Narrative Notes in the Future of Healthcare

I was recently admonished by a high-level healthcare industry consultant that “...times have changed and there is no place for the archaic practice of narrative notes in the future of healthcare delivery.  It is not possible to capture meaningful data from a page of text.”   I took exception with this pronouncement in two regards:  1) that narrative notes are archaic—hundreds of thousands of physicians who find narrative notes the most concise and efficient way to tell a patient’s story will disagree; and 2) this will come as a surprise to Google users, who regularly depend on the ubiquitous search techniques of the world’s largest search engine to find information at the rate of over 300 million (!) searches each day, mostly from pages of text.

We are involved in a national debate that is both too complex and too important to reduce to bumper sticker slogans or uninformed bias.  Much of the EMR certification and Meaningful Use discussions have been dominated by legacy EMR vendors whose products were designed and built many years ago to meet needs considered important at that time.  The environment has changed significantly since then in two major ways.  First, all participants in the healthcare delivery have a much better-defined idea of what problems IT can and should solve for different stakeholders.  Second, a number of technologies have evolved over the past decade that change the solution sets available to healthcare providers seeking EMRs to automate their practices and meet the current demands of their patients and government.   There has been growing grass roots momentum from organizations such as the Markle Foundation’s Center for Health IT and the Health Story project that recognize the drawbacks of abandoning the traditional narrative note and the viability of alternative solutions available. 

The American Recovery and Reinvestment Act (a.k.a. ARRA, or the Stimulus Bill) includes incentives for meaningful use of certified EHR technology, and specifies that meaningful use shall include the use of electronic prescribing, electronic exchange of health information to improve the quality of health care, and reporting on clinical quality and other measures.  Experts advising the federal government have proposed expanding the definition of meaningful use to include six key functional areas that individual doctors and their ambulatory practices will have to address

1)                  Provide access to comprehensive data for patient’s healthcare providers,
                     which means an electronic record of visit documentation with selected data 
                     easily available;

2)                  Computerized physician order entry, starting with e-prescribing;

3)                  Exchange of meaningful clinical information among healthcare team;

4)                  Provide patients and their families access to data, knowledge and tools to make
                     informed decisions;

5)                  Communicate as required with public health agencies; and

6)                  Ensure adequate privacy and security protections for health information.

ARRA presents unique challenges for non-hospital based providers, but also offers an opportunity. Let’s look at each of these six functional areas and present solutions for each that are readily available today, and can be delivered cost-effectively and with low risk of disrupting the practice.