Why the medical chart may not improve patient care

Why do we physicians chart the way we do? Hopefully, you do it perfectly well and have no concerns at all. But where I practice emergency medicine, we are approaching maximum inefficiency in charting.

It all became much clearer when we started using our new EMR system. Let me make it clear, I’m not against EMR. In fact, typing and templates work better for me than dictating. My dictations were usually a mine-field of blanks and misunderstood words.

Furthermore, if I wanted to use it, we have a new voice recognition dictation system, in addition to our templated chart. Though admittedly, the voice recognition program clearly hates some of my partners, as evidenced by the way they grasp the screen and yell at it: ‘Chest Pain, not West Rain!’ And by its inexplicable use of profanity in the occasional chart.

But I digress. The problem, as I see it, is the evolution of the medical record. Why does the medical record exist? In the beginning, though I wasn’t there, I suspect it was really for one reason, and that reason was continuity. So that we would know what we had already done before we did something else. It’s why old docs had records that said things like: ‘Chief Complaint: Abdominal pain and vomiting. History: Pain began in upper abdomen yesterday. Today in right lower quadrant. Anorexic, vomiting. Exam: Abdomen shows tenderness in the right lower quadrant at McBurney’s Point. Guarding present, with rebound. Diagnosis: appendicitis. Dr. Surgeon was called and will see patient at hospital.’

By today’s standards, that’s a truly skeletal chart. (Probably fine for an orthopedist). Certainly not a chart you would want to take to court, nor one from which you could generate much of a bill.

Today, that same chart is more complicated by far, because it must contain pertinent negatives, a library of extraneous information and an almost entirely parallel universe of information, generated by the nursing staff.

Today’s emergency department chart, for our unfortunate victim of appendicitis, must include a Review of Systems that again addresses his abdomen, then asks about his head and neck, his breathing, his urination, his musculoskeletal system, his heart. Even if only to say, ‘all other systems negative.’ If not properly dotted and crossed, it will result in down-coding of the bill.

It has all of the nurses’ notes pulled over to the physician chart. This includes not only the allergy, medical history, medications, family history and social situation, but also the patient’s predilections for alcohol, drugs or tobacco. It also, as prompted by the nurses, asks about his nutrition, immunizations, and in the case of women, explores domestic violence concerns. Of course, the holy of holies, the pain scale, is also prominent on the nursing side. And at discharge, the nurses are tasked with medication reconciliation forms, to ensure that the patients take the right things at home and stop the wrong ones.

Time stamps and responses to therapy are noted, as are the times that physicians were paged, the times they called back and probably the time I left the bedside for the restroom.

The shiny, modern chart, at least in the emergency department, must also note that the nurse’s notes were reviewed; that we agreed with them or documented discrepencies. And what a thing to agree with!

You see, our nurses have to do their own detailed assessment. It includes their unique interpretation of the history (which the patient may change between professionals) and their own physical exam. And woe to you if your chart should exhibit an unmentioned discerpancy between physician and nurses’ charts’! You can hear the attorney now: ‘Doctor, the nurse felt this patient had rigidity and guarding, but you did not. Can you explain that?’ At which point you might have to suggest that your assessment was probably more reliable than that of the 22-year-old nurse who has only just graduated with her RN; a fact that the attorney will likely dispute.

Sadly, physicians and nurses alike are now slaves to the keyboard. Computer systems are overwhelmed with data. Discharge instructions, in order to keep up with the belief that ‘more is better,’ are the size of pulp fiction novels (with naughtier pictures).

I wonder, are our patients better off? Are we better clinicians now? Are we more compassionate? Are we faster? Are we more careful, or do we rely on the automatic to the detriment of the cerebral?

Evidence-based medicine seems to assume that a better computer system, or a longer chart, is always better. But what I want to know is this: now that the money has been invested, are we even willing to ask the question?

And would we be any worse off, lawyers and insurers and federal regulators aside, with the old hand-written chart, one to two blessed paragraphs from start to finish?

We won’t ever find out.

Edwin Leap is an emergency physician who blogs at edwinleap.com.

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  • anonymous

    My biggest complaint is that my paper charts (yes, I still use paper charts, but I am sure this applies to EMR charts also) are so stuffed with information written for other people (such as those negative ROS lists) that I have a hard time finding the information I wrote for myself to remember! I had to create a few new separate and running sheets so I can summarize the things I wanted to be able to look at quickly.

  • http://onhealthtech.blogspot.com/ Margalit

    The “old timer” physician notes evolved from a need identified by physicians in their daily work. Both structure and content were created by those doing the work to help them make their work easier.
    Today’s chart structure is a result of outside factors, be it billing, regulations, the greater good and a variety of non practicing folks who supposedly can better see the “big picture” which cannot be gleaned from “just seeing patients”.

    Also the goal of medicine seems to have changed from treating the patient in front of you the best you can, to improving cost effectiveness of care for entire populations, and no, it is not supposed to be done one patient at a time. This is one big research project now and, as such, the documentation must be ample.

  • Doc99

    Mirrors on the ceiling
    The pink champagne on ice
    And she said, “We are all just prisoners here
    Of our own device”
    And in the master’s chambers
    They gathered for the feast
    The stab it with their steely knives
    But they just can’t kill the beast.

    Don Felder, Don Henle, Glenn Frey
    Hotel California 1977

  • http://www.pacificpsych.com/ pacificpsych

    There’s no such thing as a medical chart anymore. It’s a bureaucrat’s chart. Just thank your lucky stars you’re not a psychiatrist! At least you save lives in between the scribbling. In psychiatry the job is now 99% paperwork.

