Death of the physician progress note

I am not sure of the date or time of death. However, I am reasonably certain of the cause. Death was by electronic data and formatting. The victim was the time-honored physician’s progress note. To be sure, these notes, even the now “ancient” written ones, were far from perfect. And they were often illegible. Shortcuts such as “as above” or AVSS (all vital signs stable) littered the pages of the now nearly extinct hospital chart.

Yet, what replaces it sometimes resembles a random collection of information and numbers more than anything readable or coherent. The EHR is drowning in data excess where the truly pertinent information is at best lost is a sea of cut and paste gobbledygook, and at worst, repetitive false information.

The designers of the EHR sowed the seeds of this mess. Initially, computerized health records were created to more accurately bill medical procedures, CPT codes, and hospital services. Clinical information was added out of necessity, but layered on a framework of billing and coding, making a very imperfect marriage as the final product. I have used our office EHR now for ten years, and learned four different hospital systems over the past three to four. Thus, I have seen more than my share of this landscape, and trust me, it is far from pretty.

I have worked with IT personnel to try and make my notes more readable and coherent, using everything from larger fonts, to SOAP formats. But in order to comply with coding requirements for mid-level and higher coding, I am forced by Medicare to throw in stuff that is redundant and clinically useless.

For example, “No change in PMH/FH/SH/ROS.” (Translation: past medical history, family history, social history and review of systems.) Since it is unlikely that my patient with CHF will remember a new symptom, or discover a family member had a stroke, between day one and two of his hospitalization, this exercise is a waste of time, but required by CMS if you want to be reimbursed for a complex visit.

I review my patients’ medication administration record (MAR), daily. However, if I document those medications in the record, the end result may be a morass of unorganized and scattered drugs. The worse offender here is the system used by a well-known large hospital corporation. When integrated into the progress note, the list is neither alphabetical, nor chronological, or by route of administration. In other words, it is a jumbled mess. This quirk has been pointed out to the hospital IT staff, and they say they have forwarded the doctors’ “concerns” to the programmers, who say they are “working on it.”

The other issue with the electronic progress notes is the “carry forward” features. The aforementioned EHR system’s physical exam auto-fills from the previous day, unless you specifically change it. This is nice for the time pressed doctor, but leads to false and inaccurate documentation. I have seen patients who days following extubation still have noted an ETT in the mouth.

In order to keep the physician honest, you must fill in “general appearance” daily, but the rest can be all too easily repeated. Ditto for the impression and plan. Again I have noted plans like, “for bypass surgery” a day before hospital discharge. In its defense, you can free text anywhere, but that takes work and typing skills, and many older doctors simply are lacking here. And the local large corporation hospitals have refused to install voice recognition software to make the docs’ jobs easier.

Other hospital systems force the doctor to refill the H&P daily, but there are auto-click buttons, which when repeated daily are obvious cookbook catch phrases. You can free text for sure, but again that takes more time. Another large local hospital system has thankfully installed proprietary voice recognition software to accommodate the keyboard-challenged physicians.

The end result is often a misleading and unhelpful recording of the day-to-day patient’s progress. There seems to be more than enough information in the notes, it’s just that the forest is lost inside all of the trees.

I place the blame at the feet of CMS and insurance companies. They are the ones who have created this checkbox and laundry list approach to medical documentation. That is if the doctor wants to get reimbursed for anything above the simplest visit level. I review others notes and have to search for nuggets of informative prose. Emergency department notes are even worse. It takes effort to sometimes find out why the patient even sought urgent care.

There must be better information systems around. Unless we can free ourselves from being reimbursed by the number of words in a note, I fear the valuable physician progress note will continue to drown in mountains of data and illiteracy.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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