Tech

The Medical Chart: Ground Zero for the Deterioration of Patient Care

emr note

EMR Alert – Featuring radiologist note in illegible font color

For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.

I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.

I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.

This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.

While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.

What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?


At the risk of infecting my readers with a feeling of helplessness and depressed mood, I’d like to discuss my findings in a series posts. Here I’ll discuss why electronic medical charts have become ground zero for deteriorating patient care.

1. Medical notes are no longer used for effective communication, but for billing purposes. When I look back at the months of training I received at my alma mater regarding the proper structure of intelligent medical notes, I recall with nostalgia how beautiful they were. Each note was designed to present all the observed and collected data in a cohesive and logical format, justifying the physician’s assessment and treatment plan.

Our impressions of the patient’s physical and mental condition, reasons for further testing, and our current thought processes regarding optimal treatments and follow up (including citation of scientific literature to justify the chosen course) were all crisply presented.

Nowadays, medical notes consist of randomly pre-populated check box data lifted from multiple author sources and vomited into a nonsensical monstrosity of a run-on sentence. It’s almost impossible to figure out what the physician makes of the patient or what she is planning to do. Occasional “free text” boxes can provide clues, when the provider has bothered to clarify.

One needs to be a medical detective to piece together an assessment and plan these days. It’s both embarrassing and tragic… if you believe that the purpose of medical notes is effective communication. If their purpose is justifying third-party payer requirements, then maybe they are working just fine?

My own notes have been co-opted by the EMRs, so that when I get the chance to free-text some sensible content, it still forces gobbledygook in between. I can see why many of my peers have eventually “given up” on charting properly.

No one (except coders and payers interested in denying billing claims) reads the notes anymore. The vicious cycle of unintelligible presentation drives people away from reading notes, and then those who write notes don’t bother to make them intelligent anymore.

There is a “learned helplessness” that takes over medical charting. All of this could (I suppose) be forgiven if physicians reverted back to verbal handoffs and updates to other staff/peers caring for patients to solve this grave communication gap.

Unfortunately, creating gobbledygook takes so much time that there is less old fashioned verbal communication than ever.

2. No one talks to each other anymore. I’m not sure if this is because of a general cultural shift away from oral communication to text-based, digital intermediaries (think zombie-like teens texting one another incessantly) or if it’s related to sheer time constraints.

However, I am continually astonished by the lack of face-to-face or verbal communication going on in hospitals these days.

When I first observed this phenomenon, I attributed it to the facility where I was working. However, experience has shown that this is an endemic problem in the entire healthcare system.

When you are overworked, it’s natural to take the path of least resistance – checking boxes and ordering consults in the EMR is easier than picking up a phone and constructing a coherent patient presentation to provide context for the specialist who is about to weigh in on disease management.

Nursing orders are easier to enter into a computer system than actually walking over and explaining to him/her what you intend for the patient and why.

But these shortcuts do not save time in the long run. When a consultant is unfamiliar with the partial workup you’ve already completed, he will start from the beginning, with duplicate testing and all its associated expenses, risks, and rabbit trails.

When a nurse doesn’t know that you’ve just changed the patient to “NPO” status (or for what reason) she may give him/her scheduled medications before noticing the change.

When you haven’t explained to the physical therapists why it could be dangerous to get a patient out of bed due to a suspected DVT, the patient could die of a sudden pulmonary embolism. Depending upon computer screen updates for rapid changes in patient care plans is risky business.

EMRs are poor substitutes for face-to-face communication.

In one case I remember a radiology tech expressing amazement that I had bothered to type the reason for the x-ray in the order field. How can a radiologist be expected to rule out something effectively if he isn’t given the faintest hint about what he’s looking for?

On another occasion I called to speak with the radiologist on a complicated case where the patient’s medical history provided him with a clue to look for something he hadn’t thought of – and his re-read of the CT scan led to the discovery and treatment of a life-threatening disease.

Imagine that? An actual conversation saved a life.

