Yesterday I saw a pretty good trick: a 65-year-old man who was 62 years old for three years.
In our electronic medical record, he was ageless, timeless. Despite showing up for multiple office visits, and probably celebrating several birthdays at home, he remained, through the wonders of cut-and-paste, forever 62 in our eyes.
True, he developed several new diseases, he had some personal and health crises, and even had surgery a couple of times to remove some poorly functioning body parts, but he stayed 62.
In our (seemingly well intentioned) efforts to document, be compliant, and bill, we rushed through the process, focusing far too much energy on the computer screen taking up a lot of space in the exam room, and perhaps not enough on the person in front of us.
When did we take the medical record and turn it into such a large clinically useless beast, good for clicking boxes, good for compliance, good for billing, but no good at taking care of patients? How did we let this happen to us, to healthcare, to our patients?
Just like the paper charts from long ago we remember and loved so well (or actually hated so much and could never find) this chart has gotten fatter and fatter, bloated with more and more stuff added on to the end.
Despite being a bit of a Luddite, I am not proposing we go back to paper. I can recall my hand aching at the end of a day of writing my notes, and I always felt my clinical thoughts raced faster than my pen could scrawl.
Now we all get carpal tunnel from typing and clicking.
The tremendous benefit of my notes instantly being visible to the surgeon who asked me to do a pre-op, or my being able to see what a dermatologist colleague thought that rash was without waiting for a letter to come in the mail, is priceless.
And the beneficial functionality of an EHR cannot be denied. E-prescribing, automatic drug-interaction checks, trending labs, population health. Great, and with great potential for even more.
But, we see documentation in charts of physical examination on body parts that patients no longer have (and sometimes never had to begin with), medical problems that have long since resolved, medications listed as being taken that a patient stopped taking years and years ago.
And sadly, each time, we click buttons testifying that we’ve reviewed medication lists, problem lists, medical history, attesting that what stands here is a true and accurate representation of the state of our patients, that this is what actually happened in our office today.
We’ve heard people say that we are still in the nascent period of electronic health records, that the best is still ahead of us. We’ve been using these systems for over 30 years, and the promise has not been fulfilled. In fact, things seem to be getting worse.
People talk about the next generation of electronic health records being just around the corner, that someday soon we will have a real system in place that creates exactly what we want, and our patients need, the electronic health record to actually be.
The dream is that patients will be able to walk into any healthcare setting anywhere in the country, or even anywhere in the world, and all of their life’s health information will be instantly available to every provider. Patients carrying their entire medical history on some special chip, maybe even embedded under their skin. Or that it all is in the cloud somewhere, safe, secure, and instantly available. Or that every different electronic health record from every different vendor speaks fluently with every other one. A CBC in my chart is the same thing as a CBC in yours.
Will Open Notes be the answer? Where patients can see what we write, and have the ability to edit or add their own input? Or does this filter our thought processes in ways that might limit care?
One vision is we separate out all of the clicking, compliance, and billing stuff from what we as the providers trying to take care of people really think the essence of a medical record should be.
That might look like this:
Here is what they told me. Here is what I asked. Here is what I learned. Here is what I think.
As far as I can tell, this is a pared down version of what we as providers are doing in nearly every healthcare interaction.
They told me their stomach hurts. Where does it hurt? It hurts when I push on their appendix. I think their appendix needs to come out.
There, that was easy.
Wading through years of summarized prior history, endless copied in labs and radiology reports, templated review of systems and physicals, and macros testifying that all a patient’s questions have been answered to their complete satisfaction, adds little value.
Somewhere, all the rest of the stuff that clutters up our charts needs to be in there. But mostly it gets in the way when I want to find out what is going on with my patients.
Let that live off to the side somewhere, out of the way of all of us trying to take care of all of these patients.
Or else we risk staying 62 forever. Forever.
Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine. Pelzman’s Picks is a compilation of links to blogs, articles, tweets, journal studies, opinion pieces, and news briefs related to primary care that caught his eye.