English is the second language of medical documentation


acp-logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

English is the international language of medicine, according to many. Regardless of whether that is true, what is becoming increasingly clear is that English is the second language of medical documentation.  For those of you who blame EHRs for this, the replacement of English by something else started in the pre-EHR era, but EHRs certainly accelerated it. The use of English in medical documentation is a casualty of the payment system, regulatory agencies, performance measurement, the tort system, time pressure, and, yes, EHRs.

What should we call this language of documentation if not “English?” Templatish? Beancounterese? Complyian? Rushian? (I think that one’s already taken.)

How and why did this happen? Most of it stems from the morphing of the medical record from a clinical tool to an audit and billing tool. The focus is no longer on capturing the patient’s history, examination, test results, and the physician’s thought process. Instead, today’s goal is to record as many things that were said or done as one can in order to justify the highest billing code, meet the performance measure, earn a high quality score, and lawyer-proof the record – and to do so in as little time as possible.

Among the drivers of this new language of medical documentation are shortcuts such as templates and forms, insurance company rules, practice and hospital administrators (who often miss the big picture – see my blog post Practice transformation is more than checking off boxes), and technology. Perhaps one of the most important drivers is the fact that many people don’t trust physicians anymore. We’ve accepted the principle that “if it isn’t documented, it didn’t happen” as dogma. Did whoever came up with that rule anticipate that in the EHR era, the motto would be “even if it is documented, it might not have happened?”

Of all the idioms of this new language of documentation, my favorite has to be the expression “ten-point review of systems.” What exactly is a ten-point review of systems? When I see the term, I can’t help but think of what my car gets at the rapid oil change shop: lube chassis, check/fill fluids, inspect filters, inspect wipers, inspect hoses, check pressures, clean windshields, vacuum interior, inspect headlamps, and change oil. I suppose these are euphemisms for the “ten point ROS” performed by physicians. Then there is “twelve-point review of systems” Is that a “ten-point” plus check battery and breather elements?

Another feature of this yet-to-be-named language is the overuse of passive voice, often combined with words seen only in medical documentation: “The patient endorsed shortness of breath,” “Informed consent was obtained,” “Side effects were reviewed and the patient verbalized understanding,” and so on.

Thanks to EHRs, the language of medical documentation has interesting sentence structures. For example, sentences beginning with the words “yes” or “no,” as in “Yes chest pain. No radiation of chest pain. Yes shortness of breath. No diaphoresis. No nausea.” Some of the notes generated by EHRs look like the “Mad Libs” that many of us grew up playing. Instead of entering an adjective, three nouns, a verb, and an adverb to generate a funny story, we can enter a duration, location, quality, and intensity of a symptom to generate a “Med Lib.”

The EHR takes this new language even further by making it easy to drop in phrases, sentences, or even entire generic paragraphs that give a progress note the look and feel of the fine print at the bottom of a credit card application.

A progress note, whether for an office or a hospital visit, used to tell a story: what the patient said, what the examination showed, what the doctor thought was going on, and what the plan was to make the diagnosis or treat the problem, all of it written to help the physician take care of the patient and communicate with other physicians taking care of the patient. Today it is all about cataloging everything that was asked, everything that was examined, everything that was considered, and everything that was ordered (plus how long the visit was and how much of the time was spent on education and counseling). The goals are to code at as high a level of service as possible and meet the requirements of the “initiative du jour,” in a way that makes it as easy as possible for a non-physician reviewer to check off boxes. If there is a story to be found in today’s EHR-generated note, you often have to read between the lines to find it.

It is time for an “English First” movement for medical documentation. Call it “Leave No Narrative Behind” or something equally catchy. Let’s defend the medical record from the compliance officers, insurance companies, lawyers, regulators, accreditors, and EHR vendors. Let’s exile the “ten-point review of systems” to the auto repair shop!

That’s why the American College of Physicians recently approved a resolution that “endorses and actively promotes documentation within the electronic medical record (EMR) to improve communication that emphasizes the thought process underlying decision making, patient complexity, and medical necessity with clarity and without requiring repetition of past notes, tests and extraneous data.”

One of the most liberating things that I’ve done in a while is to use voice recognition software with my EHR. Instead of clicking boxes to generate a “Med Lib” supplemented by hastily typed short phrases, I now dictate a paragraph or two for the HPI, the review of systems, and the examination, and I document as thorough an assessment and plan as I did in the days that we documented in English. Someone can read my notes and know what I did, and more importantly, what I was thinking. That still doesn’t cure the systemic illness of billing needs trumping clinical needs in medical documentation. But it’s a start.

Yul Ejnes is an internal medicine physician and immediate past chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.


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