Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem

By  |  September 3, 2012 |  49 

A colleague recently sent me a remarkable video – of Professor Lawrence Weed giving Medical Grand Rounds at Emory University in 1971. It’s fun to watch for many reasons: the packed audience composed mostly of white men in white jackets and narrow ties, the grainy black and white images a nostalgic reminder of Life Before High Def.

But the real treat is seeing Weed, then 47 years old, angular and frenetic, a man on a mission. He begins his talk by rifling through a typical medical chart, thick as a phone book. It is filled with garbage, he says disdainfully; “source oriented” rather than “problem oriented.” Weed was promoting his new vision for the medical record – one organized around patients’ clinical problems.

In 1964, in an article in the Irish Journal of Medical Sciences (reprised, rather more famously, in the New England Journal in 1968), Weed described his new model for patient care records, known as the SOAP note (“Subjective, Objective, Assessment, and Plan”). The idea was to begin with the patient’s history, then to present the objective data (physical examination, and results of labs, radiographs, and other studies), and finally to describe an assessment and plan for each of the patient’s problems. SOAP notes were designed to populate what Weed called the POMR: problem-oriented medical record.

This was revolutionary stuff at the time, and Weed was ready for pushback from doctors who argued that their random jottings were sacred totems of the “art of medicine.” At 51:30 in the video, Weed addresses these objections:

Art… is not a scribble in the middle of the night…. We debase the word art itself when we call what we’ve been doing art… As Stravinsky says, ‘art is nothing more than placing limits and working against them rigorously’ …and if we refuse to place them… you do not have art, you have chaos, and, to a large extent that’s what we’ve had.  

I like Weed’s problem-oriented format – so much so that one of the reasons I’m pleased when my patients leave the ICU (other than the fact that this usually means that they’re getting better) is that my trainees’ oral presentations morph from being organ-system based (“Neuro: sedated, moving all fours, head CT negative for bleed; Cardiac: MAP 75 on 2 mics of Levophed, heart rate 85, lungs clear, 2 over 6 systolic murmur at apex, good systolic function on echo….”) to problem-based (“Problem 1: dyspnea. Patient remains short of breath, O2 sat 92% on 5 liters, lungs clear on exam and chest x-ray negative. Plan is for chest CT to rule out PE…”). When I hear an organ-based presentation, I find myself struggling to translate it into a problem framework, like someone who isn’t quite fluent in a foreign language trying to make sense of a song in that language.

Whatever the method used to divide patients up into manageable chunks, there is always a tension between a reductionist view of a patient’s problems (or organs) and a big-picture view. Just as we are, biochemically, simply the sum of our cells, even atheists know that humans are far more than that. So too are patients more than the sum of their problems.

Note that I’m not being touchy-feely and holistic here, decrying the dehumanizing aspects of modern healthcare. No, I’m saying that even if you are a coot who doesn’t give a damn about what the patient is feeling, even if you gloss over the social history in a mad dash to the liver function tests, even if you think that “patient-centered care” is mostly an empty slogan, even if you’re the kind of doctor who simply wants to figure out your patient’s problems and deal with them effectively, you must balance the simplicity and practicality of a systematic approach with the need to see patients as more than the sum of their problems.

With paper notes, this tension usually managed to work itself out. Even as we embraced Weed’s problem-oriented approach, there was something about the act of writing things down that made you realize that there was a person attached to the problems, and that each patient needed an über-assessment – a paragraph or two summing up his or her issues. The reason for this was not so much to honor the patient’s humanity (although that’s nice too) as it was to offer a crucial synthesis of what was otherwise a jumble of facts and impressions.

At UCSF Medical Center, we went live with our version of the Epic electronic medical record three months ago. It beats pen and paper, and it beats the EMR system that we traded out (at a cost of a hundred million dollars or so) by a long shot. The implementation went well overall, notwithstanding a few snafus (several thousand missing billing charges, a few patients temporarily unaccounted for, that kind of thing). I’m certain that these glitches can and will be ironed out.

But I’m less confident that we can fix what Epic is doing to our notes, and our brains.

The system, you see, places the problem list at the core of the patient’s clinical world – in a way that goes well beyond what Larry Weed imagined. One really doesn’t “write a note” anymore; rather one charts on each of the patient’s problems, one by one. At the end of a session, the computer magically weaves these fragments into what outwardly appears to be the patient’s progress note. But it’s not really a note, it’s a series of problems (each accompanied by a brief assessment and plan) held together with electronic Steri-Strips. In other words, it takes Weed’s vision of the POMR and hypertrophies it. As with muscle, while some hypertrophy can improve function and be attractive, there comes a point when more hypertrophy becomes constrictive, dysfunctional, even grotesque.

Why did Epic and our UCSF IT gurus structure things this way? The primary virtue is that this charting-by-problem approach allows the patient to be followed longitudinally, since one can track problems such as “hypertension” or “ovarian cancer” over years, seeing how they have been managed and observing the response to therapy. It isn’t a bad conceit, and it probably makes tons of sense when described in a fishbone diagram on an informatics seminar whiteboard.

But the effect I witnessed on patient care and education was less positive. When I was on clinical service in July and read the notes written by our interns and residents, I often had no idea whether the patient was getting better or worse, whether our plan was or was not working, whether we need to rethink our whole approach or stay the course.

In other words, I couldn’t figure out what was going on with the patient.

If Epic was the only thing promoting this kind of reductionist approach, it might be survivable. But it’s not. In the face of duty-hours limits, our trainees are increasingly programmed to operate in a “just the facts, ma’am” mode, to approach patients as a series of problems to be addressed expeditiously and algorithmically. This “if X, then Y” mode of thinking isn’t wrong, per se, but – particularly in the hospital – when unaccompanied by an effort to paint a coherent overall picture, the notes (and accompanying presentations) can become data without information, empty e-calories.

(Note that this problem comes on top of the copy-and-paste phenomenon so cleverly skewered by Hirschtick a few years back in JAMA. While copy-and-paste must be addressed, I’m less worried about it than I am about the impact of the EMR on clinical synthesis and reasoning.)

Larry Weed was acutely aware of another objection to his problem-oriented approach: the concern that each problem would be viewed in a vacuum. In his 1968 article, he wrote:

Fragmentation of single diagnostic entities resulting from listing separately single related findings is not a legitimate complaint against a complete list of problems. If a complete analysis is done on each finding, integration of related ones is an automatic byproduct. Failure to integrate findings into a valid single entity can almost always be traced to incomplete understanding of all the implications of one or all of them.

In the old days, failure to connect the dots between problems 1, 3, and 6 may well have been due to cognitive gaps. But the modern IT system can prevent even smart physicians from performing this essential act of synthesis. The patient with cough, sinus problems, and kidney failure cannot be thought of as the sum of the differential diagnosis of each of these problems. Instead, as Occam insisted, these problems must be placed in a Venn diagram, accompanied by strenuous attempts to figure out what lives at the intersection. This is damn hard to do when one is electronically charting each problem independently. Monkeys and typewriters come to mind.

Over the past few years, Epic has “won the game” in the competition among IT vendors trying to sell to large teaching hospitals. This is fine – it is a robust system and an impressive company. But something needs to be done to preserve the essential act of clinical synthesis, and soon.

