How smart do we want our electronic health record to be? Somewhere between as dumb as a piece of paper and a pen, and too smart for our own good. Many, many years ago, before we spent the majority of our office visit staring at a flatscreen LED and typing away, our charts were simple manila folders with those bendy metal bars that allowed you to insert new pages, separated into multiple ...

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Repercussions. Every action that is taken, especially when it comes to healthcare, has ripple effects, which often end up being more far more significant than we anticipate, turning that ripple into a tidal wave. Every time somebody besides actual health care providers steps into the mix and tell those of us taking care of patients that there is "something else that we have to do," we often see it open up a ...

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Noticing. If you think about it, that's really a lot of what we do a lot of the time. As clinicians, we are trained as observers to notice, to use our eyes, our ears, our hands. To notice. We notice that our patients seem different today. More tired. A little pale. Notice a change in their gait. Notice they are in pain. We notice swelling in their legs, a new heart murmur, a ...

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Wouldn't it be cool if ... ? Wouldn't it be better if ... ? Wouldn't it be much easier when we see patients if ... ? How come we can't ... ? It seems like every day, someone in our practice comes up with an idea for a way to do something better:

  • From our front desk staff who check patients in, and have to deal with a multitude of electronic systems for registration, ...

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Actual conversation heard in the hallway outside an exam room earlier this week: Doctor: "So, we're going try this medicine for your blood pressure; you keep checking it at home as we discussed. If the numbers remain high, we can increase the dose or add another medicine." Patient: "Well, what do we do if the pressure stays high; if this medicine doesn't work?" My partner told me later that she had explained the ...

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Where is everybody? It's a Wednesday morning, and after 8 o'clock grand rounds I headed back from the medical college auditorium to our practice, and as I walked back into the office our med-tech told me that my first two patients were already in their exam rooms. So I dove right in, starting with a husband and wife there for their annual physical exams, and I set about getting to my morning ...

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Just sign here. How many times a day are we asked to do this? "Just sign here." "Just put down your license number." "We need a stamp with your doctor's info on it." "Give us your NPI." "Initial here, here, and here." If we took the time to read all the things we're signing, we wouldn't have time to do any doctoring. The other day I was asked to hand-write the date on ...

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It all started out with Malaysian methimazole, and didn't end until two highly trained medical professionals sat on opposite ends of a telephone call, scratching their heads and wondering how two digits being transposed could lead to so many problems. Those two transposed digits caused a thyroid uptake scan to become a bone marrow scan (whatever that is). But look at all it took to get there. Mystery illness, mystery medicine It started ...

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I need your help. I'm trying to figure out how to get rid of something that's terribly broken in our process of taking care of patients, and I can't do it alone. It's time to kill the referrals process, get rid of them altogether. Every day, a huge proportion of the messages we receive through the electronic health record are requests for us to "put in a referral." Patient has low back pain, has ...

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It's 10 p.m. on Wednesday night, and I'm finishing up my notes for my patient visits from this morning while I do my bowel prep for my colonoscopy tomorrow. Now, I know we can argue the biomechanical challenges of doing both of these tasks at the same time, and this certainly may be TMI, but it struck me as I was sitting there trying to do both of these things how ...

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Last week I made a patient's chart perfect. Not bragging, but ultimately it ended up being pretty easy, and I'll explain how and why in a little bit. This was a patient I had not seen in several years, with a number of chronic medical problems, for which he had been taking less than optimal care of himself since I had seen him last. Here for a "checkup," we talked about his health ...

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Too much data, big and small. Every morning when I log onto our electronic health record, one group of messages are from patients with their self-recorded health information data that they've sent to me for review. Here's my home blood pressure over the past 24 hours. Here are my fingerstick glucose readings over the past 24 hours. Here's my weight over the past 24 hours. Here is my depression score over the ...

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178 measures. This is what we're up to -- the collected compilation of quality and performance metrics for our ambulatory care network, across all the different divisions. Where did these come from, who decided this is what we should measure, does anyone really have any idea if measuring these things reflects the true quality of the care our patients receive? That's a lot of questions all at once, and I'm not sure we're ...

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Earlier this week, one of the residents and I saw a new patient who apparently had been sent in to see us for a pre-op visit, an evaluation to make sure that her medical conditions were well controlled and that the surgery was safe for the surgeons to proceed with. She reported that she forgot the paperwork they gave her. All she knew was that whatever we wrote had to ...

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There are a couple of times a year when there are no house staff to be found anywhere in the hospital or the outpatient practices. These include the holiday and end-of-year parties, resident retreats, and the annual house staff picnic. The house staff picnic is a particular favorite among the interns and residents, a full day away from the hospital, dressed like civilians, fun in the sun, barbecue, softball with their ...

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On the porch. It's that time of year again, when we escape from the heat of New York City summers, and head to New Hampshire, to the Central Lakes District, where my wife's family has had a house perched out over the clear waters of Newfound Lake for over 120 years. It's a small wooden house, with barely enough room for all of us squeezed in, painted bright yellow and orange, with ...

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"So, I'm getting routine labs on her." Wait, what? Statements like these often make the hair on the back of my neck stand up. One of our residents was seeing a healthy young woman for her "annual physical," seen just a few days after a routine postpartum visit with her OB/GYN after the uneventful birth of her third child two months ago. The resident was coming for his afternoon continuity clinic from an ...

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Yesterday, we had a meeting about leakage. No, it was not about urinary or fecal incontinence, but it was about care that could have been provided within our institution that ended up, for a multitude of reasons, happening with providers beyond the walls of our institution. Representatives from our accountable care organization had requested a meeting to go over some issues they've been having with our practice, including low levels of usage ...

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A patient of mine recently came to see me in a follow-up appointment after an emergency department visit. He had been working out at the gym, on a hot day, after he had skipped breakfast, and after his usual routine he felt extremely lightheaded. Everyone told him he looked "white as a sheet", and a physician who was at the gym told him he must go to the emergency department. In ...

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Recently, getting dressed after working out in the gym, the guy in the next locker decided to complain to me about his recent surgery. Having lockers next to each other had led over time to "What do you do for a living?" After discovering that I was a physician he has occasionally asked some medical questions, and done what a lot of people do when they know you're a health care ...

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