Back in the 1990s, I was one of the few doctors who used an EHR regularly with my clinic patients. I strongly believed – then and now – that shared information can improve the quality of care and empower patients to take more control over their own well-being. But sharing that information can be a challenge. EHR data isn’t always organized or readily accessible. As a result, it is difficult to be confident in what exactly will be shared or seen when looking at the screen together.
Summarizing data in the EHR
Having data organized in the EHR to summarize and highlight key decision points can simplify interactions with the patient and minimize uncomfortable stretches of time spent clicking and searching for information. A problem-oriented view of the entire health record is one way to organize information that mirrors the way clinician’s think about their patients. Most doctors are trained to use the “SOAP” model of documentation (subjective, objective, assessment, and plan). However, what actually happens more frequently is “OHEAP” (orientation, history, exam, assessment, and plan). Having a summary of the patient’s prior work-up available as an orientation allows for targeted history taking and examination around a particular problem, leading to more efficient assessments and plans. The EHR can definitely help by pulling together and summarizing information in a way that both the clinician and the patient can understand together.
Telemedicine and the shared EHR
In recent months, the COVID-19 pandemic has dramatically transformed the patient-doctor encounter. There is much less sharing of the EHR across the exam room. Indeed, most clinic interactions are happening virtually, and even after COVID-19 I believe many more encounters will happen via telehealth. This makes the notion of a shared EHR/screen even more important. Understanding how to most efficiently summarize and present data in the EHR for both patient and doctor will be one of the most important challenges we tackle going forward.
