Archive for the 'Opinions' Category

Medical Records for Amnesiacs

I wish CMS and my EMR would stop treating me and everyone who reads my office notes as if we were all amnesiacs.

I also wish they would recognize that primary care is not something that happens only once, in a fifteen or thirty minute visit, and never again.

If we accept these two premises, we are a long way toward health care, or at least primary care, reform.

Before EMRs I used to secretly smirk inside at how much better family physicians’ medical records were than internists’:

Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.

Internists, I thought, were like bag people. They carried all their belongings with them, or, they told each patient’s story over from the beginning in every visit, like this:

“This 62 year old male with a 40 pack year smoking history, psoriasis on methotrexate, well controlled diabetes, hypertension, prior myocardial infarction with two bare metal stents and ongoing Plavix therapy, current EF 59%, has a history of mild GERD managed with OTC omeprazole and a history of a normal colonoscopy at age 50 has a baseline hematocrit of 39 but was recently rejected at a company blood drive due to a low hematocrit. He comes in today for a swollen left knee.”

(Every office visit would start about the same way, and almost every visit would touch, at least briefly, on each diagnosis.)

Oh well, when EMRs came into being, the internists’ office note, albeit in bullet form, came to be the model we all follow. Sure, we have side bars with some background information, but all the background information shows up in every single office note, even though all that history is visible on the same computer screen or only a click away.

Somebody seemed to think doctors are all amnesiacs, and that we really need the thumbnail sketch of every patient, every time. Or (Gasp!) some of us may have wanted to give the impression that we truly ask about all that history from scratch at every visit just to score a higher reimbursement.

Of course, the internist way of story telling is modeled after the hospital record, which tells the story of a distinct “episode of care”. And now hospital thinking has crept into and contaminated primary care with disastrous consequences.

The primary care record doesn’t just tell stories of separate “episodes of care”; it is more like a quilt of many story lines, which play out simultaneously and over extended periods of time at different speeds.

Why, then, are our office notes modeled after institutions that deliver nothing but episodic care, and who view a returning patient as a treatment failure?

Primary care is practiced over time; we have more than one opportunity to ask those sensitive questions, offer that immunization or have that talk about smoking or obesity. In fact, there is a right time and many wrong times for most things in life. The right intervention at the wrong time can be insensitive, insulting and counterproductive.

In today’s office visits, we force our way through laundry lists of items our patients never asked us to cover, and we are obligated to fill up our office notes with them.

The cumulative effect of bulking up the office note with historical data that belongs in a sidebar, and the misguided idea that primary care doctors may have only one single shot at delivering preventive care and all the social interventions the Government has now shifted from the public health sector to the health care sector have caused primary care to slow down to a crawl.

Because we are so stuck on the idea that we must provide comprehensive care in every single visit with extensive documentation of what is almost a spinal reflex for experienced physicians, we are seeing many fewer visits than we used to.

We are turning away patients in need of primary care and we are limiting patient access to timely care by making it too cumbersome for primary care practices to see patients for simple problems like sore throats, ankle sprains and rashes. This results in unnecessary emergency room visits and fragmentation of care through the use of unconnected urgent care facilities.

Here is a solution to the mess we are in:

Put those items that are not immediately relevant to the chief complaint or diagnosis of today’s visit in side bars and flowsheets, which would give summaries and timeline documentation of all our efforts at comprehensive care over time. Then, let us refer to these when we make an entry or simply review their contents, but please deliver us from the onus of including every detail of it in every visit. Even if we auto-import them, it makes our own office notes too long to even have time to review the next time we see a patient. And when we get outside records on patients transferring in, it is impossible to find anything relevant in the reams of printed notes we get, because every visit runs 6-8 pages and each one contains virtually the same information.

Let us do well by the patients we are entrusted to care for by paying enough attention to the problem they’ve come to see us about, instead of touching everything in a superficial, perfunctory manner and accomplishing little or nothing except creating an illusion of comprehensive care only meant to impress or placate insurance billing people and public health bookkeeping types. You can only cover so many topics in fifteen minutes.

Why Can’t We Speak Our Own Language?

