Just the other day, while I was in the middle of seeing a morning schedule full of patients, I opened one patient’s chart and was thrilled to see a whole bunch of new icons in Chart Review in the electronic health record that I had never seen before.
These apparently indicate office visits and other health care encounters with outside providers.
Sometime during the night, little electronic mice had run far and wide through the digital electronic system and retrieved the electronic traces of places my patient had been since she had seen me last.
Here was an endoscopy report linked to an office visit from a doctor in Connecticut, as well as a place marker indicating that she’d seen her outside gynecologist, a report from an urgent care center she’d visited while on vacation, and apparently a radiologic procedure she had undergone at some point over the past year as well.
Unfortunately, when I clicked on each of these, I was greeted with a lot of administrative fluff, but not much substance.
Here, for example, is what I learned from what had initially been billed to me as an endoscopy procedure’s office visit documentation:
Take it easy today. Increase activity as tolerated. No driving or operating any power machinery. Do not make any personal or legal decisions today. Drink extra fluids to rehydrate yourself. No alcohol today. Resume your regular diet unless otherwise instructed. Call your doctor right away if you have any problems or concerns or a fever over 101°, persistent abdominal pain, nausea, vomiting, or blood in your stool, chest pain, or shortness of breath. Avoid the following medications for 10 days or as directed by your physician …
Clearly, this is all of the electronic fields that have been clicked by the people marshaling her through her office visit, from the time she arrived, had her vitals taken, had medications administered, had the procedure done, and then went to the recovery room.
But where was what I needed to know? Where was the clinical meat of the matter?
Sure, I could glean that she had a colonoscopy done, and that it seemed to have gone okay without any definite complications, and they appeared to have sent her home, but I already figured that out because she told me she had had a colonoscopy, and was sitting there in my office in one piece.
I don’t need to see the Reason for Visit, Encounter Details, Social History, Last Filed Vital Signs, Discharge Instructions, Discharge Disposition, Plan of Treatment, Lab Results, Visit Diagnoses, Admitting Diagnoses, Administered Medications, Orders, Patient Demographics, Document Information.
Who allowed this to be the way the electronic medical record defines interoperability?
No one asked us.
What if the people who are creating these systems had come to the providers taking care of patients and said, “What is it you need to know? What is it that you want us to electronically fetch from outside sources and present to you? What’s the most useful format? What will make your lives and the lives of your patients better?” Don’t you think that if they asked us, we would have been able to tell them?
Give me what I need to know, and cut out all the rest of the stuff that was created when we were forced to click a bunch of buttons. I don’t need all the legal disclaimers.
Sure, if someday I want to dig back deep into the system and find out what her blood pressure was on the day she had her colonoscopy, maybe I might want to be able to find that.
But is the operative report really going to provide anything useful for me?
All the patient’s questions were fully answered to her satisfaction; risks, benefits, and alternatives were reviewed; and informed consent was received. The patient was prepped in the usual sterile manner and taken to the OR, where the procedure was performed with ease and grace with an estimated blood loss of zero cc’s, and then she was transferred to the recovery room in stable condition without complications.
No, really all I need to know is that she had a colonoscopy; here’s what we found, and here’s what we recommend.
Every time a new system is created and a new form needs to be filled out or a new way is found to create a discharge summary or transfer a patient from one place in the hospital to another — all this does is create more noise that blocks the signals we are so desperately looking for. All it makes is yet another recipe for disaster, another opportunity for errors to occur, another way for actual clinical care to slip through the cracks.
As these systems get more and more sophisticated, the likelihood that this stuff gets better instead of worse becomes vanishingly small.
When was the last time you read a hospital discharge summary and said, “Wow, that thing was a piece of art; I lived and breathed the experience my patient had in the hospital, and I know how to take up the reins of their care now — thank you very much?”
Unless all of us rise up and demand a better system, a better way to take care of patients, it’s just going to keep getting worse, and try as we might, we’re going to have no one to blame but ourselves.
Tell me what I need to know, and I’ll follow you anywhere.
Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.
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