What would I do? I’d build into each Epic note a mandatory field, and call it “Über Assessment” or “The Big Picture.” Mousing over a little i icon would reveal the field’s intended purpose:

In this field, please tell the many people who are coming to see your patient – nurses, nutritionists, social workers, consultants, your attending – what the hell is going on. What are the major issues you’re trying to address and the questions you’re struggling to answer? Describe the patient’s trajectory – is he or she getting better or worse? If worse (or not better), what are you doing to figure things out, and when might you rethink the diagnosis or your therapeutic approach and try something new? Please do not use this space to restate the narrow, one-problem-at-a-time-oriented approach you have so competently articulated in other parts of this record. We know that the patient has hypokalemia and that your plan is to replace the potassium. Use this section to be more synthetic, more novelistic, more imaginative, more expansive. Tell a story.

All in all, I am pleased that UCSF went with the Epic system and I remain a fan of electronic health records. And Larry Weed was right: we must have a structure to record what is happening to our patients, and his problem-oriented approach remains the most appealing one. (Ultimately, one wonders whether natural language processing will make such a structure less important, in the same way that I no longer pay much attention to filing documents on my Mac now that its search function is so powerful.)

But the time is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive forcing functions, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. Let’s show these computers who’s boss, and put the “A” back in SOAP.


  1. Chris Johnson September 3, 2012 at 2:24 pm - Reply

    Nice post, Bob. I have a few thoughts about it.

    As an ICU doc, I’m actually not a big fan of the problem-oriented approach to clinical notes in the ICU. I think it works much better to go by systems: ABCD — Airway, Breathing, Cardiovascular, Da brain, etc. You can usefully weave together a problem list in the assessment part of the note, though.

    We have Epic, too. What I do to ameliorate the issue you describe is that I never, ever use smart text. I just type the note out as if I were writing it with a pen — I don’t even import the lab values because I type them, too. It does take more time but I think it’s time well spent. I think smart text can kill people. Importing gobs of undigested lab results and such satisfies the billing coders but, as you point out, makes it very difficult for somebody reading the chart to figure out what is going on with the patient — better? worse? no change? What?

    • Paul D Simmons September 4, 2012 at 1:18 am - Reply

      That is brilliant, Dr. Johnson! Our system just got Epic and I am struggling to figure out a way to preserve my clinical reasoning and (what I think was) quality documentation in a post-Epic world. If you have time as an ICU doc to do it, I probably have time to type out my notes without “smart” text too. I’m going to try it! Thanks!

  2. bev M.D. September 3, 2012 at 3:40 pm - Reply

    Pathologists encounter the same problem in pathology reports, where the free text comment used to be the place where we explained and synthesized the diagnosis, or expressed our degree of certainty, or raised the possibility of other diagnoses. Somewhere in the vast EMR world there must remain room for free text, or indeed doctors as well as patients can be reduced to algorithms. Robots, anyone?

  3. Brian Clay September 3, 2012 at 5:17 pm - Reply

    We have certainly had our share of impenetrable and overwrought note entries into Epic as well (and we don’t use much of the problem-based charting approach at our institution).

    I can see how the problem-based charting approach would naturally work against the goal of integrating multiple problems on a patient. Added to this is the variance in style and approach regarding the definition of a problem itself: at admission, is “volume depletion” a problem? Is “sepsis” a problem if we already know it is due to a urinary tract infection? One can easily envision the Problem List becoming a repository for all of the requested medical terms that our clinical documentation improvement teams recommend we add to the record.

    At the APDIM national meeting this year, the folks from the University of Pittsburgh held a fantastic breakout session where the topic of discussion was the quality and content of progress notes. Their examples were from an electronic medical record, and were passed around to 40 or so faculty in the room. What struck me was the utter lack of consensus about many of the core questions regarding progress notes: should the medication list be included? Should it be problem-based or system-based? (Not even agreement on this last one.)

    One point that was seen very favorably in this breakout session was the idea you describe — a dedicated field for the brief summary of the hospital course thus far. (Not, as is so often seen in the EMR, the “build-a-discharge-summary-as-you-go approach to progress notes.) An evolving “summary sentence” at the top of the progress note can be very helpful to guide the reader as to what is going on with the patient.

    We will be embarking on attempting to build this prompt into our progress note templates, although having been live in the inpatient setting for 18 months now, I suspect that habits will be that much harder to break.

    I look forward to hearing what others have to say on the topic.

  4. AD September 3, 2012 at 6:57 pm - Reply

    This is probably the most lucid exposition of the shortcomings of the EMR available. Congratulations.
    While the EMR depicted in this post is Epic, in defense of Epic I would like to state that it is the best of the many available.
    Unfortunately there is little impetus to audit the quality and accuracy of notes in electronic records. There is no financial gain from such tasks. Rather, the audit functions are geared towards the billing component as organizations attempt to game insurers while avoiding fraud and abuse.
    Documentation specialists and audit consultants who now make handsome rewards are little interested in the concerns you voice.
    Templates and drop down menus only enhance often inaccuracies from earlier notes or clinical examinations never conducted but recorded by a click on the enter button by the in attentive user. These inaccuracies can become patient safety problems.
    Dr. Faith Fitzgerald vividly described the electronic diagnosis of Ehlers-Danlos syndrome and it’s perpetuation because of fear by subsequent users to challenge an inaccuracy http://annals.org/data/Journals/AIM/22170/0000605-201203060-00017.pdf.
    The EMR which yet has great potential must have safeguards placed on its use to prevent it from becoming a tool for harm and scoundrels.

  5. Geff McCarthy September 3, 2012 at 7:32 pm - Reply

    Bob, as usual, you have penetrated to the heart of the issue…maybe… All above reasoning and comments indicate that the note is intended to communicate to subsequent care-givers, and of course, subsequent lawyers. Is it?
    Shouldn’t we be wailing and gnashing teeth over the many, self-inflicted, arbitrary, physican-centered communication nodes, of which the chart note is most obvious.
    I would recommend for your followers a review of Paul Uhlig and Jeff Brown’s “Collaborative Rounds” for which they received a major PS prize.
    Briefly: all decision makers, including family, MUST be present for the bedside conference. Yesterday’s goals are debriefed, today’s goals set, and written in plain view on the white board in the room.
    Note the similarity to airline briefings, football huddles, quality circles. EVERYbody who has an interest contributes, and the patient…well he/she basks in the deserved attention.
    Make no mistake, this model is NOT a case conference. It is decision making in real time, for the next relevant period, typically a day. Note also how SA – “Situational Awareness” is maximized for all. In medicine SA is dismal, because SA is established by the mission plan briefing…absent in medicine.
    The unintended consequence of Collaborative Rounds is…far fewer calls from concerned family. After all, they were there, and contributed!
    Later, a scribe can write the legalisms (orders) and SOAP note, or better yet, continuous graph, for lesser interested parties. Everybody has already heard and scribbled down the decisions ( orders.) Have you tried this at UCSF?

