It’s usually some minor irritation that gets me into blog-writing mode, much as a grain of sand forces an oyster to produce a pearl. Judging by the dearth of blogs I have written recently, one might assume that my life has been remarkably free of irritation lately. That’s not the case. I’ve just been too busy to write. Today with my wife and son out of town and the Louisville weather amazingly cool and breezy, I did a nice early morning run at Iroquois Park. Nothing like it to get the creative juices flowing! And now to the irritation.
In the middle of doing a dozen things simultaneously on Friday, I received an “important fax” from Medical Records. This was a discharge summary I had dictated on a patient admitted for ventricular tachycardia who had multiple ICD (implantable cardioverter defibrillator) shocks. The Hospital Course describes how the patient was placed on the antiarrhythmic drug amiodarone, how he was to taper the amiodarone dose at home, and so forth. The Discharge Medication section lists the amiodarone as a discharge medication. This medication was circled and a hand-written annotation from Medical Records stated “Not on DMR, No script.” I imagine DMR is the drug reconciliation form I fill out when the patient is discharged. Attached to the fax is a sticky note. “Dr. Mann. Will you please amend this D/C Summary? Will you please remove the Amiodarone?”
I think any comment I could make about this would only detract from the sheer Kafka-esque lunacy of it all. How have we as physicians allowed ourselves to be ruled over by zombies? A topic for another day. This incident did get me thinking more about medical documentation.
Medical documentation is in a sorry state, both in its written and electronic forms. Different hospital committees have produced different preprinted order sheets, addressing things like DVT prophylaxis, heart failure guidelines, acute myocardial infarction guidelines, and so on. These multi-page, multiple-choice order sheets are put into the chart among the blank sheets used to write admission and daily orders that don’t overlap or conflict with the preprinted orders. If these paper charts are messy, the electronic ones are even more so. Filling out chart notes and physician orders on a computer is like navigating a maze. You double-click here. You select from a drop-down list there. You press F12 on this screen, but you click Save on this other screen. You can’t find anything you actually need. You can’t find the diagnosis “Syncope” because it is listed as “Fainting (syncope).” There is no Undo key. Dialog boxes appear everywhere to confirm every trivial choice that you make: “Are you sure you want to add this order???” Everything lags like you are back in the dial-up modem Internet era. Apparently most of the processing is done on the server-side rather on the client. The software appears to be written by high school students learning the BASIC programming language at summer school. And yet these miserable electronic health record (EHR) systems cost millions of dollars to install. If you don’t install them and use them, Uncle Sam will dock your Medicare payments.
You have a hundred orders and notes to sign. To sign them, you must click a Sign button a hundred times, waiting for each new document to come up on the screen. There is no option to batch sign all your documents. There is never a batch signing option on any medical software. After all, we all know doctors have plenty of time to proof-read every document they produce — sure! Proof-reading is a luxury few busy physicians can afford. So the occasional stupid typo gets into the medical record. Anyone with half a brain can tell from context what was meant (excluding lawyers of course). Computers are supposed to save time, so why not a bulk signing button? You don’t have to use it if you don’t want to. Everyone knows that physicians do not have time to proof-read every order and document that they generate, so why not acknowledge that fact and save time by not forcing your doctor to sit down and mindlessly click the left mouse button for 20 minutes while staring out the window? (By the way, I did write a program to batch sign medical documents that works with the Allscripts EHR and should work with most other EHRs).
Just as a software program like Microsoft Word has predetermined sensible default settings that you can customize to your heart’s desire, so should EHR software. For example, if a patient comes to the hospital with chest pain, there is a group of orders (cardiac enzymes, healthy heart diet, etc.) that are the same for 99% of these patients. I don’t want to go through each of these orders and click them. I want one click to fill out my default orders (hmm… didn’t Amazon patent the “one-click?” Maybe that’s the problem). I can then go back and tweak any orders that need tweaking. I want short-cuts. That’s what computers are for.
To those who may be upset that documentation may suffer if it is made easier: I don’t care because documentation, despite what the insurance companies, the government and the coders believe, is NOT the most important thing that we physicians do. It has nothing to do with caring for patients. It is a way to make the Byzantine billing system of American Medicine work, to allow uneducated people to figure out how much we can charge for what we do. The system does not work on this model: Dr. Mann saw Patient X in the office to render an opinion. Dr. Mann is triple-boarded, has over 30 years of experience in his field. Dr. Mann charges X amount of dollars for a consultation. No, it works like this: Dr. Mann failed to complete a 12-point review of systems on this patient who he consulted on for a complex arrhythmia issue. By charging at a Level IV office visit, Dr. Mann committed fraud.
Ask a patient which is more important: skill in maneuvering a catheter in the heart or filling out forms. Documentation remains a very poor surrogate for what we doctors do. My hope was that computers would help reduce the amount of busy work documentation we have to do to satisfy the limited imaginations of our burearucratic overlords. I think the potential is there, but only if real doctors who practice real medicine have input into these systems.