing in mind that template medicine may be a symptom rather than a cause.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

2 Comments

  • Corporations build competitive advantage by putting in place best practices.

    They can either use their best practices or those developed by others. Easy to guess which approach gives the higher competitive advantage.

    In healthcare, much of the protocol is imposed by legislation and this has greatly reduced productivity/increased costs.

    From an outcomes data analysis perspective, open text is very difficult to work with so a mix of structured data/unstructured data is the way to go.

    Data should not control clinical interviews – put a focus on the patient, collect what is needed to treat, then augment that data with mandated data.

    I don’t agree with “.. the issue isn’t necessarily that doctors are having templates forced upon them”.

    Typically they are having templates forced on them.

    Many of the EMRs don’t allow a hospital/clinic to ‘configure’ their EMR, they have to have it customized (read cumbersome, expensive).

    There is an entire community of practitioners working in Business Process Management/Adaptive Case Management who have evolved truly efficient ways and means for building and using “best practices” across multiple industry areas.

    You can check out a small subset of published material at http://www.kwkeirstead.wordpress.com and http://www.bpm.com.

  • Anne, all valid points. However, there are some systems in behavioral health that has bridged this quite neatly and provides minimal text systems that take a fraction of the time notes usually take and are MU comprehensive.

    When you understand the clinical flow so well that a shrub based system facilitates a point and click interactive/intuitive note system, is when the promise of EMR starts to be realized.

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