Above is the same text-based chart note shown in my last post. In print format, this particular chart note is three pages in length. In my last post, we considered the low data density of the note, both at this magnification . . .

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Chart Note 10/15/2008

. . . and at full scale, viewed 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

Consequently, when viewed on the EHR monitor, the user has to scroll or page down about six time to see the entire note. . .

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.

. . . as shown here. Hence, the user has to retain information in working memory as opposed to being able to retrieve it with a glance from the same screen.

In addition to having low data density, there is second reason these text-based EHR documents tend to be inefficient -- they often have a low data-ink ratio -- the amount of ink used to display data divided by the total amount of ink used in the graphic or display.

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. Cardiovascular: The patient denied arrhythmia, chest pain/pressure, edema, exercise intolerance, orthopnea and palpitations. Respiratory: The patient denied dry cough, asthma, pleuritic pain, productive cough, dyspnea and wheezing. Gastrointestinal: The patient denied hemorrhoids, hepatitis, abdominal pain, constipation, diarrhea, gastroesophageal reflux, melena, nausea and vomiting. Genitourinary/Nephrology: The patient denied dysuria, nocturia and urinary incontinence. Musculoskeletal: The patient denied stiffness, swelling, muscle weakness and myalgias. Dermatologic: The patient denied rash and scar. Neurologic: The patient denied radicular pain, dizziness, headache, neck pain and syncope. Psychiatric: The patient denied anxiety and depression. Endocrine: The patient denied goiter, hyperglycemia and hypoglycemia. Hematologic/Lymphatic: The patient denied abnormal ecchymoses, petechiae, abnormal bleeding and bruising, anemia and lymph node enlargement/mass. Allergy/Immunology: The patient denied wheezing or food allergy. OD Dva 20/25cc OS Dva 20/40 cc 20/25 ph

Consider the information in the Review of Systems section above. While it looks comprehensive, it is boilerplate text that is often included in chart notes to support coding and billing at a higher lever of service. All the findings are negative. There is no way of knowing whether all the above questions were actually asked. Furthermore, there is no way to distinguish a true pertinent negative from the boilerplate negatives. So in fact, the data-ink ratio in this example is close to zero.

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. Cardiovascular: The patient denied arrhythmia, chest pain/pressure, edema, exercise intolerance, orthopnea and palpitations. Respiratory: The patient denied dry cough, asthma, pleuritic pain, productive cough, dyspnea and wheezing. Gastrointestinal: The patient denied hemorrhoids, hepatitis, abdominal pain, constipation, diarrhea, gastroesophageal reflux, melena, nausea and vomiting. Genitourinary/Nephrology: The patient denied dysuria, nocturia and urinary incontinence. Musculoskeletal: The patient denied stiffness, swelling, muscle weakness and myalgias. Dermatologic: The patient denied rash and scar. Neurologic: The patient denied radicular pain, dizziness, headache, neck pain and syncope. Psychiatric: The patient denied anxiety and depression. Endocrine: The patient denied goiter, hyperglycemia and hypoglycemia. Hematologic/Lymphatic: The patient denied abnormal ecchymoses, petechiae, abnormal bleeding and bruising, anemia and lymph node enlargement/mass. Allergy/Immunology: The patient denied wheezing or food allergy. OD Dva 20/25cc OS Dva 20/40 cc 20/25 ph

The same information could have been conveyed, with a much higher data-ink ratio, as shown here.

Family History Yes / No Disease Detail Family Member Name Age Glaucoma Mother Review of Systems Negative in detail OD Dva 20/25cc OS Dva 20/40 cc 20/25 ph

Similarly, consider this portion of the exam: it looks comprehensive, but when you actually read it, you realize that most of the information consists of boilerplate normal values. In fact, the only real data on this screen is . . .

Confrontation OD: confrontation fields full to finger counting OS: confrontation fields full to finger counting Motility OD: EOM is full OS: EOM is full Adnexa OD: no rashes or rosacea OS: no rashes or rosacea Eyelids OD: no ptosis, retraction, or lid lesions OS: no ptosis, retraction, or lid lesions Conjunctiva: OD: white and quiet OS: white and quiet Cornea: OD: normal endothelial, epithelial, stroma and tear film OS: normal endothelial, epithelial, stroma and tear film Anterior Chamber: OD: PXF OS: no cell or flare Iris: OD: iris normal OS: iris normal Lens: OD: PCIOL OS: 1+ NS and cortical changes

. . . the information highlighted in yellow. So in this screen as well, the data-ink ratio is exceedingly low. In some encounter notes, one could make a good case that the data-ink ratio is actually a negative number because the default values don’t reflect the actual findings.

Confrontation OD: confrontation fields full to finger counting OS: confrontation fields full to finger counting Motility OD: EOM is full OS: EOM is full Adnexa OD: no rashes or rosacea OS: no rashes or rosacea Eyelids OD: no ptosis, retraction, or lid lesions OS: no ptosis, retraction, or lid lesions Conjunctiva: OD: white and quiet OS: white and quiet Cornea: OD: normal endothelial, epithelial, stroma and tear film OS: normal endothelial, epithelial, stroma and tear film Anterior Chamber: OD: PXF OS: no cell or flare Iris: OD: iris normal OS: iris normal Lens: OD: PCIOL OS: 1+ NS and cortical changes

If both the data density and the data-ink ratio of this text-based note were increased, instead of having to display the data for this patient encounter in six screen views . . .

. . . all the relevant data could be presented in a single screen, as shown above. It should be noted that some EHRs do a much better job than others of creating text-based chart notes of both high data density and high data-ink ratio.

These differences in visual presentation make an enormous difference in how much cognitive effort goes into making sense of a patient encounter. Unfortunately, for many EHR vendors, increasing the data density and data-ink ratio of their text-based chart notes is not a high priority.(last slide)