If You Can Read My Note, The Patient Was Sick

When my junior year in medical school started in September of 1971, my classmates and I entered daily notes in patients’ hospital charts, loose leaf notebooks that documented their medical progress – or not – over the course of their hospitalizations. The notes were official, legal – and largely useless. About half of what was entered by faculty and consultants on any single day was so illegible that the medical alphabet more resembled cuneiform than English. The possibility of a note being misread was not lost on one of our senior professors, who mumbled: “If you can read my note, you know the patient was sick,” as he slowly wrote a note on a patient who qualified as “sick”.

Legibility has ceased to be an issue in 2015. A variety of federal incentives have made it financially advantageous to switch to an electronic health record or EHR, so that most record systems in hospitals and many in physician offices have evolved into digital files that can be rapidly – Microsoft willing – viewed as some combination of the boring  26 print letters and 10 numerals. These same systems are also capable of storing laboratory and imaging reports, and accounts of medical communications. They can directly communicate with pharmacies, transmitting prescriptions without forcing pharmacists to translate medical hieroglyphics from prescription pads. There are built-in –algorithms that even notify prescribers about potentially harmful drug interactions. The EHR can be viewed remotely, so that on-call physicians can see the detailed history of patients from home and provide better advice about acute problems at night and on week-ends.

Given the very clear benefits of a typed, digital medical record, why are so many people upset by the move to EHRs? Charles Krauthammer, the nationally syndicated columnist and a physician himself, recently suggested that the EHR is a major reason why many of his Harvard Medical School classmates from 40 years ago have become disenchanted with practice. One suggested that the EHR “produces nothing more than ‘billing and legal documents’ – and degraded medicine.” They, and other critics of the EHR, are correct – but only to a point.

The most widely used EHR is byzantine. Learning its idiosyncrasies requires hours of online and classroom education. When it is finally deployed, a horde of experienced users are still required to tutor new users. Even after gaining familiarity, entering a note or data can be more time consuming than a handwritten entry. When used in the midst of a patient encounter, entering information into a computer distracts physicians from the patient’s gaze to the computer screen, making sensitive interactions impersonal.

But the most damning aspect of EHRs is self-inflicted, iatrogenic abuse. Physicians have learned to populate EHRs with a vast amount of “cloned” and automatically imported data.  Because physician compensation is partly determined by the content of medical notes, there is a strong incentive to maximize their length and document a level of service beyond that provided. In the papyrus era, compensation was determined by the level of care that had to be provided and the time required for that care.  Today, physician and hospital payments require compulsive documentation of services – “if it isn’t documented, it wasn’t done”. This makes “copy and paste” technology for inserting long templates very seductive. In theory, this saves time that would be wasted on re-entering information honestly obtained. But, it also allows for the insertion of reams of redundant information. It is also tempting to describe patient conversations and aspects of a physical examination that never actually took place.

One physician group, with which I am familiar, enters the same, multipage note on a daily basis, changing only a few words or phrases. This allows them to continually bill for the highest level of service. Unfortunately, it creates an ordeal for other physicians consulting on their patients, who have trouble determining if a patient has any new problems. More humorous are cloned notes, created for adults, that include items inappropriate for children (6-month-olds walking). These self-inflicted flaws, arising from absurd documentation requirements, are the real obstacles to harnessing the EHR to improve care.

While it is tempting to blame government regulations for corrupting hospitals and physicians with expanded payments for using EHRs and filling them with bloated, useless notes, the real culprit is a health care system that bases compensation on volume of care provided. In that way, we are much different than most other developed nations. However, changes are coming to the medical care compensation system, and it would be major step backward if we jettisoned EHRs. They just need to be used sensibly as a conduit for information, not dollars.The immediate access to the legible record of complex patients reduces expensive duplication of tests and allows rational changes in therapy. I made my peace with the EHR in 2007, when I was forced to abandon paper, and it is now hard to imagine being at the mercy of decaying, handwritten notes. My medical school professor, who died three years ago, would have been thrilled that every one of his notes would be readable; he would have been appalled at what he read in everyone else’s.

Steven Rothman, MD is a pediatric neurologist at Mercy Health System

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2 replies »

  1. This is right on target, with a few additional points. First is the fact that we are not paid for the amount of work we do, but the number of codes we submit (and support with documentation). Since this is the basis of billing, and hence is central to the financial transaction, the entire purpose of the record changes to support the business. This business is not about giving care to patients, but codes to providers. Second is the new encroachment of “Meaningful Use” criteria and ACO’s which base payment on data submission in a specified format. This has further subverted the role of medical records away from that of…well…medical record-keeping. I agree that the handwritten notes were mostly useless due to their brevity and illegibility, but the current notes are fully legible, but awash in data and documentation “computer vomit” that equally hides the important medical information. The notes will continue to be this way until we change what we are being paid to do. If we are truly paid to take care of patients, we will document that way.

  2. What could be more reasonable than for us to demand that our administrators correct the dangerously excessive time we spend at the computer vs with the patient? It is their job. Fix it.