When 'note bloat' masks a fatal condition: The care team vs the EHR

In 2022, a healthy 34-year-old Louis-Hunter Kean found himself in and out of the hospital after experiencing vague symptoms. ^[] Kean was seen by multiple specialists, but a diagnosis wouldn't come until it was too late (he died in November 2023).

It wasn’t until Kean was in organ failure that they determined the cause: visceral leishmaniasis (VL), a severe but treatable disease caused by a parasitic infection from a sandfly, says Brian Labus, PhD, MPH, Associate Professor in the Department of Epidemiology and Biostatistics at the University of Nevada.

The path to diagnosis was paved with missteps, captured in a disorganized and EHR, according to the the law firm representing Kean’s family in a malpractice suit. ^[]

Critical entries were somehow missed altogether, like the request for certain kinds of tests, and warnings against certain medications in the setting of a potential infectious disease. 

The EHR: An invaluable but imperfect tool

Neima Briggs, MD, PhD, an infectious disease specialist and Instructor of Medicine at Yale School of Medicine, says that modern EHRs are simply not optimized to disseminate medical information, including recommendations, between medical teams. 

“I have managed similar cases that require a substantial investment in time to pull together records between different health networks and even within my own,” he states. 

Dr. Briggs also wonders if the chronicity and “waxing-waning nature” of VL could have contributed to the complexity of the EHR in Kean’s case.

Jared L. Ross, DO, an emergency medicine physician, agrees, saying the EHR is an undoubtedly invaluable but imperfect tool: “The increased amount of information available in the EHR has created a situation of information overload where physicians are expected to sort through hundreds of data points to find only one or those that are meaningful.”

Too much information—and too little

In fact, a 2022 article in the  Journal of Patient Safety found that physicians often complain of “note bloat,” or excessive chart information. ^[] Excessive information in a chart, the authors  found, can impair comprehension and lead to errors. Docs might even spend more time in the EHR than they do interacting with patients.

“One study looking at adverse patient safety events due to the EHR cited a lack of EHR usability for 28% of these events,” the authors wrote. ^[]

On the other hand, there are also problems with information that does not get entered into the EHR. Dr. Ross cites problems with how tests are ordered and how results come in.

“Doctors cannot possibly keep track of the often hundreds of tests they ordered today,” he says. “When tests do not get performed for one reason or another, doctors are often not notified of that fact.” 

Thankfully, some EHR systems have redundancy systems: “Several electronic health record systems now allow doctors to flag especially important tests they have ordered and to receive secure notifications on their phone when the test results are available,” Dr. Ross adds. In the end, for Kean, it was a case of both too much and not enough information. 

“This is a tragic case, and my heart goes out to the patient's family and friends,” Dr. Ross says. “However, medicine is an imperfect science practiced by fallible humans using inadequate technology.”