We need to reassess the patient note

I recently tweeted about Danielle Ofri’s important piece, The Doctor Will See Your Electronic Medical Record Now.  I like the piece, and especially like some of the quotes, but still I believe the problem needs an expanded take.

Context represents the major advantage of 38 years experience as a physician.  Over time, one sees trends come and go.  Hopefully one can see the strengths of the “good old days” and yet recognize progress.

Most physicians love medicine the most when we are with our patients.  We like talking with patients, examining patients, and trying to help patients.  We do not like charting.  We dislike filling in meaningless data just to meet billing requirements.  We hate reading computer generated notes; notes generated to satisfy Medicare, Blue Cross/Blue Shield, etc.  We like getting it right.  We hate forms.

When I started, most private physician notes were undecipherable.  Most resident notes actually were helpful.  We learned to write SOAP notes, and often you could actually understand what your colleague was thinking.

Along came the resource-based relative value scale (RBRVS) and notes began to deteriorate.  We started having coding workshops, learning the components of a billable note.  The notes began to deteriorate again.  Then came electronic medical records to save us.  They guide us through the note, demanding all the information to allow a level 4 or 5 billing.  But high billing codes do not require sensical notes.  Our notes had more “stuff,” rather more “fluff,” but less meaning.

Electronic health records are a great idea, poorly executed.  Too often they are more about billing than communication.  Too often physicians use checklists rather than free text, because checklists are quick and free text is slow, because we can do easy data analysis on checklists, but not on free text, because checklists allow us to bill higher and we get paid more.

We need to reassess the patient note.  The patient note should have nothing to do with billing, rather it should focus on communication with other professionals and reminders to ourselves about how we thought about the patient when the note was written.  The note should be informative.

Physicians should spend more time with patients and less time with computers.  Physicians should spend adequate time with each patient rather than rushing through visits to improve their RVUs.

Dammit, we are not making widgets.  Patient care takes as long as patient care takes.  Some patients need short visits and some need long visits.  Most do not need a 12 point review of systems or a full physical exam documented.  When I see a patient in the hospital with pneumonia who is improving, why should I examine the oral cavity again, or even the abdomen again (assuming no new symptoms).  I should listen to the lungs, assess the work of breathing, review the vital signs and assess the patient’s progress. I should consider every day the possibility of discharge.

I should care for the patient. Caring for the computer does not compare.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Suzi Q 38

    You are so right doctor.
    I hate that computer, too.

  • Chip Lohmiller

    Article: read;yes. Thesis: agreement;yes. Problems: emr;templates;not designed for narrative;yes. OTHER: This physician aknowledges that he/she feels/felt pain of author.

    Heart failure handouts:given. Smoking cessation: discussed. (Pneumonia vaccine due.) Time spent: 5 mins. electronically signed by author/scribe/PA/NP.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Addendum: Hilarious.

  • Ron Smith

    Hmmm. Maybe its not your computer that is the problem but the IT guy who programmed it who has no clue how doctors think and what we need to record.

    I designed my own EMR and deployed it in 2000. It is based on the H&P and has readable notes. And it has quick choice lists and the ability to edit and change any of the fields. I also have the ability for each provider to create and modify as many ‘templates’ for different types of exams as they want, worded the way the want.

    These are not checkboxes either. They are real text choice lists with English sentences that read the way I write.

    I focus on the exam. Yes, we mostly do the same exams for different types of patient issues which means we can do good, consistent medicine. EMR’s are good at helping me do that.

    What I really hate is when a patient brings me the printed emr records from a previous doctor with those checkboxed forms you have to fill out, and they point out specific things that it says for specific parts of the exam which they know the doctor didn’t do.

    As physicians we should demand better from the software! If I can do it in my office then it can be done. Just the other day, my practice manager and I were discussing some of the features one of my nurse practitioners had. My practice manager mentioned that our last HEDIS evaluator commented that our documentation was the best that she had ever seen, something that I forgot.

    Not everyone can write their own software, but doctors can vote with their feet! The most used and popular stuff out there actually is probably the worst as helping us do our job.

    Ron Smith, MD
    www (dot) ronsmithmd (dot) com

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Just curious, is your EMR meaningful use certified?

      • Ron Smith

        Hi, Margalit. No, I chose not to get involved with meaningful use certification. I personally would not want to be on any kind of government assistance for my livelihood, even if I wasn’t able to work as a physician. Taking the meaningful use dollars just felt like that to me.

        Besides, meaningful use does not mean that you are going to make money with any software. It only makes you subjugated to intense government control. That is what taking those dollars means…more regulations and more reporting requirements. Failing to meet the requirements will certainly require you to pay the money back.

        What I focused on with my software was high efficiency. I’ll mention just two examples.

        In Georgia, we have the GRITS vaccine registry. It is a go idea, but a bad implementation. There is no built-in realtime access to uploading vaccine information directly from EMRs. The vaccine form 3231 in Georgia, has to be an approved form and it has to be completed in its entirety EACH time you give vaccines. With older children and lots of vaccines that could mean 5 to 7 minutes just to complete that one form.

        I am the only software vendor in the state of Georgia that has real time upload and download of the vaccine records. (It is a trade secret in fact). It take my nurses about 2 seconds to create an approved 3231. The estimated worker time saved must be in the thousands per year.

        My practice manager does all the EOB processing and billing and pay plans by herself. An extensive EOB that might take 2 to 4 hours to hand enter, only takes 15 seconds with our software. She floored me when she told me that that one feature saved me some $75,000 YEARLY on labor costs. That saving is real money and is year in and year out, not just a one-time payment.

        These examples are just a few things that show how great design handily trumps meaningful use. I will never be a part of meaningful use (what I call government abuse).

        Ron Smith, MD
        www (dot) ronsmithmd (dot) com

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Thanks, Dr. Smith. Sounds wonderful.

  • southerndoc1

    Like someone pointing out that the Venus de Milo has no arms, Dr. Centor identifies the most obvious failings of EMRs. He seems, however, to be completely clueless as to the cause, and thus the solution, of these problems.

    As Ms. Gur Arie implies, it’s not that EMRs are poorly designed, but that they are very well designed to function in an anti-patient, anti-physician ICD/CPT/P4P/MU health care system.

    “Physicians should spend more time with patients.”

    I don’t think anyone would disagree. In a sane world, one would expect the medical societies to be aggressively advocating for that.

    So, Dr. Centor, as someone who is very involved with the ACP, what has your society done to bring that about? It’s a fact that the ACP propagandized for EMRs way before they were ready for real time use. Has the ACP done anything to denounce MU/P4P/CPT/PCMH?

    I think not.

    What we have here is nothing but crocodile tears.

  • Pauline Lambert Reynolds

    I recently moved to another state and hand carried some of my records. I am struck by the essay/conversational records, taking up much more space, making my record larger, insuring that the whole record will not be read. Many pages are repetitions of prior visits and approximately one paragraph would have sufficed to record the current problem.

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