My voice recognition software insists on typing “when needed” when I say “PRN”, and the other day I saw an orthopedic note that said “before meals joint”. I was sure that the straight-laced orthopedic surgeon was not intending to tell the world anything about anybody’s cannabis use. Instead, it was obvious he had spoken the words “AC joint”, meaning acromioclavicular (on top of the shoulder). But AC can also mean “before meals”, (ante cibum).

Hospitals and health care credentialing bodies make us use plain English instead of medical terms and abbreviations. They say it is to avoid confusion. I think it often creates confusion when doctors are forced to speak as if we didn’t know medicine.

Why are we singled out for this dumbing down? Why are we robbed of the language of our own craft?

How would it be if the tech industry couldn’t use abbreviations like LCD, LED and HDTV?

What if Wall Street outlawed terms like hedge, spread and spot market?

What if military jargon was verboten in the war rooms of the Pentagon?

What if coaches weren’t allowed to scream any technical terms to their teams from the sidelines?

Do we really think a jargon free, plain speaking world will move with greater accuracy and with anywhere near acceptable speed if we remove the majority of the new language our progress was built on?

Dropping the SOAP Note

The SOAP Note isn’t what it used to be, and what it has become needs to be scrapped, because it has made the office practice of medicine cumbersome and unsafe.

In simpler times, when medical records were written by and for doctors, the SOAP Note represented a significant leap forward in terms of expanding and organizing office notes, and also notes from emergency rooms and walk-in clinics. Prior to that, notes sometimes only documented the diagnosis and the treatment, not how those were arrived at.

With S for Subjective, O for Objective, A for Assessment and P for Plan, the reader could instantly find exactly what he or she needed to know from a colleague’s medical record entries.

These days, medical records contain a lot of data that is mandated by outside parties – CMS, ACOs, PCMH/NCQA, the Joint Commission, and now even local states, like Maine.

EMR vendors have inserted these mandated items in sometimes very illogical places in the medical record, and they have also infused bookkeeping items where they probably work best for billing purposes, but definitely not to document clinical thinking.

Some examples:

I see many ER notes that don’t clearly state the patients “Chief Complaint”. I see that they got there by private vehicle, gave the history themselves, didn’t need an interpreter, had already had all their baby shots and were not yet ready to quit smoking, but I’ll be darned if I can figure out what brought them out in the middle of a snowstorm to see somebody in the emergency room.

In the SOAP Note, anything observed during the visit instead of told to us, such as vital signs, heart sounds, blood tests and in-house X-ray findings would go under Objective. Tests ordered but not expected back until later went under Plan.

In the EMR I work with (or under?), there is no Objective and no Plan. There is Exam and Treatment.

That difference isn’t subtle.

The tests I do in-house are ordered and resulted under Treatment, after I have already stated under Assessment what the diagnosis is. That makes no sense. A chest X-ray doesn’t treat anything. The antibiotic I prescribe goes there, too, so at least that makes sense. But essentially, the logical and chronological order of my notes has been hijacked by non-clinicians.

More static items like past medical history, family and social history used to go on the inside left of paper records, where they could be referenced and updated on the fly. Now, just like in a hospital admission note where the patient is presented as if they had never been seen before, they are prominently displayed in every single office note.

That is one of the fundamental differences between a paper office note and an EMR note; the former is pertinent and the second is comprehensive, because the note presumably has to document that the doctor mentally went back over known historical facts and considered their possible relevance for the problem at hand with the speed of expertly trained thought and hard earned experience.

It didn’t seem enough to keep the background data separate and simply state “I considered the Past Medical, Surgical, Social and Family history in handling the patient’s issues in today’s visit”.

Even if someone I stitched up ten days earlier just comes back to have the stitches removed, the second office note reads as if a stranger just walked through my clinic door.

In such a case, a visit that lasts less than five minutes from the doctor’s point of view requires verification of all the data that isn’t likely to have changed in ten days, and the office note is just as long as the original note about the chainsaw cut or their first get-established visit – seven pages of 99% irrelevancy for a simple suture removal.

The mandated add-ons’ presence in every single office note has created a clear and ever-present danger that time-pressured clinical staff and physicians will miss critical information and put patients at risk for clinically incomplete care, even though I’m sure the non-clinicians’ intent at some point was to ensure the opposite.

