If you have a pulse and have visited an American physician, you have surely experienced this bizarre situation. They have you show up early for your office visit to fill out a packet of paperwork on every medicine you have every taken and every orifice you have ever had examined, yet when the doctor shows up in the room he asks for all of the same information over again. MAYBE he glances at the packet, otherwise it gets scanned and filed and stored securely and uploaded “to the system”. Sometimes a nurse will even come in and confirm the info on the sheet, followed by the doctor who has no knowledge of any of this information gathering.
Or picture this. You visit a local hospital ER for some urgent thing that came up. You fill out another huge packet of info. They transfer you over to the local county hospital, where the process will surely be repeated. There’s also a good chance they forgot to send the disc with your CT scan on it, instead sending a sheet of paper with a report of what their radiologist thought it showed. I deal with these sorts of situations every single day, and the cost usually comes at the expense of the patient, with increased wait times, repeat scans, and extended hospital stays due to administrative headaches. “Transfer paperwork” is usually dozens of pages of worthless charting by nurses (patient does not have an ostomy, patient is not an Alaska native, patient does not drive a vehicle manufactured before 2004), with one short paragraph actually written by an ED doc on the patients problems, followed by another dozen pages of medical necessity for transfer and financial information.
This is the current culture of healthcare. There are two issues I want to discuss, but first some juicy secrets about how doctors interview and evaluate patients.
When I am talking to a patient, every question has a hidden purpose. There are directions that I am leaning for a diagnosis and treatment, and I am looking for specific answers that guide me in the right direction. When I ask, “When was the last time you had anything to eat?”, I don’t actually care a lot about your food choices over the last 24 hours. I don’t care if you crushed a Chipotle burrito, I usually just want to know if you can or can not be operated on today. Please don’t walk me through each and every thing you’ve eaten. When I ask about your medications I am usually asking about your health problems in a roundabout way, asking you describe the problems you have that are severe enough to require medicines instead of saying “I’m actually a healthy guy doc. Little bit of the sugars is all!”. This also gets me around the incredibly confusing segment of the population that seems to think, “I don’t have high blood pressure because I take 3 medicines for it and it is treated.” So my questions are very directed to get me what I think is the sufficient amount of knowledge need to treat you effectively. I try to start with open ended stuff just to see what you say when I ask “What brings you in today?”, but when we get on a tangent I need to bring it back to the important stuff.
This is particularly true on morning rounds, I have to see 22 patients by 530am and I am ruthlessly efficient. Are you alive? Have you pooped? Is your pain being treated? Are you actively bleeding anywhere? I can sort out any number of issues during the day, but first I need to get a handle on the things that I need to know.
So that’s the first issue we have, and it plagues healthcare. We have all of this information about you, your meds, your vitals, you name it. We know so much about you, but not very many people know what to do with any of this information. As a surgeon, I am particularly concerned about certain vitals, labs, and physical exam findings to determine if you are going home, going back to the OR, cleared to eat, whatever. Medical doctors care about all sorts of other stuff that they order that doesn’t actually matter (looking at you, pro-calcitonin and activated protein C). Anesthesiologists care about the structure of your mouth and the ease with which you can be intubated. Since we have done a relatively poor job of identifying what we absolutely need to know about each patient, we have gone ahead and decided to record every single thing about each patient at all times, just in case it turns out to matter.
This is probably the hardest on nursing staff and CNAs. At our hospital, nursing tasks are measured per hour, and an average of 42 minutes per hour is spent documenting on the computer, leaving a lousy 18 minutes for patient care (divided amongst their 3-6 patients each day). They document the patients bed position, what food is delivered to the room, visitors to the room, the temperature of the room, and the programming on television. This became an issue a few years ago at a hospital I worked at in undergrad, with nursing leadership complaining that documentation was hindering them from providing patient care. Instead of addressing concerns with workload and documentation needs, the hospital purchased 600 computers on wheels so that the nurses could wheel around the halls and do their charting. These computers initially were called COWS, but that term was deemed insensitive by the nurses who used them and they are now WOWs (workstations on wheels). I did not make any of this up.
The result of this is a massive pile of poorly utilized, very sensitive information that we must not only keep protected at the risk of heavy fines and legal repercussions, but also pick out the important parts that could lead to poor patient outcomes.
The best example I see every day regards the allergy section of a patients chart. Actual allergic reactions are life threatening emergencies. The throat swells, you can’t breathe, and you die if you don’t get treated. Bad things that happen when you take medicines are not allergies, they are actually side effects (or sometimes intended effects). Morphine making you sleepy is NOT an allergy. Lisinopril making you cough is not an allergy. Taking a medicine while you also happened to have a viral respiratory infection is not an allergic reaction. Regardless, each thing gets dutifully logged by nursing as an allergy into the EHR. EVERY SINGLE TIME I try to place an order for medications for a patient I get that stupid chart blasted at my face to review allergic reactions. I am so used to clicking through and overriding (trust me, you really do want something for the pain after your open abdominal surgery), but I worry every day that I do miss a true allergy to sulfa or something.
The second issue revolves around documentation. Taking the critical amount of information for a patient and distilling it into a usable progress note or discharge summary is an incredibly difficult task. In the days of paper charts, notes from docs tended be brutally short. “Doing well, advance diet, monitor fevers”. Nowadays since so much is automatically generated our notes contain all vitals, labs, and a plan that (more often than not) is automatically carried over from the prior day. Again, we seem to be forgetting what the critical information really is, and instead just copying everything down.
Part of this is related to money. We get payed for what we do or do not document, and if the choice comes between losing money or writing more things into charts, you know which direction medicine will head. We have a weekly conference where one of our CDI (Clinical Documentation Integrity) docs goes over how we lose money by not writing the correct coding diagnosis in our notes. It is so ridiculous that it makes me angry to write about it on a rainy Saturday morning from my couch. We don’t get full reimbursement on a trauma patient if we don’t do a complete assessment of history on their intake. This means that if we don’t specifically ask our 90 year old patient with an intracranial bleed about diseases that run in their family, the goverment pays us less money. It doesn’t matter that it’s actually poor patient care, it is a box on the form that must be filled out so it must be done. In the trauma bay, with often critically ill patients, we end up asking about family history, mental health screens, and vaccination status (tetanus is important but others not so much in trauma) to get the boxes checked. It’s absurd.
The other part of this data is related to patient care. We need better tools to analyze big data to see what really matters for outcomes. We track re-admissions and complications because they are easy to measure, and it has made us defensive physicians. We need to measure outcomes in an efficient manner so that we become better physicians. This will be it’s own post down the road, for now I will just drop a quick link to a recent Wall Street Journal article that discusses an aspect of this idea.
If you have skills in data analytics, interface development, or programming of any kind, you could make an actual mountain of money in healthcare. Build us a system that lets us document efficiently and share our documentation with our colleagues across the street and across the country. Build us a system that allows us to study all of our data, our financial measures, our outcomes, and our complications. We need to see it often, not locked away in the medical records department. The last decade of medicine has been dominated by the Epics and Powercharts of the world, who have made it this long for being not as bad as their competitors, but my generation of physicians sees these systems as the dinosaurs that they already are, and we are ready for something better.
This is frustrating to me because I am still boots on the ground slogging through surgery residency. I lack the computing skills to even know where to start, but I know we absolutely need something better. This is the information age of medicine, but right now we aren’t using any of our info, it’s just weighing us down. Healthcare is still using a flip phone, it’s time we catch up and break new ground.
Thanks for reading!