Tuesday, June 23, 2009

Killing Me Softly

I filter through progress notes looking for the few sentences different from the day before, only to find them sandwiching pages and pages of electronically-produced babble dutifully and automatically mass-reproduced in every note. I wonder, has anyone ever looked retrospectively at the mess created by this process developed to assure doctors were doing what they said they were doing? Ironically, I find we're rarely reading most of what we re-create each day.

But we're sure good at following the rules.


I now see prescription refills for each and every bottle of prescriptions ever filled by a patient, the date a patient filled it, and how many pills they received with each prescription. I’m not sure why. I sat awestruck in clinic yesterday when the list extended 94 pages, double-spaced, since January, 2009. No one, and I mean no one, filled that many prescriptions, did they? Or did they? Am I supposed to correct that list? Oh, by the way dear referring doctor, my note’s at the bottom of that listing.


I get pre-surgical notifications, even though I was the one to notify everyone else about the need for admission, just so I can click on the patient’s name again, lest it not appear I’m not doing enough, I guess.


I get EKG results forwarded for me to sign electronically, even though I’ve already read them, and signed them, by hand, on the EKG. I get notified again that the order I entered for that EKG now has a result, and I have to click on that to tell the computer, “I know.” But that, you see, is not enough. I must also log in, review, and sign off on my EKG’s on the EKG server, too. After all, I’m responsible, and it’s all about quality.

Quality three times over.

Now, multiply that same process for each and every other test I have ordered.


I see orders for things I’m not sure I ordered, just to be sure I’m responsible, and watching, literally hundreds of times per day.


I get e-mails and electronic notifications, and electronic communications, as if I know the difference.


I bypass nursing notes that are mere QA checklists and say nothing about the patient, except that a nurse was there last night.


I feel guilty entering data as I talk to my patient while serving my electronic master. Yet I find the stakes are high to assure accuracy and timeliness in clinical electronic reporting. After all, you never hear the bullet that hits you.


I go home on call, am paged, and reprimanded by a patient who wonders why I can't look up their medication list on-line, even though I'm standing in the grocery store.


Worst of all, I find myself sending myself messages, just to make sure I do something tomorrow that I could not get done today.

Killing me softly …

… with information overload.



Keith Sarpolis said...


The next big challenge of HIT will be to filter out all the garbage that populates these notes. This cut and pasting will likely pose more of a liability to MDs, all at the price of putting enough fluff in the note to justify some payment level.

For instance, I saw a note a few weeks back from a cardiologist who was cutting and pasting his note (at least I hope this was the case) who kept saying the patients coagulation levels were therapeutic, despite the fact he had a major GI bleed and the coumadin had been stopped days ago. He would sure look silly in court if anyone took a good look at the notes!

We all need to be more involved in fighting back about how this HIT is foisted upon us and assuring it works for the benefit of improving patient care; not just reimbursement. While it has many great benefits (nothing like typing notes from home in your underwear), I dearly wish physicians would stop templating their notes with gobs of information that is redundant and get to the point.

What I found particularly interesting is notes I saw recently on a patient from Great Brittan. Brief and to the point with not all the other crap that is needed to satisfy payers and lawyers. Makes one think that maybe a single payer system where we were more focused on patient care, and not jumping through the hoops of payers and lawyers would be so much more satisfying.

Margaret Polaneczky, MD (aka TBTAM) said...

Oh Boy, Dr Wes, You've hit the mail on the head yet again.

We are creating a documentation monster. It's all there, right? No go find it.

The cutting and pasting of prior notes, though, is getting completely out of hand,and I predict it is going to come back and bite us all very, very soon.