  6. Robert beltran September 3, 2012 at 7:36 pm - Reply

    As a health plan medical director in caring out my oversight functions, especially in the quality management area, the electronic medical record produces ream of disconnected clinical visits by multiple health care providers.
    I strongly agree that greater reliance and more importance be given to”clinical synthesis”
    Clinical factoids must be aggregated into clinical data that leads to relevant clinical information resulting in a clinical perfumer that results in better health.

  7. Noorullah Akhtar September 3, 2012 at 10:44 pm - Reply

    EMRs or not, as long as we require a note to meet three disparate requirements – a record/communication of patient’s status and caregivers’ decision-making process, justification for billing, and appropriate verbiage and content to fend off lawyers – there can ever be a consensus on how to generate the perfect note. Not to mention, that the ideal note will need to be succinct and be generated efficiently (quickly) enough so as not to consume hours in an already busy day!

  8. Paul D Simmons September 4, 2012 at 1:21 am - Reply

    And where are we supposed to put our differential diagnosis?! Possibly the most valuable segment of our clinical reasoning, in my opinion–and definitely the most valuable section for educating students and residents–has NO place that I have found in most EMRs.

  9. Menoalittle September 4, 2012 at 2:16 am - Reply


    It seems that you have your doubts but do not want to admit it after the $ millions spent and your politic.

    You are finally beginning to recognize the adverse impact the device has on your cognition, yet you trivialize it and the adverse events from the device.

    The EHR is destroying the creativity of doctors needed for integration and diagnosis by eliminating the interaction of the hand, the eyes and the mind.

    I do not give a hoot about billing, but I do care about the “that kind of thing” adverse event. Is that a euphemism for death causing adversity?

    “The implementation went well overall, notwithstanding a few snafus (several thousand missing billing charges, a few patients temporarily unaccounted for, that kind of thing).”

    What kind of thing exactly? Like this?:


    In the Final Rule of Meaningful Use recently released by CMS, it was determined that Epic supplied the script for its customers to send to ONC to influence and taint the ONC and CMS determination of meaningful use, especially about search functions.

    Bob, does your esteemed new Epic EHR have a search function, or are you scrolling and scanning to find historical information?

    Best regards,


  10. Ross Koppel September 4, 2012 at 2:43 am - Reply

    I agree with the previous writers. Bob gets right to the tragedy of fragmentation and isolation so often facilitated by HIT. If medicine could be mechanically summed up as the collection of organs, lab reports, vitals, etc, we would not need physicians. Sure, there are some simple cases, but that’s not what real medical training is for. We could (and perhaps should) use technicians for that. For the rest, it’s the complexity, stupid.

    If HIT enhances a view of the patient as separate elements lumped on a table, then it makes it all to easy to miss the complexity and the clues to what’s often going on. In real life, doctors swim in a sea of ambiguity, unknowns (by them) and unknowns (as yet by medicine in general). Anything that further fragments the needed information, or suggests certainty when none is there, is dangerous…even if that information is instant and legible.

    • Catherine Hinz October 11, 2012 at 12:11 am - Reply

      Here, here to both Dr. Wachter and Dr. Koppel. From the operations world, and working daily to improve patient safety issues at a health system, we rely on voices like yours to continue to advocate for safer and “smarter” technologies. In my and Dr. Koppel’s case, even trying to have a hand at better design of them. Thank you!

  11. S Silverstein September 4, 2012 at 3:25 am - Reply

    Welcome to the world of unconsented human subjects research.

  12. S Silverstein September 4, 2012 at 3:42 am - Reply

    The issues you relate are quite pertinent. They revolve around the limits placed on expression and even thinking of the so-called “EHR” (or “EMR”). In fact, those terms are, I believe, an anachronism. These are no longer innocuous filing systems. What is being installed at UCSF and elsewhere are, in reality, enterprise clinical resource management and workflow control systems.

    I use this example to illustrate the chains imposed by current technology: imagine if attorneys (let’s say, someone defending you) had to compose their legal briefs on a template-driven, expressivity-limiting, checklist-centric ‘Electronic Legal Records’ system. How would the dockets read?

    Some wisdom older than Weed’s:

    “Computer engineering experts per se have virtually no idea of the real problems of medical or even hospital practice, and furthermore have consistently underestimated the complexity of the problems…in no cases can [building appropriate clinical information systems] be done, simply because they have not been defined with the physician as the continuing major contributor and user of the information”

    Donald A. B. Lindberg: Computer Failures and Successes, Southern Medical Bulletin 1969;57:18-21.

    Little seems to have changed since 1969. The health IT industry seems incurably autocratic if not autistic.

    It purports to promote evidence-based medicine, but refuses to adopt for itself evidence-based computing (see http://hcrenewal.blogspot.com/2012/08/the-scientific-justification-for.html ).

    My question is: how can physicians change this? Health IT improvements involving major informational capture, analysis and presentation enhancements (let alone anything else) are not inexpensive, and will cause damage to the bottom line in a highly competitive marketplace.

  13. Robert Beltran September 4, 2012 at 4:48 am - Reply

    The perfect storm in health care is upon us- increase Diversity,, Complexity and Uncertainty. Medicine is a Art and a Science directed by mere mortals. The excessive over balance on EMR destroys the Art of Medicine, limits necessary creativity and innovation. The greatness of Steve Jobs was his instinct and intuition and is no different for greatness in Medicine by physicians.
    EMR maybe necessary evils, but let’s not give them greater importance than the genius of an
    experienced physician.
    Computers and clinical information systems are only as good as the humans who input the data.

  14. Stan Jackson, MD September 4, 2012 at 9:59 am - Reply

    Bob states: “But the time is now – before our trainees build habits that will be awfully hard to break – to recognize that electronic medical records do more than chronicle our patients’ histories, exams, and labs. They are also cognitive forcing functions, ever-so-subtly modifying our approach and language into something that can either improve our clinical care and teaching, or not. Let’s show these computers who’s boss, and put the “A” back in SOAP.”

    Show these computers who’s boss, Bob, is a statement that indicates your naivety.

    Did you, yourself, ever click in the admission orders from start to finish on a patient with lupus and sepsis?

    The experience of most about which I hear is embodied in the following report:


    “We went through the process of meetings where Epic showed health services the workflow they had created,” said Laura Easley, RN.  “Numerous times our health team told the Epic group there were many concerns. When we went live with the system, the problems we addressed were even more obvious. Health professionals are being told by non-health professionals how we should conduct our health practice. This cannot be.”

  15. Bob Wears September 4, 2012 at 10:06 am - Reply

    I’m not as big a fan of Weed as Bob is. I think the fragmentation we see in Epic is a direct result of the reductionism of Weed’s approach, and the considerable hubris that accompanied it.

    His statement that: “If a complete analysis is done on each finding, integration of related ones is an automatic byproduct” is the heart of the problem. That denies the emergent properties of the clinical narrative. If that it were true, we could understand an anthill simply by knowing each ant; we could learn a language by just analysing its sounds.

  16. silosearcher, md September 4, 2012 at 11:43 am - Reply

    The counterintuitivity of the functionality teamed with the hidden storage compartments for key medical information renders these medical devices not fit for purpose.

    Bob, do you know if these devices have been approved by the FDA? Is there an organized after market surveillance program?