All these additions have inflated and cluttered up the SOAP note to the point where I think it is high time we reclaim a space, however small, inside the office note for strictly medical documentation that is immediately pertinent.

This nugget notation needs to be near the top of our computer screen, so we don’t have to scroll, even to get from the beginning to the end of it.

We must accept that the office note serves the needs of many people and bureaucracies, but if we don’t make it serve us better, we’ll drive ourselves into the ground and at least some of our patients into their graves because we might miss critical things in the overinflated medical records of today.

The Meaningful Use Paradox

Our clinic is worried about qualifying for this year’s Meaningful Use incentive payments. We have this hastily purchased EMR that was supposed to make life easier and quality better for all of us. The EMR vendor got paid a long time ago but we are still dealing with the administrative burdens imposed by our new system.

By attesting that we can use this thing reasonably properly, we can receive some Government incentive monies, which even under the best of circumstances don’t even begin to make up for all the extra expenses and productivity losses we have incurred through going digital.

What we are up against is a product that doesn’t do, or doesn’t easily do, what we were told it could. And the vendor isn’t working real hard to help us achieve Meaningful Use.

I know how things could get better:

Every quarter, impose a rebate of 25% of each EMR purchase price, paid by the vendor to each practice that isn’t able to use their product as promised. That would place the problem where it belongs, instead of with the hapless consumer. I think that would speed up product improvement and tech support a whole lot.

Compare today’s struggle to achieve Meaningful Use with what happened with faulty General Motors ignition switches, exploding Takata airbags and polluting Volkswagen diesels. Nobody blamed the consumer for such problems.

Why, then, are medical providers held responsible for having bought, under pressure, less than functional electronic medical records?

Make the EMR vendors attest instead of us!

Double-Booking the Doctor is Half-Booking the Patient

Not only have we shortened medical appointments to 15 minutes. We also sometimes double book them.

I get the feeling that non-providers think of this as something fairly ordinary, and even reasonable. But it is often a very difficult and destructive thing to do.

The term “double booking” and the way it looks in an ordinary doctor’s scheduling grid suggest that the physician might possibly be expected to be in two places at the same time. That is hardly ever the case for those of us who are mere mortals.

Sometimes a patient does need a lot of non-provider time, for example to get undressed and ready for a Pap smear. In such a case the doctor could take a quick look at another patient’s sutures or something simple like that in another exam room while the first patient is getting ready.

There is a tendency to squeeze in simple things almost anywhere, but, depending on who is losing half of their fifteen minute appointment, that might be a very unkind thing to do. In today’s reality, with Meaningful Use, ACOs and Patient Centered Medical Homes, we have to screen for various conditions and risk factors, update medication lists, immunizations and family and social history in every single visit. There really are no in-and-out quick visits anymore, thanks to our well meaning(?) Government.

In small practices, where the scheduler knows patients really well, it might be possible to predict better whose visit will be short and whose will take more time. But we have found as we have grown that this kind of knowledge is disappearing a little, and in some computer programs, the scheduling grid doesn’t show the names or concerns of scheduled patients, just that a slot is already filled.

This is why, the other day, somebody else got double booked with an elderly patient of mine who was given only a fifteen minute appointment for depression.

Double booking is sometimes used as a strategy to manage no-shows. That can be really bad.

In some practices, patients who have no-showed too many times are double booked with another patient, so that the expensive doctor doesn’t risk being idle for fifteen minutes. Of course, if the habitual no-show patient does make it to the appointment, the doctor is faced with managing both the catch-up of a patient who may be well overdue for whatever they came in for and the compromised visit of another unsuspecting patient. That unfortunate person ends up paying the consequences of having another patient booked in the same time slot. Two players in this triangle pay the price of the past transgressions of the third.

There is no good solution for no-shows. Dismissing such patients may seem easy for the practice, but even if you don’t believe health care is everybody’s right, some people no-show because of their economic or social situations and really need to be seen when they are finally able to keep an appointment, for example a child who is behind on immunizations.

The double booking due to being busy needs to be looked at in a humane and business-like way, and it needs the direction of the medical provider: The random double booking of unmarked squares on a computer screen is no better than throwing darts. We need to analyze our data to better predict the demand for services on a Monday morning or Friday afternoon before a long weekend.

