Zain Syed is the author of digital thoughts, one of our favorite healthcare focused newsletters. Zain recently published his thoughts on Note taking, a topic near & dear to our hearts here at ChartFlow. We’ve reposted his article below—hope you enjoy!
You are finally in the room, waiting for your doctor to walk in.
You are thinking finally they're here….aaaannnnnddd it is the nurse.
They take your vitals, look at them and write them down. Then they log onto the computer and start typing away asking you the standard questions.
“Any changes in your medications?”
They make some small talk about the weather and head out letting you know that the doctor is on their way!
You grab your phone and start surfing social media
20 minutes later the doctor walks in.
They sit down and log onto the computer and start talking.
“What brings you in today?”
You tell them why you are here and they are furiously typing away as you are talking, nodding in agreement. They peel themselves away from the screen and conduct a quick physical exam and then let you know that they have ordered some labs. Once they are back our office will call you with the results.
During this time you have spoken to 4 people in the office and have had less than 10 minutes of eye contact during this hour-and-a-half ordeal because their faces were buried in the computer screen.
What happened to us?
What happened to human connection?
Technology was supposed to help bring us closer, not separate us further. We can’t solve all these issues but we can take steps to make things better.
Let’s start with how we take notes.
Document or die!
Notes are the backbone of medicine. The saying goes “if it’s not documented then it didn’t happen.” Notes are what we all rely on to see what has happened in the past. A good note is one of, if not the most valuable things. In contrast, a bad note leads to duplicate work and sometimes worse.
Our current workflow doesn't lend itself to good documentation or good patient care for a couple of reasons.
We spend A LOT of time documenting. Many of us try to be more efficient and make templates and or try to complete the note during or right after the visit. This can lead to more accurate notes but patient interaction usually suffers. Some people write all their notes at the end of the day. These people usually are up very late at night finishing up their documentation. They might have better patient interactions but they might forget to write certain details in their notes. Then we have the ones that don't complete any of their notes until forced to. They want to see the whole world burn!
I’m just kidding but you can see that this can lead to problems down the road if someone is trying to do some background on the patient.
So you can see you can’t have it all. Very few providers can do both, but they are very rare.
Let’s reinvent the note!
I propose that we completely reinvent this whole interaction. Transcription software has been around for some time now. Some popular ones that I have used are otter.ai and fireflies.ai. You can add them to your meeting and they will transcribe the whole meeting for you and even label the speakers! It is pretty wild.
I didn’t believe it at first and one day I got an email with a transcript of an hour-long meeting with the speakers labeled to a meeting that I wasn’t even at! My mind was blown.
I got to thinking why can't we do this in our practice? Why can't we record and transcribe the conversation with our patients and make that our note? Most of these solutions will also summarize the interaction for you. The note will be searchable and instead of writing the whole note you just correct something and add whatever you need to and you are off to the races! You can even send a copy to your patients, where the AI could write it at a 5th-grade reading level. Because those after-visit summaries confuse people more than they help right now.
These systems aren’t there all the way there yet, but they are getting close. To me, this could be a total game changer and give so many people enormous amounts of time back. You would have accurate notes and you can actually look at your patients. Sacrilegious I know.
Some companies are working on this and I could not be happier! Simple things like this are what get me the most excited. Because this would improve patient care and decrease burnout.