    Perhaps you can help all of us by publishing a list of all of the adverse events, delays, neglect, misidentifications, cognitive errors and nursing complainst that have occurred over the past 3 months? I think that AHRQ has a taxonomy outline of HIT adversity that you could use to construct an educational list.

  17. Richard Schreiber September 4, 2012 at 1:29 pm - Reply

    It may sound simplistic, but the teaching/academic heirarchy that I was taught in residency applies to the format that I believe would work best for clinical notes. The medical student–I believe most everyone would agree–gathered the best data base for all but perhaps the details of the history and for the physical exam. The R1 (“intern”) gathered the best H and P (i.e., those specific parts). It was the job of the R2 or R3 on service to synthesize the information, not to repeat it (thus the “i” in Bob’s post). The best senior resident note was rather like the discussion section of a NEJM clinical-pathological conference, reiterating only those parts of the data that supported or refuted a given point in the differential diagnosis. The attending note could then usually be short and sweet, but very telling, such as what my program director used to write: “I agree with the data base, assessment, and plans, as discussed by Drs. X and Y, with these added points: . . . ”

    What we are forced to document and repeat is data; what we need is information. Let our notes be informative, reflective, and instructive, and we will regain the thoughtfulness that modern medicine should be. The difficult part is how we can make our electronic tools help, not hinder us.

  18. Pradba Gupta, MD September 4, 2012 at 3:11 pm - Reply

    Well, you know then but, what it is that worries me is never has the FDA gone over any of these. My golly gosh, how is that possible? Well, I could see then how doctors and nurses are frustated from vigilance needed to maintain patient safeties, when these devices potentiate errors by the smartest of doctors. My golly gosh, what is happening here?

  19. Christine Sinsky September 5, 2012 at 2:06 pm - Reply

    Great post Bob.

    Ambulatory records are equally in need of brevity and clarity. These notes are often 6 pages of mostly nonsensical boiler plate, formatted on a billing template, leaving the reader asking your question: “but what is going on with the patient?”

    After 10 years with our clinic’s EHR (McKesson HAC) and 9 years with our hospital EHR (Cerner), the most important issues I’ve encountered have been

    • The time costs of data acquisition: Remember the graphic on a clipboard at the foot of the bed? It was a concise and convenient source of information that has not been reproduced in our EHR. It is now a laborious process to unearth this same information. I/Os and daily weights have become lost data points.

    • The time costs of data input: One night on call I did a time trial on six of my admissions: it took an average of 73 seconds to record the admitting orders on paper vs 17 minutes to enter the same orders electronically. And in the electronic world I find myself at higher risk of forgetting the orders I meant to write, as the rigid sequence mandated by the EHR is not always the logical clinical sequence in my mind, and it requires parking orders in my mind until I finish marching through laborious tick boxes.

    • Diminished situational awareness. Nurses, doctors and others have a more myopic view of the patient, as it is harder to see trends and to see the big picture. Nurses may only know the meds and the orders that pertain to their shift for example.

    • Barriers to synthesis: I find it harder to synthesize the diverse sources of data for a patient when each data bit is tucked away in hard to reach electronic silos, often down long navigational pathways. Sometimes one has to scroll both vertically and horizontally (without freeze frames, so the column and row headings disappear while you scroll) creating a cognitive nightmare.

    EHRs will continue to be an important tool going forward; improved usability and a better alignment with clinical workflows are needed if we are to fullly realize their potential.

  20. S Silvertsein September 5, 2012 at 6:28 pm - Reply

    Re: “EHRs will continue to be an important tool going forward; improved usability and a better alignment with clinical workflows are needed if we are to fullly realize their potential.”

    You just described what could indisputably be called serious impediments to care. 73 seconds to 17 minutes? Loss of easily accessed data on I/O and daily weights? Diminished situational awareness?

    Perhaps it’s time clinicians stopped sugar coating their statements with PC niceties such as …”if we are to fullly realize their potential”, and were more forceful with a more apt “improved usability and a better alignment with clinical workflows are needed if we are to avoid patient endangerment.”

  21. Ron September 6, 2012 at 5:40 am - Reply

    One problem is that the EMR/EHR/HIT is devoting more & more screen space to billing and regulatory junk that is not relevant to patient care. Screen after screen is full of unanalyzed lab numbers and legal boilerplate. Buried somewhere in there may indeed be the senior or attending’s cogent synthesis, but it’s impossible to find while scrolling thru the dozen or so screens needed for 1 days ICU notes. Too much garbage in makes it hard to find the pearls.

  22. RSWatkins September 6, 2012 at 2:07 pm - Reply

    “EHRs will continue to be an important tool going forward”

    Based on what came before in the post, this is a perfect non sequitor.

    Doctors are starting to realize the emperor has no clothes, but they are still too much under the influence of group-think to say it.

  23. S Silverstein September 6, 2012 at 2:15 pm - Reply

    Re: “oo much garbage in makes it hard to find the pearls.”

    The term is “legible gibberish.”

    It is a result of severe inattention to information science and norms of good (i..e, mission-supportive) presentation of information on the part of the designers.

    Today’s clinical IT can largely be described as “mission hostile” and this needs to change, but the industry fails in its talent management practices to secure and/or facilitate people with the needed expertise to remedy these issues.

    That will only happen when they are motivated to do so, and motivation will not come with users being docile about these issues.

  24. Teresa Goodell,RN,PhD September 6, 2012 at 3:34 pm - Reply

    My experience with our build-out of Epic has been similar. There is no “story” to be found in the notes. I, too, avoid “smart phrases” partly because their lengthy and unlikely names are impossible to remember, and partly because I want what I write to be one place where another health care provider can actually read about the patient. My take on Epic is that it is effective as a regulatory compliance tool, but not as a communication tool. Its appeal (to IT and administration) is that it can be audited.

    Lisa Day published an insightful reflection on the contrast between nursing documentation in narrative and “check-box: form in American Journal of Critical Care in 2009: http://ajcc.aacnjournals.org/content/18/1/77.full Brief, and definitely worth reading.

    The problem is this: how do we change Epic? Your suggestion is, I assume, tongue-in-cheek, but maybe we should add a mandatory “synthesis” field that must be completed once daily by physicians and nurses alike. (And don’t get me started on the Epic “care plan” function…)

    Thanks for this post. Enough voices might change things.

  25. S Silverstein September 6, 2012 at 11:31 pm - Reply

    @Teresa Goodell,RN,PhD

    Thanks for the article.

    Re: “My take on Epic is that it is effective as a regulatory compliance tool, but not as a communication tool. Its appeal (to IT and administration) is that it can be audited.”

    Selfsame administration wants to have their cake and eat it, too. They want the audit trails about their staff hat show exactly what happened, when, and where, but they don’t want attorneys to have the same audit trails when there is a question of malpractice.

    Re: “My take on Epic is that it is effective as a regulatory compliance tool”

    As are other clinical IT systems that go under the anachronistic acronyms “EMR” or “EHR. In fact in 2012 what they really are, instead of innocuous filing cabinets as the defense-lowering acronyms suggest, is this: enterprise clinical resource and workflow control systems.