And we need to risk a provider sometimes having fifteen unscheduled minutes. That time could be spent on patient relations or care coordination. Because doctors aren’t just faceless widget makers who produce visits. We are the ambassadors and medical leaders, or brains, if you will, of our practices.

EMRs, PCMH and OCD are Limiting Access to Care

We have a problem in our clinic.

Between our EMR implementation a few years ago and our PCMH recognition shortly after that, our office visit documentation has become bloated and our cycle time has almost doubled.

There are no brief visits anymore, since every visit entails screening for multiple psychosocial conditions and consideration of various immunization and health maintenance reminders.

Nobody sees over thirty patients a day anymore; we’re lucky to exceed twenty.

That means patients today are actually more likely to go to walk-in clinics or emergency rooms than they were a few decades ago. We’re still okay with PCMH as long as we have a single open access slot at the beginning of every day, and we don’t actually get any credit for squeezing in, or double booking, acutes.

It also means patients with chronic illnesses get seen a little less often than they used to. Sure, we have RN case managers who can stay in touch with them, but the communication between them and the medical providers is hampered by the new busyness of checking our electronic inboxes, which takes seconds longer for each item than the old paper reports used to take, and which is done “in between patients” in our already tight schedules or after hours, staying late at the clinic or logging in from home.

It wasn’t supposed to be this way.

Here is what we hoped and were led to believe would happen:

1) EMRs were supposed to make documentation lightning fast.
2) EMRs were supposed to make data review and retrieval faster than paper systems.
3) PCMH would have us transform into physician driven, super-efficient, yet warm-and-fuzzy places filled with patient friendly personal touches.

Instead, medical practices have evolved into bigger bureaucracies with OCD afflicted doctors who don’t lead practice transformation, but who feel personally responsible to compensate for all the shortcomings of their hastily implemented, immature technology.

OCD may be the most significant and destructive acronym in today’s healthcare environment. And we have all been cultivating it, medical practices and providers alike.

The old school expression of OCD, in Marcus Welby’s era, was extremely high physician productivity and unwavering personal commitment to patients.

The new manifestation of OCD is trying to follow overly ambitious, often conflicting Federal edicts and mind-melding ourselves with our computers to the point of losing touch with our patients’ real needs.

Why else did we end up with a working environment where we allow ourselves to be distracted by health maintenance discussions when somebody comes into see us for what should be a ten minute visit for a simple sore throat, or when they are in pain from an injury?

(A ten minute oil change for your car is not the same as a 100,000 mile service, is it? Why is health care any different?)

Why else do we think that it is appropriate to do depression, alcohol, smoking, domestic and drug abuse screenings on new patients the minute they walk through the door to size us up as their chosen new health care provider?

(How did it become patient centered not to spend the first visit, or even the first few minutes of a new therapeutic relationship, listening to the concerns of a new patient?)

Why else, if not because of our personal and organizational OCD, are we sending our own patients to the walk-in clinic instead of fitting them into our own schedules? Isn’t it because of our obsessive fear that we might document such a quick visit without the required Federal accoutrements and end up scoring poorly on some arbitrary quality scale?

(Do we really think the walk-in clinic will do a better medication reconciliation than we do if we squeeze a 45 year old hypertensive diabetic in for quick look at an ankle sprain?)

Pardon my comparison to veterinary medicine, but in my veterinarian’s cash practice, they manage their health maintenance reminders by simply printing them automatically on the receipt. If I bring a pet in for something simple, they don’t bloat the visit up by talking about things I didn’t come in for; they stay on schedule and I can read the printed reminders at my leisure.

Somehow, in the new vision of primary care, we went from taking care of our patients over a continuum of time to doing everything all at once, as if there were never going to be other visits. That kind of OCD is anathema to real primary care.

And somewhere along the path to more patient-centeredness, we got sidetracked by the paternalistic ambitions of our biggest payer, Medicare, into hammering our customers with Federally imposed public health agendas that have little to do which their personal vision of why they need a doctor.

To quote a new patient who came in to size me up a few years ago:

“I need a doctor when I’m sick.”

