↓Abbr.s in EMRs

One day, I was performing a laparoscopic appendectomy.  The gas insufflation system needed to be turned on.  The controls for the device were on a console at the circulating nurse’s desk in the room.  The console provided a large number of controls and options, such as which image will be displayed on which of the many screens in the room.  Another capability was the ability to adjust the settings on the laparoscopic devices, such as the gas insufflation machine, without having to leave the sterile field where the machine is situated.  However, that day we were unable to figure out how to accomplish this technological feat because the selection buttons on the software controlling the system were full of indecipherable abbreviations.  And there were no hints offered by hovering the cursor over any of the buttons.  Interestingly, there was a great deal of white space on the screen which would have allowed a full text description label for each of the buttons.

I find this practice of using abbreviations in healthcare information systems reprehensible and, quite frankly, stupid.  We human beings often abbreviate what we are writing in order to save time.  Shorthand, used by stenographers (such as court reporters) is the ultimate example of abbreviating words to save time.  However, the shorthand abbreviations that are taken down by a court reporter are subsequently translated to full text in the legal transcripts of the court’s proceedings, making the report much more understandable.

In contrast, computers work from the interactions of electrons moving through complex circuits at the speed of light.  I’m not sure why computers would ever need to abbreviate.  I mean, it’s one thing when the care providers who document in electronic medical records (EMRs) use abbreviations in their notes; after all, they’re busy people, they are trying to save time, and their typing cannot move as fast as a computer’s display.  However, it doesn’t make any sense when the labels, buttons, captions, picklists, and other items on software screens display abbreviated terms representing their functions.  This is especially true when the abbreviations used are not common or intuitive.

This is especially problematic for software that manages information of a highly technical nature, such as medical care.  Highly technical terms can be challenging enough without abbreviating them, thereby often making them unable to be understood.  Technical items should be fully self-explanatory with full text terms and not abbreviations unless the control on the screen is representing something intuitive, such as a “+” and “-” sign or even an up-down button control next to a numeric data entry field.  As a matter of principle, computer screens should not display abbreviations unless there are no alternatives.

I remember a neurosurgeon whose last name began with a “W” providing daily progress notes consisting only of the date, a Greek letter delta (Δ) with a slash (⁄) overlying the delta (thereby indicating “no change”), followed by the “W” (the first initial of his last name).  Unfortunately, such documentation may not be clearly understood by those who read it.  Moreover, should that physician’s notes be audited for billing compliance purposes, he would probably not be paid for the care he provided his patient (assuming he was outside of the global surgical package period) because the documentation failed to provide the required components.  Accurate and comprehensive documentation result in payments to physicians through the Current Procedural Terminology (CPT) codes that are applied.  A note that is replete with unintelligible abbreviations may not be reimbursable.

Attorneys use court reporters to document the proceedings of a public trial.  The court reporter uses written shorthand, machine shorthand, and voice writing to capture and produce the transcription of events at the trial.  It would be nice if physicians had the equivalent of a court reporter following them around taking shorthand notes of the physician’s activity, but that solution would be cumbersome and expensive.

Yet there is an incompletely used strategy that can and should be used for text that a physician, nurse, or other type of caregiver commits to an electronic medical record.  The user should be able to type the abbreviation (such as typing “.gcs” — that is “dot gcs”) which the computer immediately translates to the full text term (“Glasgow Coma Scale Score”) represented by the abbreviation.   The dot character at the start of the word is the signal for the computer to start looking for an abbreviation based upon the subsequent characters.  This strategy is a win-win because it saves time for the user while it improves the quality of the communication to the intended audience.

The technology for this process (commonly known as “macros”) is already embedded in the electronic medical record.  I have used both Epic and Cerner systems, and I can attest that the functionality exists in both systems and is actually fairly similar.  Nevertheless, in reviewing actual electronic medical records, I still see multiple abbreviations, many of which are actually undecipherable.  Clinicians should understand that clinical notes need to be understandable to readers in order to be effective.  It is a responsibility that is inherent to effective clinical practice.  The technology can even be fully implemented by having entire notes or reports exist as a macro identified by a word or phrase whose first character is a period (or dot).

For example, my macro for a right inguinal hernia repair was “.rih” and my macro for a left inguinal hernia was “.lih”.  So, after I completed my operation, I would take off my gown and gloves and go to the workstation in the corner of operating room, pull up the patient’s chart and start entering my operative note by typing the appropriate macro for the operation I just completed.   A near-complete operative report opened up, only requiring completion of a few specific detail items (i.e., patient name & age, presenting symptoms, etc.) that were identified by an underscore (“_”).  Within a minute or two, my entire operative report was completed and filed.  Any unusual or abnormal findings or procedures required my entering free text as necessary to complete the report.  The whole process took only a few minutes, depending upon how routine the procedure had been.

To create the macro, I went to a previously dictated and transcribed note I had completed.  I copied that entire note and pasted it into the macro entry field in the macro creation program on the EMR.  I then made whatever changes I wanted for my note and placed the appropriate underscores wher specific details for each case would be placed.