    Re: “maybe we should add a mandatory “synthesis” field that must be completed once daily by physicians and nurses alike”

    Yes, good idea. And free text should be the coin of the realm there.

    Re: “Enough voices might change things.”

    Enough LOUD and UNWAVERING voices on all the sellers. They get the fun and profit;
    patients are put at risk; doctors and other clinicians get the liability and headaches.

  26. JJ Janoyan September 7, 2012 at 12:19 pm - Reply

    All the commentary I believe misses one argument that I think is important. Originally it seems that the patient’s chart was developed ultimately to keep a record of what happened and to communicate between team members. Since CMS and other regulatory bodies have imposed their requirements for documentation, this tool is now trying to be many things it was not designed to do. To say it a different way, I think ultimately, there is one patient chart that is trying to serve what I believe is 3 basic functions. 1: The original intention as described above. 2: One for billing purposes. And finally 3: One for Risk management. Interestingly this is simply demonstrated when you review a patient that was admitted to the hospital for pneumonia from 30 years ago and then again today. If both were paper chart, you would likely ascertain that the chart from 1980’s was about a 1000X shorter and simpler to understand what happened. One personal fear is that at some point we will all simply be numbers. With ICD 10 on the horizon, I wonder what my number will be? Perhaps it will be “F23” by then?

  27. Larry Weed and Lincoln Weed September 10, 2012 at 4:47 am - Reply

    “If businesses were permitted to operate without accounting standards [for managing financial information], the entire economy would be crippled. That is the condition in which the $2.5 trillion U.S. health care system finds itself—crippled by lack of standards of care for managing clinical information. The system persists in a state of denial about the disorder that our own minds create, and that the missing standards of care would expose.”

    The above assertion comes from our recent book, Medicine in Denial (p. 1), http://www.createspace.com/3508751. (See the book’s table of contents, overview and introduction at http://www.thepermanentejournal.org/files/MedicineInDenial.pdf.) It is hard to imagine better evidence for our assertion than the situation described by Dr. Wachter’s post and the responses.

    Consider, for example, the Sep. 3 response from Brian Clay regarding two basic medical record elements: problem lists and progress notes. He observes the “variance in style and approach regarding the definition of a problem itself.” He goes on to deplore “the utter lack of consensus about many of the core questions regarding progress notes: should the medication list be included? Should it be problem-based or system-based?” Similarly, Dr. Wachter’s post describes inconsistent standards for presenting patient cases:

    “when my patients leave the ICU … my trainees’ oral presentations morph from being organ-system based … to problem-based … . When I hear an organ-based presentation, I find myself struggling to translate it into a problem framework, like someone who isn’t quite fluent in a foreign language trying to make sense of a song in that language.”

    Both Dr. Wachter and Dr. Clay refer to the “problem-based” approach to medical record keeping, but their discussions further illustrate lack of consensus on basic concepts. Like many others, Dr. Wachter equates SOAP notes with the “new model for patient care records,” known as the “problem-oriented medical record” (POMR). But SOAP notes are just one of four basic components of the POMR: (1) an initial database, including a “patient profile” of non-medical circumstances; (2) a complete problem list; (3) initial care plans for each problem, including goals determined with the patient, and (4) progress notes for each problem using the SOAP structure.

    Current electronic records incorporate only fragments of the POMR standard. Most EHRs include some form of problem list and SOAP notes, but many EHRs are not “problem-oriented” in that they do not link care plans, orders and progress notes with problems on the problem list.

    Amid such a Tower of Babel, no one should expect health IT adoption to produce major systemic improvements. For health IT to have systemic effects, it needs generally accepted standards of care for managing and communicating clinical information. Indeed, such standards are the missing foundation not only for health IT but for the health care system as a whole. That conclusion is hardly surprising. In complex social systems of any kind, simple rules to guide individual participants are foundational. That is the significance of generally accepted accounting standards in a market economy. See Medicine in Denial, pp. 121, 126-129.

    These realities have been evident for decades. But they remain absent from mainstream health policy discussions. As Medicine in Denial explains (p. 4):

    “current policy fails to comprehend the needed discipline in medical practice and thus fails to define precisely what is needed from health information technology. A dangerous paradox thus exists: the power of technology to access information without limits magnifies the very problem of information overload that the technology is expected to solve. Solving that problem demands [1] a meticulous, explicit, highly organized process of initial information processing, followed by [2] careful problem definition, planning, execution, feedback, and corrective action over time, all documented under strict medical accounting standards. When this rigor is enforced, a promising paradox occurs: clarity emerges from complexity.”

    The missing standards of care must inform the design of health IT, and their enforcement must govern use of health IT. The standards must cover two core areas of clinical functioning: (1) selection and analysis of patient data based on medical knowledge, and (2) using medical records to organize data generated by patient care over time in a clinically useful manner. These two areas are addressed, respectively, in parts IV and VI of our book, explaining (1) a “combinatorial” standard for matching patient data with medical knowledge and (2) the POMR standard for organizing patient data in medical records.

    These two areas of clinical functioning are the real subject matter of Dr. Wachter’s post. But he frames this subject in different terms. Referring to the physician’s “essential act of synthesis,” Dr. Wachter critiques the Epic EHR system on the ground that it blocks synthesis. He discusses synthesis in two different senses: (1) “clinical synthesis and reasoning,” for example, recognizing when different problems on the problem list are all manifestations of a single diagnostic entity; and (2) “uber assessment” of “the big picture,” for example, assessing whether the patient is getting better or worse and whether the care plan is or is not working. Dr. Wachter’s criticizes the Epic system for hindering both kinds of synthesis by the physician.

    Our difficulty with Dr. Wachter’s analysis is that he assumes the primary vehicle for clinical synthesis to be physician judgment. In reality, synthesis should begin before the exercise of judgment. That is, electronic tools should first be used to select patient-specific data points and then match those data with relevant medical knowledge. This initial information processing routinely yields clinical synthesis beyond what physician judgment achieves.

    But this initial, tool-driven synthesis is not enough in complex cases. There what patients need is a highly organized process: careful problem definition, planning, execution, feedback, and corrective action over time, with patient involvement every step of the way. When applied to all problems on the problem list, this process enables clinical synthesis to emerge in a systematic, organized and reproducible fashion. Effective synthesis is tool-driven and process-driven. The tools and the process minimize reliance on unstructured clinical judgment, with all of its cognitive vulnerabilities.

    This brings us back to Dr. Wachter’s call for an “uber assessment” of the “big picture.” His concept emphasizes unstructured clinical judgment. The goal is to resolve “a tension between a reductionist view of a patient’s problems (or organs) and a big picture view.” Thus, he would include in electronic records a mandatory free-text field, where the physician synthesizes the patient’s total condition into a “story,” where progress notes are “more synthetic, more novelistic, more imaginative, more expansive” than the problem-specific notes elsewhere in the record.

    Dr. Wachter’s concept of a big picture assessment is intended as a corrective to “electronically charting each problem independently.” But that practice is itself an egregious violation of the POMR standard of care. The POMR standard requires a complete problem list in large part because “proper analysis, planning and follow-up for each problem depends on awareness of the patient’s other problems, the potential interactions and unmet needs associated with each.” This awareness begins with a complete problem list. “The problem list is thus simultaneously reductionist and holistic” (Medicine in Denial, p. 156).

