Tuesday, November 1, 2011
Kudos for Electronic Medication Ordering But Problems with Electronic Physician Documentation
I then asked to see a physician using the electronic medical record to enter an order. The doctor showed me how it was done and how it helped her to avoid mistakes. Basically she was very complimentary of the new system.
So I then asked if she also found it effective for writing her medical documentation such as history and progress notes. Medical documentation is the essential communication tool providers use to collaborate on patient treatment. “No way,” was the immediate response. “It [Electronic Physician Documentation] is too cumbersome, takes much too much time, does not allow me to enter information in a logical manner – basically it wants me to use [the computer’s] logic, not mine. So I just hand-write my notes.” Not a good recommendation, so I asked a few more physicians at different locations and got the same response. I checked with the hospital CIO and learned that few physicians actually used the “physician documentation” part of the system although they gave high marks to the other elements such as ordering tests and reviewing results and images. Since then I have asked similar questions at multiple hospitals, using different major vendor systems, always with about the same response. Clearly, there is a problem here.
The long standing written methodology for physician documentation works sort of like this: the doctor writes an “Admission Note” which includes the patient’s history of the present illness, social and medical history, examination findings, diagnostic test findings, a presumed diagnosis, further testing to be done and a treatment plan. Concurrently, the doctor writes “Orders” such as bed rest, frequency of vital signs to be collected, type of diet and drug orders. Thereafter, the doctor enters “Progress Notes” on a daily or greater basis that summarizes the patient’s status since the last physician visit, new information, supplemental orders for additional testing and new treatment approaches. With an electronic medical record many commercial systems try to adjust this process to use “Check offs” and to eliminate or markedly reduce typing which cannot be readily manipulated for later analysis. Some details are readily done by “check offs” such as age, race, gender and even much of the examination. But the “history,” especially that of a person with one or more chronic illnesses, is by nature a narrative not readily amenable to check offs. A second issue is that the physician deals with the patient and therefore with the chart in a discontinuous manner. For example, he or she might visit each patient early in the morning, then go to radiology to review the films with the radiologist, then to pathology to look at slides with the pathologist, etc. Meanwhile the nurse calls with a problem to be resolved with a verbal order or an electronic order urgently. Each of these encounters may need an update to the medical record and so it needs to be adaptable to that requirement. In teaching hospitals, the intern and residents need a simple manner to sign out to each other with a list of problems for each patient – absent that it means taking notes at a sign out conference. Each of these are issues that most of the current commercial vendors have not resolved which is why the doctor I queried responded “No way.” This problem needs to be resolved promptly if electronic medical records are to gain their full potential.
There is hope, however, with innovative niche companies and new technologies to solve these problems where the vendor market has traditionally been unable to do so. Companies such as Salar, Inc., which have carefully observed how physicians work, have found ways to extend hospital EMR’s to deliver a more flexible templating solution. [Disclosure: I was a Salar board member for five years.] Furthermore, advances in voice recognition and natural language processing give promise of allowing physicians to continue to document in their own methods (allowing for narrative and flexible workflow) while coding the information and delivering the information to the EMR.
I believe that once good systems are in place for physician documentation, the electronic medical record will be rapidly adapted with the attendant advantages for patient, doctor, hospital and insurer. This will be especially important as we increasingly need to care for patients with multiple chronic illnesses with the multi-disciplinary team-based approach. The question at hand is why have the major vendors not corrected/improved their systems to make physician documentation easy and thorough for the doc? I suspect that it is because they have large bureaucracies with software written by those who have not actually observed how physicians work. Hopefully this will change.
My new book “The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You,” from which this post is adapted, will be published Feb 28, 2012 by Potomac Books
Praise for Dr Schimpff
The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.
-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).