That’s the current number of “cc’ed charts” as of this morning in my electronic health record in-basket.
While it might sound like a lot, this is not at all an unusual accumulation, partly due to the fact that I receive a notation every time a patient at our practice gets a flu shot, and also every time one of my patients or one of our residents’ patients is seen by any other practitioner across our institution.
Is it even possible to keep up with this, and is this the best way to communicate about the care our patients are receiving from other providers, and the best way to collaborate?
In some ways, this is an embarrassment of riches. In the old days, when we had big thick paper charts, those were practice-specific, stored in local medical records rooms. We closely hoarded our own charts and yet we wished we knew what was going on in other practices, even within our own institution.
For the most part, we would send our patients off to see specialists and subspecialists, and then months later, when they came back to see us, we asked them, “What happened when you saw that other doctor?”
Patients often would say, “They told me they would tell you,” and then we’d have to go about trying to track down what happened at that other practice.
In the best of situations, a consultant would send across a letter, either by fax or regular mail, and we would place a copy of that into the patient’s chart.
I always loved getting those (sometimes typed on really nice stationery with fancy letterheads), and they helped confirm my suspicions or put my mind at ease, or helped me get the patient on the right track, the right path, to a better state of health.
Now that we get everything, there’s just too much noise.
I’ve tried re-sorting these in-basket charts by date, by chief complaint, by encounter type, by department, but there’s just so many of them that trying to find the really important pearls buried within all of these charts makes me, and everyone else practicing in these systems, nervous and, frankly, terrified.
When you put the time and the effort into keeping up with your in-baskets and making sure that none of them build up, it’s a really satisfying feeling, but it takes a lot of determination and stamina. And, since every chart gets copied back to us as the primary care physician, the avalanche of information is almost always too much to keep up with.
What is the goal of these routed charts? These other providers are telling us what they thought after they saw our patients, and what their plans are, and how we can help work together to solve these outstanding health issues that our patients have. But is this, in its current state, the best vehicle for getting this done?
Just the other day, when a patient of mine was in the emergency room, the provider seeing him there bypassed the EHR system by using an alternative secure source of communication.
The patient had alerted me through the portal that something had happened that made him present to the emergency room, and the electronic system flagged me with an alert in the hospital’s “admit, discharge, and transfer” (ADT) system once he showed up there.
The provider seeing him messaged me after he’d seen the patient, and then together we looked at his relevant tests and figured out what was going on and what the plan should be. In real time, with only a few keystrokes and a few words, we were able to safely care for the patient and develop a feasible discharge plan.
This is what most health care communication between providers should be about. Tell me what the patient told you, tell me what you found, tell me what you thought, and tell me what you plan to do. That’s what I need to know.
Do this for me for my patients, and I’ll do it for you.
Cutting through the clutter
This reminds me of something I remember reading in the Guinness Book of World Records when I was a kid (loved that book!). I think it was listed as being the record for the shortest business communication.
After Victor Hugo published the English edition of his massive novel Les Miserables (1,900 pages in French!), he was overseas, and wanted to know how sales were going. He telegraphed his publisher in England the single character, “?”. His publisher responded with “!”, letting him know they had a blockbuster on their hands.
As we all get used to working in these massive electronic health record systems, we need to figure out a better way to accomplish what we want to accomplish, which is communicating the essentials of what we need to take care of our patients.
Whether it be in the inpatient world, the emergency room, the operating room, or all of the different outpatient practices where we see our patients, we need to get away from cutting and pasting every single bit of data into the chart, keeping an endless running list of massive amounts of (mostly) useless information.
We need to synthesize and minimize to communicate effectively.
Pilot projects to the rescue
Sure, at some point I may need to see every lab test, every radiology report, all the details of the pathology, but that’s there in the health records when I need to look at it. Cut to the chase and give me what I need to know, and I’ll be happier, and our patients will more safely and effectively get the care they need.
Because if we all get thousands of these charts pouring every week into our in-baskets, and each one of them is page after page of not so useful information, we run the risk of missing something really important, of not knowing who’s doing what, of not seeing what needs immediate care or further attention, and this is an unsafe and untenable situation moving forward.
If we can build a more commonsense way of communicating, of having the charts represent only the core essence of what we want them to have in them (instead of what billers, auditors, and administrators want in them), then maybe our surgeons will have more time for operating on our patients, our psychiatrists will have more time to listen to our patients, our dermatologists will be able to more leisurely examine every inch of our patient’s skin, our pulmonologists will really be able to attend to the lungs and breathing of our patients, and we won’t all get bogged down in the details of the paper trail we are all trying to leave.
We are starting a couple of pilot projects to try this, ranging from emergency department discharges, hospital discharge summaries, and preoperative consultations.
Our hope is that we can start a movement to reshape and rethink how we use the electronic health record, and how we can create a truly effective medical record of what’s going on for all of our patients.
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