    And have you ever worked in a hospital without a computer – but with the same amount of nonsense documents for you to fill out? The Joint reaches everywhere with their “QI”. If you’ve noticed, that’s the opposite of IQ. Not a coincidence…

    Doctors could put an end to this in one moment if we all banded together and said: No. No more. Doctor’s inability to stand up for their profession is the reason this paper monstrosity has been allowed to rise and flourish.

    Would they fire every doctor in the country? Throw everyone in jail? De-license everyone? Even administrators need doctors. Even judges. It’s us that are the wimps. We don’t stand up for what’s right. We need to stand together. But that ain’t gonna to happen…

  • weak and dizzy

    At least the ER docs can write : ” agree with the medications as charted by the RN”; ” agree with the allergies as charted by the RN”, etc. As an admitting physician I can’t do that. I do find the 3 paragraphs about ” are you a victim of domestic abuse?, etc. ” to be quite helpful though. Sarcasm mode off now. The EMR is about 20 pages long now ( bureaucrats love to push paper) and usually 2 paragraphs of it ( 1/3 page) are actually clinically useful.

  • Dr Downunda

    Nothing better than having the highest paid member of the team become a highly paid data entry operator!

  • http://tjgmd99@wordpress.com doctor sabelotodo

    a couple of my personal aphorisms over 25 years of practice…”the chart speaks for itself” and “if it is not in the chart, it was not done”…charting is done so the the physician can review his/her notes, or so another pysician reading the notes can understand what is being done..in todays climate the chart can look great but the patient is dead

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    So… I too am a supporter of “EMRs”. I too am disillusioned, disappointed and in despair over the direction this has all taken. Once again, we all see the problem. Its an 800 pound gorilla in a 10 foot square room. I would venture to guess that there are well over 100,000,000,000 articles, posts, emails and coffee room conversations about this problem.

    Now… how the heck are we going to fix it?
    FaST Surgeon

  • Pattie, RN

    Perhaps, in an alternate theory, the 22 year old newbie RN did not note the patient’s guarding et. al because the patient, also a 22 year old but male, was too distracted by the nurse’s assets and framework to note his own pain!

    But jesting aside, the record is usually 97 pages (or the electronic equivalent thereof) that contains 2 1/3 pages of usefull and pertinent data. And once a month or so, administration comes up with another QI “initiative” that, in an attempt to promote safety, will cause get another error or death………or, mimimally, cause yet another nurse to leave hospital bedside nursing.

  • Marc Gorayeb, MD

    Thank God I’m not alone. I have been thinking that the most efficient solution may be:
    1) a template-based check-off sheet for the medically unimportant information,
    2) a very brief separately dictated narrative paragraph that contains the physician’s particularized thoughts about the patient, and
    3) a plan of treatment that doubles as the discharge instructions.
    The physician’s documentation would be in three separate locations in the record, but the time savings would be significant and all the interested third parties would be served. I want to try this approach; we’ll see what kind of blow-back/feedback I get…

  • David Hager, M.D.

    Though a lifelong geek, I don’t assume EHR technologies are a panacea. I have experience in working with EHR technologies that are more obstructive than useful.

    Ultimately, if clinicians don’t buy into and actually *want* to use an EHR, the whole concept will dwindle, political pressures notwithstanding. The current swell of interest fueled by temporary money will end in disuse atrophy. We have to *want* to use an EHR because we find it has become an indispensable tool – so that we can’t imagine seeing our patients without one, any more than a family doc can imagine getting by without a stethoscope.

    * * *

    I think standardization of multiple facets of EHR systems can reduce proprietary lock … i.e., not changing products because patient data is too much married to the idiosyncrasies of existing, monolithic, very expensive EHR software.

    So, for example, if I can select from a variety of software packages to sit on top of a standardized set of patient data, market competition will drive software quality up and price down.

    Clinicians can then more effectively insist upon usable software with their checkbooks.

  • http://www.heartlandclinic.org/plattecity David Voran

    I’m actually beginning to take advantage of the EMR, flexible templates and existing data to slim down my notes so they are actually moving back from all inclusive multiscreen documents with a very large signal:nose ratio to a note that actually is concise, conveys the “pertinent” positives and negatives without the extraneous material.

    The time-stamped nature of data entry from multiple entities enables quick references to the supporting data for downstream readers and users without having to gunk up a specific encounter note.

    What’s even better is that our system enables capture of multimedia data so now nearly 50% of my notes have pictures (less words), movies, sounds that are available in the context of the note or viewed independent of the encounter data in a multimedia viewer. That has also dramatically reduced the need for keystrokes and descriptive words without adversely affecting communication, coding or compliance issues.

    The trick was to get out of the paper thinking that was required when time-sensitive parallel linkages weren’t possible for those who want to look at the noise (which may actually be their signal). It’s not necessary to include the data collected by others in the physician’s note unless it’s in the critical path of the medical decision making.

    Unfortunately it took a number of years to start thinking digitally and the comments I’m getting back from downstream readers of the notes is rewarding.

    Bottom line? If your notes look like crap and have a large signal to noise ratio then start experimenting around with your system. I’ve yet to see a system that can’t be manipulated to produce relatively decent, communicative, concise and enhanced notes for downstream readers.

  • Janet

    BRAVO! Well done. I am a certified coder with many years of various medical setting experience. At this point I am in the Compliance department for a very large practice and my job is to teach the physicians how to do proper documentation. I love my job and I love taking the respectful care and time to teach them something that I clearly see wrankles the tar out of them. I agree it is crazy…..that is what happens when the government touches anything….perhaps the government should swear to do no harm also… thereby allowing us to return to the simple chart. Well written, I loved it.