    The POMR standard contemplates a holistic assessment naturally emerging from careful assessment of each problem in light of the whole problem list. In contrast, Dr. Wachter sees value in a separate, aggregate assessment outside the context of any one problem.

    We have two concerns with a separate, aggregate assessment. First, it could easily degenerate to a diffuse, impressionistic narrative of the patient’s “story,” disconnected from careful assessment of identified problems and their interrelationships. Second, a truly holistic assessment depends on patient involvement. Only the patient has subjective awareness of feeling better or worse, and the patient is the source of symptomatic findings essential for a holistic assessment. Yet, the approach described by Dr. Wachter leaves it entirely up to the physician whether and how consider inputs from the patient.

    Our concern with patient involvement suggests that a separate, aggregate assessment should be a vehicle for synthesizing patient and practitioner perspectives. This can be accomplished most effectively if the assessment is focused on setting priorities. Thinking about priorities naturally requires the practitioner and patient to consult each other, naturally requires them to consider the patient’s total situation (the initial patient profile and the current problem list), naturally focuses them on options for action, and naturally avoids diffuse narrative discussion. EHR fields for a “big picture” assessment should be structured accordingly. Implemented in this way, Dr. Wachter’s concept could be a valuable component in any medical record.

    The larger point is that issues like these require organized standards setting and enforcement. In the domain of commerce, a comprehensive system exists for defining and enforcing financial accounting standards. Medicine remains in denial of the need for similar discipline.

  28. S Silverstein September 10, 2012 at 12:38 pm - Reply

    Re: Larry Weed and Lincoln Weed

    Fine theory, and perhaps a bit of argumentum verbosium, but in any case appears to be out of touch with commercial health IT reality in the entirely unregulated, unaccountable environment the industry has secured for itself.

    A prime example is the analysis of U. Sydney professor Dr. Jon Patrick at http://sydney.edu.au/engineering/it/~hitru/index.php?option=com_content&task=view&id=91&Itemid=146 , “A Study of an Enterprise Health information System.”

    That such a health IT system, lacking fundamental attention to good software engineering practices, human computer interaction, presentation of information, and other factors could was slated, unvetted prior to the report, for rollout across an entire state of Australia is evidence that real discipline is needed in the health IT industry.

    That discipline is essential if the technology is ever to help, rather than hinder, patient care (as opposed to payers), and do so without collateral damage in the form of injured and dead patients.

  29. Brian Clay September 10, 2012 at 6:13 pm - Reply

    I am here in Madison at the annual Epic User Group Meeting this week (as are several of Dr. Wachter’s colleagues from UCSF).

    I am struck by how many breakout sessions are dedicated to providing physicians more information on how to tackle these problems with the tools available. For instance, just from today’s roster:
    — Improving Your Progress Notes
    — Problem-Oriented Charting
    — Cleaning up Outpatient Problem Lists
    — A New Progress Note Format

    And there are another half-dozen physician documentation related sessions over the remainder of the week.

    This speaks to the fact that many of the EMR applications out there contain multiple methods for achieving the same goal (in this case, generating a progress note). As Larry Weed points out, without robust documentation standards overseen and enforced by the institution, there will certainly be variance in the style and content of physician documentation.

    In addition, he is correct in that EMR applications rarely contain seamless integration of physician, nursing, and therapist documentation, all sourced from a single comprehensive problem list for the patient.

    That said, I believe that such seamless integration is not present in these applications not because it cannot be programmed, but because there has not been demand for it. Recommendations to EMR vendors for application build are often based on the cultural expectatinons of those who recommend: physicians are used to writing notes in a certain style and format, and therefore they will evolve with that style and format as a starting point.

    To move to a fully problem-based charting workflow will require a cultural change of substantial degree. (I imagine that Bob knows more than most about what this requires, having been a leader in the patient safety movement over the last decade.)

    It is too simplistic to assert that “we can’t get there from here”; however, it is likewise too simplistic to say that problem-oriented charting — as we see it today in the EMR — is troublesome because it isn’t “real” problem-oriented charting.

    We have to get there from here, and the in-between can be messy.

  30. S Silverstein September 10, 2012 at 7:13 pm - Reply

    Re: “…he is correct in that EMR applications rarely contain seamless integration of physician, nursing, and therapist documentation, all sourced from a single comprehensive problem list for the patient. I believe that such seamless integration is not present in these applications not because it cannot be programmed, but because there has not been demand for it.”

    While perhaps not as precisely as stated, clinicians are if not demanding capabilities as described, are certainly complaining about the effects of its absence – as in, difficulty in forming a cohesive picture of a patient’s progress, or lack thereof. So are med mal attorneys, by the way, which perhaps looms more ominous for this industry.

    As I wrote at http://hcrenewal.blogspot.com/2012/09/from-what-i-can-tell-epic-was.html , it is stunning that even basic modern database functionality – he ability to search an open patient’s record for all notes that contain a string, or across a set of many records, for free-text strings or other values – appears to be largely missing from commercial offerings, so much so that the public comments for MU2 were seeded with vendir-driven comments to delay such an essential function.

    The industry is a backwaters of IT.

  31. Margaret Polaneczky, MD September 25, 2012 at 5:24 pm - Reply

    Great post, Bob. I’ve often thought that what we need in EPIC (Which I use in the ambulatory setting) is a good short summary assessment and plan not that lives on top of all the rest of the content in a progress note. The content below (ie layered below) the top note serves as supporting documentation needed for billing, medico-legal, etc, but is not necessary to see that data to take care of the patient in real time.

    If we need to see that documentation we can double click the note and open it up. I see it in much the same way we see a blog that is presented as a series of posts with brief summaries with the option to “read more”.

    Most of the thoughtful effort of the provider is spent in writing that top note. By separating it and placing it atop the data part of the note, the provider is given a mental nudge to step back as it were, synthesize and communicate.


  32. K Luman September 26, 2012 at 5:08 pm - Reply

    I agree that our electronic notes can be much worse than our old hand written ones. I agree that it could lead to less synthesis. I don’t see this as a problem inherent in EMR or one that can be fixed by putting in a new text box or space for another few sentences.

    I think we have gotten sloppy. Just type in the assessment in your note prior to the list of the problems, or use the assessment section after the first problem to describe what is going on, how the first 5 problems might be related (ARF, anemia, AMS could be TTP or multiple myeloma, etc.), what the differential dx is and what we are going to do to find out what is going on. I do see many horrible notes, but I am not sure I can blame the computer or the EMR. I think it is us; we can be lazy and sloppy. EMR might allow us to slide into laziness easier, but I think this is a human fault.

    We do need to put the A back in the SOAP note. I think it is our professional duty. I don’t think it requires a fix from Epic.

