Patients never ask me if I’m maintaining their medical records properly, even though this is an important part of what doctors do. Occasionally I mention this to patients, but they always give me a blank look.
Quality medical records allow for portable care. Clear and well-organized records allow the next doc to take over where the previous doc left off. The main impediment to the smooth transfer of care used to be doctors’ bad handwriting. Handwritten notes are becoming a thing of the past, but nowadays we struggle with a different set of challenges.
I’m one of those old curmudgeons who prefer written communication to be as clear and brief as possible. If my English teachers could see me now, they’d be proud. When I was new in practice, I had my reports typed as rough drafts so I could make corrections with a red pen, but as my practice grew, this labor-intensive practice became impossible. These days, medical dictation is rarely proofread by the doctor, unless the patient is a celebrity or a VIP.
Referring physicians used to send consultants a cover letter with the patient’s records. This note summarized the patient’s problems and explained why the referring doctor was sending the patient to the consultant. That sort of courtesy is also a rarity these days, and often the hapless patient is left to explain the reason for their visit, although the pitfalls of this lack of communication between the referring physician and the consultant are obvious.
Unfortunately, electronic medical records (EMRs) are often an amorphous mass of unorganized data and a poor substitute for direct communication from the referring practitioner. Consider the following excerpt of an EMR that a nurse practitioner sent me regarding a new patient:
"The patient is doing well this past month. No new problems. Pt states PCP decreased her Synthroid from 115 to .88 cc mcg over the past year; reports increased fatigue. She reports increased generalized pain; forgot to change patch for 24 hours and had increase pain. She denies new pain or injury. Will f/u with PCP within the next six weeks. Sleep is good, averages 10 to 11 hours of sleep. Bowels move daily with 100 to 120 oz’s of water, fluids, diet, and Yogurt. I feel oversedated No. I have a new medical problem No. I have run out of my meds No. I have reported lost or stolen meds No."
This stream of consciousness went on and on, but I think you get the gist of my dissatisfaction. Computer-assisted record keeping can produce notes that are dense, rambling, and sometimes even nonsensical.
EMRs also add large amounts of data that don’t belong in progress notes. Notes from a referring doctor describing a middle-aged woman with back pain had a long, obscure paragraph identifying the ICD-9 billing codes that were applicable for her problems. Perhaps that information is helpful for the billing department, but it doesn’t belong in a progress note. It is equally frustrating trying to print a lab or x-ray report from the hospital’s EMRs. What should be a 1-page report is usually bloated into a 10-page manifesto.
New patients often come to see me with thick packets of photocopied records. Sitting there as I silently and rapidly flip pages, the patient looks at me hoping that I am finding information that will help them. Perhaps they think I am speed reading, or careless. The truth is that I am doing a paper triage, trying to separate the useful information from the chaff. Usually a small amount of clinically relevant information has been spread over a vast number of pages.
I recently saw a young man with complaints of fatigue. The referring physician sent me a printout of the EMR, which included a detailed physical exam including details of the external and internal gynecologic exam. Undoubtedly, the referring doctor clicked on the wrong link when he used the EMR to create his report, causing the computer to spew out the boilerplate dictation for a physical exam of female genitalia. We can laugh about such silly mistakes, but that sort of thing makes us look careless and detached.
Many doctors are too busy to enter information directly into the EMR, and instead use a "scribe" to take notes and transfer information into the EMR. This adds another person in the exam room. It’s a shoddy practice, and it infringes on the doctor-patient relationship.
Hospitals’ progress notes can be bloated with information. Having good information is important, but having the computer import the patient’s medication list, pages of labs, and radiology reports that the author didn’t review is a dishonest practice. We could just as easily have the computer throw in a few textbook chapters for each diagnosis code. Wouldn’t that look splendid and justify billing for a higher level of service? As useful as this information bolus might be, without a sentient being to coalesce it into coherence, it is just a data tsunami.