Creating a truly meaningful and useful patient medical record

I have a vague recollection, a memory shrouded in mist, where I pondered what seemed like a radical question: What would a health record look like if my only concern was patient care?  This was a radical question because in my previous life I was an electronic health record aficionado.  I was good at EMR, which meant that I was really good at finding work-arounds:

  • How can I work around the requirements for bloated documents and produce records that are actually useful?  The goal of records in that previous life was to justify billing, not for patient care.
  • How can I work around the financial necessity to keep my schedule unreasonably full and keep my visits unreasonably short and still give good care?
  • How can I work around the fact that I am paid better when people are sick and still try to keep them healthy?
  • How can I work around the increased amount of my time devoted to qualifying for “meaningful use” and still give care that is meaningful?

Computers were all about automating the drudgery, organizing the chaos, and carving out a sliver of time so I could spend the extra minutes needed to give the care I wanted to give.  I was using them to give good care despite the real nature of the medical record: a vehicle for billing.

But that was my past life. Now I no longer have to worry about a Medicare audit (and the looming threat of an accusation of “fraud” for simply not obeying the impossible documentation rules).  I no longer have to keep my office full and my patients sick enough to pay the bills.  I am actually rewarded for handing problems early, for communicating well, and for keeping patients healthy and happy, as it keeps them paying the monthly subscription fee.

Ironically, in asking the question, what would a health record look like  if my only concern was patient care,  I was really asking the question: what does “meaningful use” of the record really look like?  Now this question is no longer a hypothetical; it is real.  My rejection of EMR systems that catered to my previous needs and my quest to build one that fits my current needs have given me the chance to work very hard at answering that question.  The success of my practice, and the success of other practices like mine, will depend on our ability to answer that question.  I am now in a system that actually values communication, prevention, and organization, so I no longer need computers for work-arounds; I need computers to help me reach those goals.

As I’ve spent an enormous amount of time and energy (a.k.a. obsession) on my own system, I have come up with unexpected opportunities:

1. Abandon the artificial centrality of the office visit

The care I gave in my former life was held hostage to the office visit. This is not only (as I have mentioned before) the unit of commerce, but the unit of documentation.  Even in my new practice, where I am no longer loathe to give time and information outside of the office visit, I still am drawn to this unit of documentation.  Why?  Isn’t in-office care merely one of many communication options?  Isn’t it part of a continuum of communication happening over time?  Why should I separate the phone call earlier in the day from the visit that phone call prompted?  Why should I wait until they are in the office before getting a history?

An example came a few weeks ago when a patient injured her finger.  She has close contact with a dentist, who offered to get an x-ray of the hand.  I got a secure message with a jpg attachment of that x-ray, revealing a fractured bone at the end of the finger.  I messaged her back, telling her what to do about it, including my nurse on the message, asking if we had purchased splints when we started the practice.  We hadn’t, and so Jamie ordered them, notifying the patient when they arrived.  The patient spent a total of 5 minutes in my office, but the care extended over several days.

This scenario has repeated itself in other forms, including: diaper rashes that don’t heal (more pictures), intermittent abdominal pain, new-onset diabetes treatment, and post-lumbar puncture headaches.  Attending to these problems as they happen (instead of requiring office visits) is far better for both patients and me.  My availability to help patients in this circumstance lets me handle problems while keeping my office empty, while my empty office enables me to have the time to answer these questions (without the previous angst over lost revenue).

So how do I document this?  The records of my former life didn’t consider such questions, but my new freedom brings this issue front and center.

2.  Embrace simplicity and organization

When dealing with such problems, the focus is not only on communication, but informed communication.  Since I am not forced to gather all of the facts at an office visit (a truly impossible task for both doctors and patients), I need to have a better way of keeping track of things.  I have to have a record that immediately tells me what I need to know about the person with whom I am interacting.  The best decisions are made with the clearest picture of the situation, and I need a record that gives me that picture as efficiently as possible.

This is a far cry from my former life, where I was forced to include massive amounts of E/M vomit in every note to justify billing.  The facts were hidden in the medical record, not revealed by it.  What was the penalty for not having all the information I needed or for the bad decisions that were the result?  Patients stayed sick, came back to the office, and I got paid more.

So, I have been forced to find new ways of organizing information.  When I look at a person’s medical condition or a specific symptom, I want to have access to:

  1. All medications related to it.
  2. All encounters where it was addressed.
  3. All  associated testing, procedures, surgeries, and hospitalizations.
  4. The opinions and contributions of other doctors on the issue.
  5. A clear idea of it’s impact on the patient.

I want this information with as little work as possible so my communication can be as efficient and effective as possible.  It’s been a tough task, but I think I’ve found a way to do this without demanding extra work.

3. Give that record to the patient

I am not the only one who needs good information; the patient is an equal participant in these conversations, and the one with the most to gain from good decisions.  The only solution I can see is to put this information where it belongs: in the hands of the patient.