  33. […] Read Bob Wachter’s comments on keeping the “A” in SOAP […]

  34. b October 3, 2012 at 6:37 am - Reply

    Thank you for articulating the impact that an EMR’s construction can have on the clinical care our patients receive, and on the practice patterns of our physicians in training. As a resident in your program at UCSF, I see first-hand the problems you describe, and could not agree more with your (ahem) assessment. It’s not a new problem at all; but, our particularly restrictive implementation of Epic does appear to greatly exacerbate it.

    The root problem, of course, involves not only the way an EMR is constructed, but also the way in which its architects planned it and the way in which its users are told to use it. During the Go-Live of Epic at UCSF, my colleagues and I (the medicine housestaff) were explicitly told (in no uncertain terms) to never delete a SmartText, to never edit any auto-populated content, and to never document anything outside of the confines of the ICD9-constrained Problem List.

    Many of us asked right away, “Where do we write an assessment statement? Where do we write a summary statement? Where do we summarize the gist of a patient’s complicated hospital course?” The answer we received to all of these questions was: “You should never write these things; if people need that type of information, they should just read the rest of the chart themselves.” The idea that a chart should convey actual thought — thoughts that might transcend individual diagnoses, thoughts that might be of interest to other members of the healthcare team — had clearly never been considered.

    It is of interest that many of the housestaff began to predict the emergence of this exact problem even before the system went live; unfortunately, our thoughts were not solicited. For me, hearing these concerns shared by a member of our faculty (and by a division chief, no less) restores some hope for constructive change.

  35. Michael Turken, MPH October 12, 2012 at 5:15 am - Reply

    The SOAP note is a decades-old innovation in health communication technology, the H&P even older. Both are built on an even older technology, storytelling. Medical students are taught to dogmatically accept both as the only way to gather information from patients and communicate it to other providers, the only way to construct the medical story and arrive at an assessment and plan. And when one hears that 90% of diagnosis comes from the history, it’s hard to argue with the sense behind this: both the H&P and SOAP note are firmly established communication tools, and being able to share information accurately and consistently is crucial. But is this not simply a just-so justification for why we cherish and cling to this technology? Should we not assess how we are assessing?

    One hundred years ago, eye-witness testimony was probably the most effective way for identifying and prosecuting thieves. When the security camera was invented and the fallibility of eye-witness testimony proven, did we use the newly invented video cameras AFTER the crime and solely to prove that the eye-witness had been there? Of course not. We used the new technology in the way it was meant to be used – to identify the thief directly, alert the authorities and, if possible, prevent the crime. Digital health is giving us more “video cameras” than we can count, and yet we are still asking these cameras, of which the EHR is supposed to be our best and biggest, to focus on our “eye-witness,” the ancient SOAP and H&P.

    There is deep pain around even the best EHRs, and I often wonder if it’s because they’re all built on a very old legacy technology no longer suited to the understanding and practice of modern medicine. Could it be that the H&P, which was created in an era when doctors had boundless time, limited technology, and a nascent base of data and evidence, is no longer the best way to understand, diagnose, and record illness? Do we still believe that it is the best tool we have for promoting and supporting preventive care, which is, as we all know, the best kind of medicine?

  36. Raymond Simkus October 15, 2012 at 4:17 pm - Reply

    Excellent essay and gratifying replies from many people. Some of the difficulties that have been mentioned could be resolved if the design of the EMR or computer based patient record included a few things. The computer based record has one advantage over the paper record in that the information that is recorded can be manipulated, reorganized, filtered and sorted. It is also possible to provide links between different bits of data. Unfortunately there are very few EMRs that take full advantage of what could be done.

    In one reply there was a comment about ‘variance in style’. I have been at several meetings were physicians were adament about how they thought things should be organized. Some wanted everything in the Problem List others wanted to keep medications, surgical history and family history in separate sections of the EMR. The thing is that if these items were tagged properly then the lumpers and the splitters could both be accomodated.

    The fragmentation problem could be resolved if there were links between an entry in one part of the record and another part of the record. For instance if a prescription is written then an indication is selected from the Probelm List. If a referral is made or an investigation is ordered then again an entry from the problem list is linked. This bit of functionality has been left out of EMR requirements specifications and various EMR/EHR standards until recently but it is in some of the more recently revised versions of standards like the HL7 EHRS Functional Model or ISO 10781. Work is currently going on with the ISO 13940 System of concepts to support continuity of care that would help resolve some of the problems discussed here.

    Raymond Simkus, MD

  37. Curtis October 16, 2012 at 1:00 pm - Reply

    I remember as a boy of 6 or 7 in the early 1960’s visting the family PCP. He was the same MD who delivered me into this world and provided wonderful care for me up through my teenage years. Patient notes were simpler then. It was a 3 x 5 card whereby he would simply jot down and few words then place it back in the green metal box sitting on his desk top. Medical records have come a long way but have a long way to go. Many are simply not ready for prime time and as alluded to in earlier posts, are created by non-clinicians who have no idea of clinician work flows and the like.

  38. Isaac Gorbaty MD December 3, 2012 at 7:09 am - Reply

    I was trained for one week and worked on the EPIC EMR system for 5 months in 2007 during a brief employment at Kaiser Permanente. Previously, I had used the VA Unix based EMR as a voluntary Nephrology attending. In my second month at Kaiser all the new physicians were required to go to a meeting chaired by Regional Physician managers. There were many complaints regarding the EPIC system.The moderator explained that the EPIC system was expensive and was customized to Kaiser’s specific needs. When I asked the moderator why they had not made use of the VA software offered free of charge which had been debugged and was used at over 100 VA hospitals and clinics He drew a blank. In the last two years of solo practice I have used Care360 EHR, an inexpensive basic system.
    My observations are the following: The EPIC system is an expensive EMR system customized to transfer clerical functions to the Doctors and provide a monitoring tool of the physicians to management so as to maximize their throughput. If the Hospital or healthcare entity trusts their doctors they should download the free VA software and invest in providing typing classes to their medical staff so that they can freetext their notes and records.This will restore sanity to the medical record and allow the doctors to figure out what is happening. The check and click method of entering medical records is essential to capturing documentation to get the highest billing for services. In the EPIC EMR every trivial clinical encounter can be buffed up by clicks and downloads to justify level 5 charges. Lawrence Weed was right. If we reduce medical records to his format with freetexting we will save time in charting and lives of patients by restoring legibility and clarity to our medical records
    Isaac Gorbaty MD

  39. E Siegal December 5, 2012 at 4:46 pm - Reply


    Right on target as usual.

    I’ve lived through 3 Epic implementations and have spent a lot of time working directly with their people (the company is headquarted just down the road from me).

    Transitioning data from a paper chart to an electronic format offered an unprecedented opportunity to rethink how we organize and share complex information. Instead of capitalizing on this opportunity by bringing in the best operational engineers and healthcare informatics experts, Epic basically recapitulated the paper chart on a monitor, in many ways giving us the worst of both worlds. I’m not sure who to blame for this, but in my opinion it represents a colossal failure of imagination and leadership. I often (wistfully) wonder what would have happened if Steve Jobs or Sergey Brin had applied their brilliance to EMRs.

