Above is a reduced-scale mockup of a text-based chart note generated by an EHR to provide a record of a patient encounter. The document is usually in Microsoft Word or PDF format. It can be viewed on the EHR monitor, printed, or sent electronically as a PDF. The document is constructed by combining previously entered discrete data elements into a single text-based file.

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Chart Note 10/15/2008

In print format (above), this particular chart note is three pages in length.Such documents are usually organized in SOAP note (Subjective, Objective, Assessment, Plan) format, starting with the Chief Complaint and History of the Present Illness and ending with the Assessment and Plan (highlighted above).

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Chart Note 10/15/2008

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One measure of the efficiency of a graphic or page design is its data density – the ratio of information conveyed per unit area on the page or screen. Within reason, the higher the data density, the better the display or graphic.

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Chart Note 10/15/2008

At this reduced scale, it is easy to appreciate the low data density of this text-based note.

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Chart Note 10/15/2008

This slide shows the same text-based note as it would appear in digital format on the EHR monitor.

PATIENT: Maria Smith DATE OF BIRTH: 08/14/1929 DATE OF EXAM: 10/15/2008 Chief Complaint and HPI Complaint 1: This 79 year old female presents for a 6 month follow-up for glaucoma in her right eye. She reports no change in her vision. She has been using Alphagan-P drops on a regular basis 2x/day in the right eye without any problems. She is planning to move to Florida permanently. History Historian: Jenny Avarro Past Ocular History Eye Year Dx Ocular Disease Nuclear Sclerosis OS Trichiasis OU Nuclear Sclerosis OS Glaucoma suspect OD Keratitis Sicca OU Pseudoexfoliation OD Ocular Medications Brand Name Dose Sig Start Date Stop Date Alphagan-P 0.15% 04/17/2003

The low data-density is again apparent in this view. First of all, large areas of the screen are simply not used. Furthermore, several areas on the screen (Year Dx, Sig, and Stop Date) are blank because the underlying EHR data was unavailable or not entered.

PATIENT: Maria Smith DATE OF BIRTH: 08/14/1929 DATE OF EXAM: 10/15/2008 Chief Complaint and HPI Complaint 1: This 79 year old female presents for a 6 month follow-up for glaucoma in her right eye. She reports no change in her vision. She has been using Alphagan-P drops on a regular basis 2x/day in the right eye without any problems. She is planning to move to Florida permanently. History Historian: Jenny Avarro Past Ocular History Eye Year Dx Ocular Disease Nuclear Sclerosis OS Trichiasis OU Nuclear Sclerosis OS Glaucoma suspect OD Keratitis Sicca OU Pseudoexfoliation OD Ocular Medications Brand Name Dose Sig Start Date Stop Date Alphagan-P 0.15% 04/17/2003

Accordingly, the physician typically has to scroll down (see green arrow) or page down multiple times to see the entire note. When she does . . .

PATIENT: Maria Smith DATE OF BIRTH: 08/14/1929 DATE OF EXAM: 10/15/2008 Chief Complaint and HPI Complaint 1: This 79 year old female presents for a 6 month follow-up for glaucoma in her right eye. She reports no change in her vision. She has been using Alphagan-P drops on a regular basis 2x/day in the right eye without any problems. She is planning to move to Florida permanently. History Historian: Jenny Avarro Past Ocular History Eye Year Dx Ocular Disease Nuclear Sclerosis OS Trichiasis OU Nuclear Sclerosis OS Glaucoma suspect OD Keratitis Sicca OU Pseudoexfoliation OD Ocular Medications Brand Name Dose Sig Start Date Stop Date Alphagan-P 0.15% 04/17/2003

. . . the previous data disappears from view. She has to retain that data in working memory as opposed to being able to retrieve it with a glance (see Humans Have Limited Working Memory). Note the low data density of this screen as well.In order to read this relatively simple note in its entirety, she has to navigate through about six screens (or view three pages if printed out).

Past Systemic History Year Dx Systemic Disease DM type 2 w/o comp. Ocular Procedures Sx Procedure Eye Date Gl End Date Surgeon Cataract Surgery OD 2002 Systemic Medications Brand Name Dose Sig Start Date Stop Date Metformin 04/17/2003 Allergies Allergen/Ingredient Brand Reaction Timolol breathing problems Penicillins Family History Yes / No Disease Detail Family Member Name Age Glaucoma Mother Review of Systems Constitutional: The patient denied fatigue. Ears/Nose/Throat/Neck: The patient denied vertigo, hearing loss, nasal discharge and sinus congestion.

Recall that we have been viewing the chart note for just one encounter. Each encounter requires its own chart note. It takes time and cognitive effort to wade through these documents of low data density, but for many EHRs they provide the only way a physician can get a snapshot in time of the patient’s past health. Due to lack of interoperability, these inefficient, text-based notes are also a major way physicians using different EHRs communicate about mutual patients.

Chart Note 5/27/2012

Chart Note 10/15/2008

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In summary, while it is easy to write code that takes data from discrete fields in the EHR database and converts it into text-based documents, it often results in documents of low data density that are exceedingly hard to work with. Such documents are examples of computed-centered rather than user-centered design (see my first post). My next post will address another measure of efficient data presentation – the data-ink ratio – as it applies to EHR design. (last slide)

Past Systemic History Year Dx Systemic Disease DM type 2 w/o comp. Ocular Procedures Sx Procedure Eye Date Gl End Date Surgeon Cataract Surgery OD 2002 Systemic Medications Brand Name Dose Sig Start Date Stop Date Metformin 04/17/2003 Allergies Allergen/Ingredient Brand Reaction Timolol breathing problems Penicillins Family History Yes / No Disease Detail Family Member Name Age Glaucoma Mother Review of Systems Constitutional: The patient denied fatigue. Ears/Nose/Throat/Neck: The patient denied vertigo, hearing loss, nasal discharge and sinus congestion.