If I had embraced this idea fully in my previous life, I would have been faced with a problem: the medical records sucked.  The useful information that happened to be present in the record was buried in piles of coding compliance refuse, obscured by reams of superfluous data.  Our records were better than most, and yet sharing them would reveal to our patients how little time was spent keeping them organized and accurate.  We simply had more important things to do: things that paid the bills.

Creating a truly meaningful and useful record has not simply been something I’ve done for myself; my ultimate goal is to not only give them to the patient, but to invite them to help me in the never-ending task of keeping them organized and updated.  My job will be to curate that information, as I better understand which parts of the information should be emphasized, and which should be available when needed.

I’ve got more points to make, but will let that go to another post.  The point I want to make clear is this: the radical change in my payment model has forced an equally radical change in the systems that support that model.  I can’t put new wine in old wineskins.  The medical record of my past life was built to help with the problems inherent in that sad existence, and they served to amplify the sadness of that existence.  Now living in a much happier, patient-centered world, I can build something that will increase that goodness and happiness.

Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).

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  • Thomas D Guastavino

    It sounds as if you have converted to concierage care. For better or worse you have the discovered the sad reality that patients with the most financial resources, tend to have the simplest probelms, are the most cooperative, and are least likely to sue. Therefore, physicians that can carve out treating this group of patients are doing the best. This is why concierage care, ambulatory surgicenters, specialty hospitals, and urgentcare centers are thriving while physicians are avoiding hospital emergency rooms, Medicaid, and now Medicare. Accountable care is going to make this much worse.

    • Dr. Rob

      For the record, I am not doing a concierge practice I am doing a direct care practice, with my patients and average of around $40 per month. I have also not “cherry picked” any of my patients, with some highly complex patients including a kidney transplant patient and one in liver failure coming to me just this past week. I also have a very nice combination of uninsured, insured, and patients with Medicare and Medicaid who have come to my practice because of this lower-cost model.

      • Thomas D Guastavino

        Im sorry, I assumed that when you stated “I am actually rewarded for handling problems early, for communicating well, and for keeping patients healthy and happy as it keeps them paying the monthly subscription fee” that you had a concierage style practice.

        • guest

          It’s amazing. You are asking a worthwhile question about how to get EHRs back as an actual medical record rather than a device for data mining and billing. It’s sad that you actually have to ponder about this. If technology was authentically doing it’s job a physician such as yourself would not have to figure out IT’s job for them. But given the reality i guess we do.

  • meyati

    All of things you mention are possible with a doctor that can write well or who has a nurse write well-and maintains the focus on being a doctor. I’m changing PCPs now, because of these problems. I didn’t have any problems in taking care of problems electronically-But-can you imagine the symptom that a patient of any age would have when their thyroid goes completely-BLAH-and they have an acute strep infection after 6 weeks of radiation? I’m 71-I think that my age and the radiation overwhelmed him. I went in in person, and he got it in his mind that it would come back up on its on-but this was 4 months after radiation ended, and my TSH before radiation showed I was out of range. Thanks 2 the EMR or EHR whatever you call it, I was able to write him 2 days later-and say, “I can’t take it anymore. Why did you prescribe skin lotion when U No that hypothyroidism causes dry skin?” I got results. I found an 80 year-old Urgent Care doctor that ran a strep test, instead of saying “I don’t do cancer or radiation.” So I had 6 months of hypothyroid and 3 months of strep at the same time.

    I was hospitalised and I was released with any antibiotics, because he wanted the discharging doctor to prescribe the appropriate antibiotic and dosage. It just said-Augmentin and his name. That was on the prescription page. I argued with 2 doctors and somebody from the pharmacy. I went home at night. I checked with my pharmacy-it was Sat, I left a voicemail, an EHR message, and on Monday I kept calling the clinic. Monday is his day off. I finally got hold of a nurse that contacted him, and he drove to the clinic-called me to come right in-and had a nurse waiting for me in the lobby-but my thyroid was still out of range, and the strep started a few weeks later.

    What I love about my EHR, is while I was on the phone trying to find a new doctor-they could see that i had radiation, the other problems, even that I was willing to handle thyroid on the EHR. I have a PCP that is an internist that likes to diagnose thyroid problems. I know that he knows about everything. I hope it goes well.

  • Stefani D

    Right before the EMR tidal wave, there was a movement toward integrated progress notes….anyone else remember that time? The same pages in the chart were used by every single provider so that anyone could get a snapshot view of the patient. If meds were changed; if discharge plans were on target; how the patient was responding to the treatment; if nursing uncovered new information; if PT identified a need; or if a consultant wrote a report….it was all there in chronological order. No hunting around through those department tabs. It wasn’t perfect, but it was a big improvement.
    Then came the EMR push and guess what, we went back to the tabs except this time they are electronic. Still fragmented, disjointed, and chaotic. Yes, all those electronic fields collect information, but I don’t know what’s happening with the patient.

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