    We have trained our residents to cram as much crap as they can on a note in order to create the appearance of thoroughness and to jump through the necessary coding hoops. The copy and paste functions in EMRs have made it far too easy to port every vital sign, lab result, CT report, etc into the note, resulting in a 5 page magnum opus, 95% of which conveys no useful information. (One of my colleagues termed these notes “yard sales”; where one has to wade through a huge pile of crap to find a single useful item.) We need to train (or retrain) physicians to resist this impulse, and to reward clean and parsimonious communication over verbosity.

    Then, we need to storm the Epic headquarters with torches and pitchforks and demand that they send their leadership out to be drawn and quartered. Hey, a guy can dream.

  40. Epic December 7, 2012 at 9:48 am - Reply

    Physicians – thanks for your thoughts. However, we are not mind-readers and we can only work within the bounds of our archaic code. If you think you have it rough, you should hear what we hear from the nurses, you know, the underpaid ones that actually provide patient care and have to put up with your whining, bossiness, and superiority complexes. Anybody can memorize A&P. It takes common sense to use a computer. Perhaps time spent complaining could be more effectively be used in Epic ClinDoc training. Gotchya…

    • Chris Johnson December 7, 2012 at 3:42 pm - Reply

      Blaming the users for flaws in Epic is strange. In my comment upthread I’m not pointing out flaws that can be fixed by tweaks in the software. My complaint is with the underlying paradigm.

      The progress note, particularly the physician progress note, is the lifeblood of the patient’s medical record. Epic mangles it. To care for that patient I need to see the story, the narrative of what has happened and what others think and did about it. The ability to blow piles of extraneous data into a progress note, disguised as a problem-oriented approach, at best makes this difficult. At worst it can hurt people. I have seen that.

      I am not saying templates can’t be helpful. I use them myself, but they are of my own design because of my frustration with Epic (I made them in MS Word). My template looks just like a progress note they taught you to write in medical school. Mine aren’t oriented toward the needs of coders and lawyers, but I’ve never had any complaints from either of those users about how I do it.

      In sum, your disdain for what physicians regard to be the purpose of the medical record is not helpful. And, sad to say, I’ve met it before. Telling us we don’t understand or appreciate Epic’s brilliance is arrogant. And typical.

      Of course, you could be merely a troll enjoying what internet trolls do. It’s high on my differential diagnosis in this case.

  41. S Silverstein, MD December 7, 2012 at 3:18 pm - Reply

    To whomever left the reply “Physicians – thanks for your thoughts” under the pseudonym “EPIC”…

    Your comment is, quite simply, perverse. It reflects an unfitness for you, if the comment is serious, to be involved in any aspect of healthcare.

    Your comment might have been at least humorous if it referred to, say, IT issues in a nail parlor or pizza shop.

    We are discussing, however, IT problems in patient care, that affect everyone, including the most ill of patients who expect the healthcare system to focus on their needs.

    Further, you show a lack of understanding of what the National Institute of Standards and Technology (NIST) has recently made plain: the concept of “use error”:


    … The EUP (EHR usability protocol) emphasis should be on ensuring that necessary and sufficient usability validation and remediation has been conducted so that use error [3] is minimized.

    [3] “Use error” is a term used very specifically to refer to user interface designs that will engender users to make errors of commission or omission. It is true that users do make errors, but many errors are due not to user error per se but due to designs that are flawed, e.g., poorly written messaging [or lack of messaging, e.g., no warnings of potentially dangerous actions – ed.], misuse of color-coding conventions, omission of information, etc.


    Take your perverse attitudes and ignorance elsewhere. Preferably far from your nearest healthcare facility.

    Scot Silverstein, MD
    Drexel University Philadlephia

  42. Sunil Gupta, MD December 8, 2012 at 2:35 pm - Reply

    Yes, it is always a good strategy for hospitals and HIT vendors to blame the users of unproven medical devices when said devices are involved with a death of a patient. Those hopspitals most aggressive at blaming the doctors to protect the EHR integrity are those who have signed lucrative deals with the HIT vendors, often with what they call kickbacks in the USA.

    Well yes, the “A” should be in the SOAP note, for sure, in that the vendors do not get an “A”.

    I give them an “F” for device design and usability.

  43. Matt Burton March 11, 2013 at 2:48 am - Reply

    GREAT Discussion! If only we could get out a whiteboard, a decent collection of real patient presentations, a few more innovative clinical informaticians, and a prototyping environment, I suspect that this collection of folks could come up with some very capable EMR designs. Designs that we can apply the SOAP method to in a “recursive” fashion:

    Subjective- “Clinicians complain of information and communication tools that, while meeting meaning use and provide many advantages over paper, don’t quite resonate satisfactorily with their cognitive models”;

    Objective- “Plenty of Informatics literature out their to support both advantages, challenges, and even adverse effects of Health IT with plenty more data sitting around waiting to be analyzed. Overwhelming opportunity and need to capture and analyze the ‘pathophysiology’ of our health care delivery systems for better design of optimal ‘interventions'”;

    Assessment- “Plenty of opportunity for improvement in information and communication tools that are becoming even more critical to the effective, efficient, and safe practice of medicine. Unless we clinicians find a way to (change our behavior and) lead the evolution of Health IT as a profession (not a bunch of independent consultants, entrepreneurs, pundits, unengaged observers, complacent victims, whiners, etc.), the prognosis is unfathomable amounts of waste, missed opportunity to achieve new heights of excellence, and dire consequences all around.”;

    Plan- “Clinicians work together in an open, transparent, collaborative, respectful, and productive manner to design, continually optimize, as well as develop usable requirements and truly meaningful metrics for ‘ideal’ information and communication tools that could be made available through open source efforts as well as used to inform continuous improvement efforts to leverage investments (or sunk costs) in existing large EHR installs. Create hundreds of realistic test cases used to inform/ evaluate designs. Link information tool functionality to clinical and process (workflow) best practices through use cases, requirements, prototypes, etc. Work TOGETHER as a community of professionals to lead and “educate” the information technologists so that they are enabled to deliver the best suite of tools and challenged to avoid repeating the same or similar mistakes. Clinicians recognize that as “uber” knowledge workers in the most informationally intense and cognitively demanding profession, that Information and Communication Technology based tools are fundamental to their effective and collective practice whether it be art or science or both.

    Ok, off my SOAP Box now…

    Dr. Wachter- I like your breakdown of the missing “Assessment”. Could you please tell me exactly what is “the Plan” and where I can find it in an EMR, what all does it include, how can any and all providers be certain that they are on and following the exact same “Plan”? How do we know that it changes when it changes? How can an entire care team collaborate toward the same goals through the same plan sharing the same “big picture” as well as their own little pictures? Should our daily progress note continue to be a snapshot of an instance in time accurate for a few minutes around the time it was written or should it be a “progressing note” that lives and changes as the findings, assessments, and plan all change with a clear record of what changed, when, why, and by whom? Should it look more like a Progress Wiki? I ask because I am a clinical informatician who has fellow clinician “customers” who have these needs, so your answer may make it into the design of an actual EMR. Greatly appreciate the “webside” consult.


  44. […] it’s an issue that good hospitalists think about too: several people brought up Dr. Bob Wachter’s post from last fall, in which he noted how using EPIC’s problem-based charting at UCSF’s hospital was having the […]

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About the Author: Bob Wachter

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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