Stop the noise and get to the point.

www.ccmjournal. org February 2013 • Volume 41 • Number 2 In this issue of Critical Care Medicine, Thornton et al (1) report that at least 20% of the text in the assessment and plan sections of > 75% of physician critical care progress notes is copied from previous notes. Not examined is how much of the auto-populated data the electronic medical record (EMR) so effortless allows entered is just wrong. As one antidote, I cannot be the only EMR user to discover an endotracheal tube size brought forward into a note of someone extubated 3 days earlier. That critical care physicians use the electronic functionality of copy and paste aligns us nicely with other physicians so far reported (2, 3). I agree, as the authors conclude, further studies are necessary to discover outcomes associated with copying. Although not all analyses of the impact of copied text are disparaging (4), most opinions come down firmly on the dangers of the practice. There are a number of brilliant commentaries on the issue and I will not attempt to out-duel the cynicism (5, 6), but I will add to the plea (copied and pasted from reference 7), to “change not only the health record but also the way we create it, evaluate it, and use it” (7). First, three observations: Observation 1: It is hard to say it better than did Dr. Weed about 45 yrs ago. In a pair of articles called “Medical Records that Guide and Teach,” he attempted to launch a problemoriented medical record in part to develop “. a more positive attitude about the computer in medicine” (emphasis is mine). He wrote, “all narrative data presently in the medical record can be structured and in the future all narrative data may be entered through a series of displays, guaranteeing a thoroughness, retrievability, efficiency and economy important to the scientific analysis of a type of datum that has hitherto been handled in a very unrigorous manner. ” His view of the future with data entered through a series of displays has been realized. Unfortunately, the remainder of his vision has been actively sabotaged by current “state-of-the-art” EMR systems. Observation 2: In a cognitive task analysis of critical care physicians, five key cognitive activities were discovered (8). Two of the five activities, pattern recognition and creation and transfer of meaning through stories are both are quite relevant. Physicians are fundamentally pattern recognition experts. At the bedside, we recognize a pattern seen before, recall the treatment, and if the treatment delivers the expected outcome our mental model is deemed correct. Experts are better pattern recognizers than novices. Some patterns (or mental models) are comprehensive (e.g., uncomplicated asthma) but most are partial (e.g., fever, tachycardia, and high white count). Again, experts do better at juggling these partial mental models than do novices. Physicians create meaning by aggregating and aligning these partial mental models into a story (or picture). We communicate with everyone on the multidisciplinary critical care team by telling stories, and we should be striving to impart the same mental model within all team members. Observation 3: In 1948, Claude Shannon founded information theory with the publication of “A Mathematical Theory of Communication” (9). He wrote, “The fundamental problem of communication is that of reproducing at one point either exactly or approximately a message selected at another point. Frequently the messages have meaning; that is they refer to or are correlated according to some system with certain physical or conceptual entities. ” Although Shannon dismissed “meaning” to allow the math to be generalized, a serious clinical documentation problem is the meaning is often obfuscated or completely decoupled from the message. At the conceptual level, work by Shannon is quite relevant. Within the Figure 1, view the “message” as the assessment and plan in the EMR. The information source and destination are Stop the Noise and Get to the Point*