Finding God in the EMR

The dim monitor atop the COW (Computer on Wheels) outside room 916 flickered to life after a few insistent mouse clicks. COWs are now a ubiquitous part of hospitals, since medical records have essentially all been digitized. I briefly reacquaint myself with the patient’s chart before I enter the room. I head over to “Notes.” Pain management checked in with adjusted morphine dose. Cards noted that the patient’s EF was diminished, and that they would be starting a diuretic drip. In neat 2 hour increments, nurses left notes about bowel habits, pain, and vitals. People are constantly logging in and out of the COWs, and I don’t begrudge it the few seconds it takes for the screen to turn on. Though essentially all hospital personal document their patient interactions electronically, sometimes I get the feeling the COW would rather just be left alone.

Of all the notes the COW displays, the most incongruous has to be the ones from the “clinical chaplains.” Hospitals employ religious leaders of most mainstream faiths to help those inclined navigate the uncertain terrain of severe illness. While I’m not particularly religious, I think it a kind and decent thing for hospitals to do. Discussions that help patients clarify their end-of-life goals, or even their life goals, are helpful. But it has always struck me as somewhat bizarre that notes from these chaplains are mixed in among those from doctors and nurses.

Cows and God have a bit of a history. Moses got very angry at the Hebrews for deciding to worship a golden cow while he was away getting the 10 commandments on Mount Sinai. Thought it was disrespectful. I have to think that Moses would be, at the very least, confused by our modern COW/God symbiosis. We don’t exactly worship COWs, but we come pretty close. Medicine depends on COWs these days. As any medical professional will tell you, if the hospital-wide EMR ever shuts down (which has happened to me several times), the result is Tower of Babel chaotic.

I find the notes left by clinical chaplains, rabbis, imams, and pastors incredibly strange. For one, I don’t think most patients even know about the existence of such notes. I suspect it might change the way patients interact with hospital clerics. I’m guessing Catholic confessionals would be very different if the priest were jotting down what he heard and storing it in a permanent online file.

The bigger, issue, though, is that these notes just don’t get read. It may be due to the template-based format that so many EMR notes take nowadays. I will often peruse these notes out of curiosity and see the same auto-filled sentences trotted out. “Counseling offered.” “Spiritual empathy employed.” “Affect brightened by encounter.” Chaucer this is not. What it also is not, though, is useful, especially when you are trying to find an actual medical note. This may seem trivial, but I have seen patients with no fewer than 10,000 total notes written about them over the course of their hospitalizations. It is hard enough to piece together what different medical teams plan to do to patients, even when talking face to face, without having to wade through rivers of unnecessary text.

Moreover, everything you’d want covered by a note in the medical chart from a pastor is already covered, elsewhere. Patients have facesheets that document their religious affiliations. Hospitals urge patients to consider end of life decisions and advance directives early in their stay. Trained, professional social workers and counselors are also always available. And if patients reach a decision about their treatment plan from a talk with a chaplain, it can always be communicated to doctors in person.

It’s been a strange few millennia for God. After guiding desert tribes as an alternating pillar of smoke and fire, smiting those who dared to touch his ark, and creating the entire universe, he now finds himself rather unceremoniously inserted between the “total urine output” and “pre-anesthesia checklist” notes on EMRs across the country. I think guidance from religious leaders is perfectly appropriate for the faithful, and I am happy to call clinical chaplains for my patients. But please, let’s keep those conversations between the patient and the pastor, and out of the medical record.