Access, in other words.

From Learned Professionals to Skilled Workers: The Dangerous De-professionalization of Medicine

Physicians today are increasingly viewed and treated as skilled workers instead of professionals. The difference is fundamental, and lies at the root of today’s epidemic of physician burnout.

Historically, there have been three Learned Professions: Law, Medicine and Theology. These were occupations associated with extensive learning, regulation by associations of their peers, and adherence to strong ethical principles, providing objective counsel and service for others.

Learned Professionals have, over many centuries, worked independently in applying their knowledge of Law, Theology or Medicine to the unique situations presented by those who seek their services. They have done this work with a significant freedom that has been balanced by their commitment to the fundamentals of their disciplines and responsibility to their professional corps. They have answered to their clients, their profession and to the legal system of their countries, perhaps with the exception of where the Church has defied or resisted Government.

Skilled workers are different from Learned Professionals in that they, although their work may be highly complex, don’t independently interpret the theories behind what they do, but instead follow strict protocols and orders from supervisors. Examples of skilled workers are nuclear reactor operators, commercial jet pilots and Certified Public Accountants. No matter how much skill we require from nuclear reactor operators, for example, everybody sleeps better at night if they always follow their protocols and we assume that there are protocols for every imaginable scenario.

This is how many people, and particularly those who are now in roles of administration and finance in Government and the healthcare “industry”, have come to view Medicine; they think it is too important a job to trust individual providers to do well in without lots of supervision and protocols even more detailed than those in the nuclear or airline industries.

A few, narrow, specialties in Medicine and probably also in Law and Theology, might lend themselves to closer comparison with running a nuclear plant or flying passenger jets, but the definition of the Learned Professions is that they deal with not only complexity of but also with the uncertainty caused by the infinite human variation in expression of their science.

The narrower areas of Medicine, like joint replacement surgery, have tempted many to compare Medicine with manufacturing, for example. But even joint replacement surgery requires a level of judgement that goes far beyond the manufacturing paradigm, beginning with making the assessment, in collaboration with the patient, whether joint replacement is even indicated and safe for the individual in the first place.

The management of everyday conditions like diabetes, hypertension, depression and abdominal pain requires solid scientific knowledge, yet also involves high degrees of uncertainty and complex decision-making with infinite variables to consider. In other words, to think these conditions can safely be managed by protocols is naive; “guidelines” in Medicine are only broad brush strokes of the general principles we follow or at least consider, but would be detrimental to countless patients if actually followed as if they were protocols.

The argument has been made that Medical Science has grown so exponentially that individual doctors can never stay informed enough to make independent judgments about patient care. Logic dictates that this explosion requires even more independent judgments, because it is simply not possible to develop “protocols” for everything. Anyone can see that a patient with four or five conditions will have issues where what is done for one condition has a negative impact on another, for example. We face this issue in almost every patient encounter.

The other day, I had to prescribe an antibiotic for a patient with a serious blood clotting problem. The antibiotic I thought of using could interfere with my patient’s blood thinner, and the ones that don’t interfere are less effective. There are no protocols for that.

The same day I talked with a student about the risk of serotonin syndrome when you co-administer certain medications. For example, modern antidepressants and common migraine medications could theoretically cause this syndrome. My student had read it in a textbook and our computerized databases warn us every time that prescribing them both may not be a good idea. The literature reports this interaction to be rare enough that major headache societies support using the combination with common sense precautions when both medications are indicated. Making that judgment in individual cases requires knowledge of the drugs, understanding of the patient’s condition, and awareness of the current literature, because textbooks quickly become outdated.

I also talked with my student about the new study that suggests that more aggressive blood pressure targets for treatment of hypertension than the JNC 8 “guideline” are associated with lower rates of cardiovascular events. Which number should one strive for – in a high risk middle aged patient, and in a frail, elderly, patient?

This is why Medicine should still be classified as a Learned Profession. And this is why doctors must hone and honor their scientific knowledge and critical thinking. And this is also why patients, who can get any isolated piece of fact they would ever want from the Internet, still need us as trusted guides, whose understanding of Medicine runs deeper than sound bytes, blog posts, news flashes – and “guidelines”.


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