Table 1. Themes, Definitions, and Supporting Quotes
ThemesDefinitionsSupporting Quotes
Understanding context drives visit preparationThe main reason to review prior clinic notes was to understand past events and that might help the physician understand the problem being addressed in the current visit.“So it's pretty context dependent. I always read my last note or the last note, and usually any other recent notes that anybody has written. And then if there's a particular problem that I identify then I go searching for other details.” (Physician 1)
“If there was, like, lung cancer in the family history I might want to know that. That might make somebody kind of [worried] … ‘I'm worried that this might be lung cancer and there's, like, somebody else in the family.’ And then smoking history would probably be important, that they're a former smoker, not a current smoker.” (Physician 11, speaking about a patient presenting with a cough)
Forces driving note contentClinical, legal, and billing requirements all contribute to note content, often with lengthy results.“You know, I appreciate this effort but we're swimming upstream here, and the stream is the torrent of billing-related regulations, right? First and foremost, this serves the god of billing and it has to continue to do that, and I wish it didn't, you know?” (Physician 14)
The assessment and plan is the main information neededThe Assessment/Plan was viewed as the most important and informative part of the note.“I open a new note I immediately scroll down to the assessment and plan to get a broad view of what I'm gonna be looking at… . I maybe didn't realize it but that is always the first thing I look at.” (Physician 7)
A narrative HPI supports the assessment/planThe HPI was viewed as a secondary narrative source of information, as an adjunct to the Assessment/Plan.“I will just read the assessment and plan and then if something doesn't jibe with what I remember sending them for I'll go back up to the history of present illness and be, like, if they got a different history than I did or they didn't get a piece of information that I knew, then I'd probably go back up to that.” (Physician 10)
ROS is “useless”The physicians did not regard the ROS as particularly useful. Many identified this as a source of note clutter.“And the review of systems I skip entirely because hopefully somebody told me something in the HPI that was gonna be important for that visit. Otherwise, I hate the review of systems. I think it's useless… . I do it in my notes to satisfy billing requirements because I can't bill without it… . I'd rather be able to get a short story here and have things like the hypoglycemia and other stuff, technically that could be considered a review of systems but our billers tell us that they want us to mark it out separately so that way we have to get audited but it's not dinged that you don't have it, but it doesn't add anything to my medical decision making.” (Physician 3)
“I think the review of systems is greatly oversold and practically worthless… . We have to do it for billing, so it's got to be there, but as I review this note, getting ready to see the patient in follow-up, I would just skip over that section.” (Physician 6)
Role of a patient summary dashboard in workflowPhysicians reported finding most information on this patient dashboard screen rather than navigating to specific parts of the chart or past notes to find this information. Thus, the visit preparation workflow is now different with an EHR with a useful dashboard screen.“We also have a patient summary [dashboard] sheet that's printed off, too, that has all the meds on there that actually much more concise, it's all on one sheet, what their last vitals and, you know, everything else is on, their diagnoses, everything else is on there, too.” (Physician 11)
“But again, though, I would probably have gotten that information before I even look at the progress note by looking at the, a summary [dashboard] page of some kind. I try not to scan notes for any of that information anymore.” (Physician 3)
Relationship buildingSometimes physicians wanted to see small amounts of “medically irrelevant” information to help them create or preserve the patient relationship.“I picked the married two children this time. It might help me do a little chit chat at the beginning of the visit, which is a nice thing to do.” (Physician 1)
“I would note that she was in the Peace Corps and congratulate her for doing that, or him.” (Physician 2)
“I actually probably would find this interesting either because I knew that they were going and I, you know, it's just nice to talk to people about their lives more… . Oh, I didn't know it, had a class reunion. So I, I'd probably, so probably I would pay attention to that.” (Physician 9)
Emotion and frustrationMany physicians began to become emotionally charged during the interviews, reflecting how poor note construction and display hindered them in their important but mentally challenging tasks. Much of the frustration centered on the ROS.“It's my life's goal to eliminate the review of systems from all clinic visits and all notes. It is a way of getting paid. It is not a way of taking good care of patients. If you wish for me to expound on that I'd be happy to. It represents much of what is wrong with medicine, meaning to take a good review of systems you have to talk more than you listen, and that's wrong. You should listen more than you talk. It is an unprompted fishing expedition, and it's not helpful to do unprompted fishing expeditions and it is a bizarre way of getting paid, which has absolutely nothing to do with the complexity of the patient.” (Physician 14)
  • EHR, electronic health record; HPI, history of the present illness; ROS, review of systems.