Problem: too much text

This post is part of a series detailing the problems of current electronic healthcare records. To orient yourself, you can start at the index page on “presentation” on the iota wiki. You will find this and other pages on that wiki as well. The wiki pages will be continuously updated.

Current electronic health-care record systems contain huge amounts of textual data without any useful structure. The mass of text in itself becomes a big problem when there is no structure, standing in the way of the reader. Since there is no useful structure, the entire text must be read and internalized at every encounter where the patient is new to the doctor or if he hasn’t seen the patient recently, which in primary care is most encounters. If the amount of text could be reduced to the absolute essentials, then the reader might have a chance of getting through it, but we passed that point a while ago in most systems. That was a point of no return, as far as current EHR systems are concerned.

A number of initiatives coming from the outside of direct patient care result in an additional increase of the amount of non-essential or duplicated text. For example, a number of quality register initiatives and the “lifestyle” questionnaires add large amounts of text to the EHR, further obscuring the useful text we’re looking for.

Once a certain point is reached where the amount of text becomes too large to read before each encounter, several things happen, all of them bad:

  • The reader gives up on the EHR text and asks the patient instead. Since he needs to allow time for the patient to answer, he actually reads considerably less of the EHR than he did before. Most doctors I asked admitted to often reading just the one or two most recent entries before simply asking the patient for a short history.
  • Once the doctor does understand the essentials of the patient’s history, he usually summarizes the history and adds it to his own journal entry, so as not to lose it. This isn’t as useful as it may seem since it will scroll away beyond the “reading horizon” of two entries pretty soon. Once it has scrolled away beyond the “reading horizon” it isn’t useful anymore and only contributes to the enormous mass of unstructured text, reinforcing the vicious circle.
  • Not knowing what’s in a medical record is very stressful and tends to make doctors more defensive in writing new notes. These notes tend to be more elaborate than they need to be, once more further contributing to the mass of text.

In other words, as the EHR looks today, it is of critical importance to maintain the absolute minimum of text in the records and to avoid duplication and unrelated information as much as humanly possible. A disturbing number of government initiatives, however, result in exactly the opposite effect, interconnecting EHR systems over large geographic areas while at the same time sprinkling the EHR text mass with redundancies and irrelevancies to a degree that is outright dangerous.