3. It’s easy to be mindless with electronic orders. There’s something about the brain that can easily slip into “idle” mode when presented with pages of check boxes rather than a blank field requiring original input. I cannot count the number of times that I’ve received patients (from outside hospitals) with orders to continue medications that should have been stopped (or forgotten medications that were not on the list to be continued).

In one case, for example, a patient with a very recent gastrointestinal bleed had aspirin listed in his current medication list. In another, the discharging physician forgot to list the antibiotic orders, and the patient had a partially-treated, life-threatening infection.

As I was copying the orders on these patients, I almost made the same mistakes. I was clicking through boxes in the pharmacy’s medication reconciliation records and accidentally approved continuation of aspirin (which I fortunately caught in time to cancel).

It’s extremely unlikely that I would have hand-written an order for aspirin if I were handling the admission in the “old fashioned” paper-based manner.

My brain had slipped into idle… my vigilance was compromised by the process.

In my view, the only communication problem that EMRs have solved is illegible handwriting. But trading poor handwriting for nonsensical digital vomit isn’t much of an advance. As far as streamlining orders and documentation is concerned, yes – ordering medications, tests, and procedures is much faster. But this speed doesn’t improve patient care any more than increasing the driving speed limit from 60 mph to 90 mph would reduce car accidents.

Rapid ordering leads to more errors as physicians no longer need to think carefully about everything. EMRs have sped up processes that need to be slow, and slowed down processes that need to be fast. From a clinical utility perspective, they are doing more harm than good.

As far as coding and billing are concerned, I suppose they are revolutionary. If hospital care is about getting paid quickly and efficiently then perhaps we’re making great strides? But if we are expecting EMRs to facilitate care quality and communication, we’re in for a big disappointment.

EMRs should have remained a back end billing tool, rather than the hub of all hospital activity.

It’s like using Quicken as your life’s default browser. Over-reach of this particular technology is harming our patients, undermining communication, and eroding critical thinking skills. Call me Don Quixote – but I’m going to continue tilting at the hospital EMR* windmill (until they are right-sized) and engage in daily face-to-face meetings with my peers and hospital care team.

*Note: there is at least one excellent, private practice EMR (called MD-HQ). It is for use in the outpatient setting, and is designed for communication (not billing). It is being adopted by direct primary care practices and was created by physicians for supporting actual thinking and relevant information capture. I highly recommend it!

Val Jones, M.D., (@drval) is the President and CEO of Better Health, LLC. Most recently she was the Senior Medical Director of Revolution Health, a consumer health portal with over 120 million page views per month in its network. Prior to her work with Revolution Health, Dr. Jones served as the founding editor of Clinical Nutrition & Obesity, a peer-reviewed e-section of the online Medscape medical journal. She currently blogs at Get Better Health, where this post first appeared.

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Steve O'
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Steve O'

Medical care is an experiential, interpersonal process. It is possible to take notes to refresh one’s mind regarding individual experiences. Notes are forever subservient to the humans involved in the encounter.
There is no way to generate an independent robot to record that interpersonal process. The cart is there, but not the horse.
But what is coming – OMG U got CNCR! 🙁

Lee H. Beecher, MD
Guest

We know that moms and teens are constantly at odds over use of smart phones about whether it is OK to use them, what not to post, and with whom it’s OK to Friend or Tweet. Doctors need to have these conversations with their patients. Dr Val Jones (below) comments on the current state of professional doctor-to-doctor non-communications. Professionals are now preoccupied with producing electronic medical records (EMR) and checking boxes and cook-book case notes. Most doctors are now coding for pay. There are companies who make their money deciphering the ICD-!0 and CPT diagnostic and procedural codes that physicians… Read more »

Robert Feder, M.D.
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Robert Feder, M.D.

