1. 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 . . .
1 2 3
Chart Note 10/15/2008

2. . . . 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

3. 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.

4. . . . 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.

5. 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

6. 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

7. 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

8. 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

9. . . . 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

10. 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 . . .

11. . . . 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.

12. 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)