Having seen about 50,000 patients with hand-written charts, and 50,000 patients with Electronic Health Records (EHRs), I am deeply aware of some of the benefits of EHRs.
For example, having immediate access to an old EKG has helped prevent unnecessary admissions. Seeing a lung lesion on a CXR, but then seeing that same lesion unchanged on a CXR ten years prior can instantly help you reassure a patient. And let’s face it, who hasn’t written a preliminary prescription for medicine when you suddenly get a warning pop up, pointing out a drug interaction or allergy you missed?
Yes. EHRs can be very helpful, but we should also recognize we lost something with paper charts too, and one of them was a focused chief complaint, which now has morphed into what I call the Infinite Chief Complaint.
Let me expand on what I mean.
Back in the old days (good ole’ days? maybe, maybe not), when someone presented to the desk or a triage nurse, because the physical, paper chart had only a narrow, limited box for it, and because writing is slow, the chief complaint—why a person wanted to be seen—was generally just 3-4 words: “Sore throat.” “Cough.” “Abdominal Pain.” “Back Pain.”
The triage person, usually an experienced nurse, would spend a little bit of time trying to get to the heart of why they wanted to be seen, and then document that as the chief complaint. Other issues then generally are documented in the History of Present Illness, or the Review-Of-Systems, usually identified by the physician.
However, now—because EHRs have no physical boundary to word input—it’s not uncommon to see 4-5 Chief Complaints on a chart. In fact, in theory, the triage nurse or receptionist can put in as many Chief Complaints as they want! 1, 2, 5, or 100! Heck, maybe even infinity and beyond!
Put another way, in the old days, a written chart of a 55-year-old patient in flu season may say:
Chief Complaint: “Cough “
HPI: “Chest hurts and stomach muscles hurt when coughing.”
But nowadays, thanks to the unlimited boundary of the digital Infinite Chief Complaint Box (which allows for an unlimited number of Chief Complaints), the same 55-year-old patient may present like this:
Chief Complaint: 1. Cough. 2. Chest Pain. 3. Abdominal Pain
Granted a good physician should be able to sort this out, but really, if you have a 55-year-old with a documented chief complaint of Chest Pain, the workup becomes instantly more complicated (and expensive).
So, we shouldn’t deceive ourselves.
We gained some things with EHR implementation 10 years ago, but we also lost some things too, and some of the things we lost have resulted in dramatic increases in both complexity and cost.