Thank you, Dr.Jones! Excellent article which reflects my impressions of the EHR. One additional serious weakness which you didn’t sight concerns patient confidentiality. EHRs have essentially no confidentiality. Anyone in the hospital system can get into any patient’s chart, and they are just as susceptible to hacking as the financial and personal records of the multiple organizations that have been victims of this of late (e.g. Sony, Target, Home Depot, numerous banks, etc.). Paper files are much more secure. As to the potential benefits of EHRs, you sight more efficient billing. This may be true, but as recent studies have… Read more »

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Dorcas
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Spot on with this write-up, I really believe this site needs much more
attention. I’ll probably be returning to read more,
thanks for the info!

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game-day footprints, When opinions and conjecture can make or break an athletes reputation.A string of leading ladies also embraced the trench coats photogenic,Any of these eco-friendly techniques or devices will zap the contaminants in your water, so international travellers should make sure their filter is also a purifier where water is filtered and then chemically treated. Invest in a 4×4 with high clearance, peninsulas and numerous small coves. last week. Climate and weather here are represented by the table for Faya in Chad. Early booking is pretty much essential here (Vicolo dei Soldati 31; mains from 22). but said it… Read more »

George Dougherty, MPAA Group
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Data on social media creates a grave risk and concerns about emr security. Data abstracted from practice should be concise, effective, and encrypted to prevent risk. Social media and emr is not a good idea.

More about data integrity and efficiency here http://www.authorstream.com/Presentation/mpaagroup-2158255-data-abstraction-mpaa-presentation/

George Dougherty, MPAA Group
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George Dougherty
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“EMRs are poor substitutes for face-to-face communication.”

Electronic health record (EHR) systems have the potential to transform the health care system from a mostly paper-based industry to one that utilizes clinical and other pieces of information to assist providers in delivering higher quality of care to their patients. How exactly do EHRs improve care? And what is the current evidence that certain EHR “meaningful use” functionality will translate into benefits? EHR impacts include both benefits and drawbacks. Obviously , someone needs to dig deeper to find a solution for a problem arising from the aforementioned solution.

Panha Chheng
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Dr Hassman

Easy, convenient, and popular are not only desirable, they are required, for anything to work. In general, it is not about technology, it is about how people use it. Except when the technology sucks, as is the point of this article.

Social networking is here to stay. I’d encourage you to consider what might happen, Dr Hassman, if your patients – who are likely on social networks – discovered your note about how you think about people who use social networking.

Joel Hassman, MD
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Joel Hassman, MD

Frankly, per the level of health care I have been providing for most of my career, I think a sizeable number of the patients reflect my point very painfully and accurately. And your first sentence illustrates the level of political representation that exist in this country of late, for yes, you are again painfully accurate that people only seek what is easy, convenient, and popular, and thus why health care deteriorates at the logarithmic pace it proceeds. And why people not only are not seeing real improvements in disease and dysfunction, but gives ammunition to the profiteers to continue the… Read more »

Curly Harrison, MD
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Curly Harrison, MD

I thought the post to be astute and accurate. They radically alter the administration of care. These EHR devices are doing more harm than good to overall outcomes and costs.

I like that you recognize the errorgenicity of these devices. They set up doctors and nurses to make errors.

Adverse events are common. Send yours to the FDA, using Form 3500 on line.

Paul Davidson
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Paul Davidson

Thanks for the info. This really helps. BTW, if anyone needs to fill out a form 3500, I found a blank form here http://goo.gl/NLhPMI. This site PDFfiller also has some tutorials on how to fill it out and a few related forms just in case you need to fill out one.

Joel Hassman, MD
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Joel Hassman, MD

I think this is a great post, but, then reading the author’s credentials doesn’t speak for one being an active Locum doc. So, if there is some incongruency at hand, I would hope it would be clarified. As I am doing Locum work again, and dealing with EMRs with regularity, I find them contraindicated for the patient-physician interaction until proven otherwise. Rapport and alliance is not built with no eye contact nor normal flow of discussion. Oh, and reading some of the usual quick and rigid defenders of EMR here, spare us the undertone of disgust and outrage to have… Read more »