Thursday, January 05, 2012

How to Stop Incenting EMR Note Bloat

It happened again today: an elderly lady with critical aortic stenosis with all it's cool findings: late peaking harsh, palpable murmur, Gallavardin phenomenon, LV heave - the works! And what did the electronic medical record from the intern picking up the patient say?
"CV - Irreg rate and rhythm, no murmurs, clicks or rubs."

No doubt this was a documentation macro that was not edited or else the intern failed to examine the patient (or maybe both).

No excuse! It's time to end the crap being spewed forth into electronic medical records!

I say that every time such a note is discovered like this by our new medical trainess, they fail their rotation. Yep: make the penalty severe and make it stick! That way, they'll think HARD about what they contribute to the medical record and be held accountable!

Of course there's a few sticky problems with such a heavy-handed approach:
  1. Attendings do not critically review what is actually written in the chart by interns because it is buried in pages of electronic morass and rarely found, and...
  2. No one has a clue what to do to attendings who do the same thing. After all, when it comes to getting paid for your work, it's not about what doctors write in a chart, it's about how many things doctors write about so they can bill the government for their professional services.


Jay said...

You are right on the money.

Wouldn't it be cool if someday accurate and intelligent documentation was considered a quality measure?


Tim Hulsey, MD said...

Wouldn't it be cool if, someday, the EMR was eliminated because it is not only NOT helpful, it is detrimental to patient care?! EMR = devil's spawn!

DrWes said...


You and I disagree on this one.

It is not the EMR that is the devil's spawn, but rather the overly regulated requirements for documentation each and every time a doctor sees a patient that breeds this mess. The EMR was developed, in many respects, just to satisfy those ever-burgeoning requirements so hospital systems (and doctors) can meet those requirements effiently and still get paid. To further covertly ration care, they just keep adding more and more bloat by adding new "meaningful use" requirements that serve no function to improve patient care.

This bureacracy is the devil's spawn, not the EMR itself. Having the information to make clinical decisions instantly at our fingertips is the EMR's crowning achievement. The rest of broad promises assumed by the IT guys does little more than pollute the process.

Anonymous said...

A little harsh there bro. (we luv our residents. Remember when you were one?)

What I find frustrating is try to make a correction either takes an Act of Congress or you have to wait until Y3K.

Who "owns" the EMR? Shouldn't it be a little like "open source" software engineering?

But of course, he who owns the info has complete power and as we know absolute power corrupts!


Keith said...


It seems to me that the increased documentation required when using these systems is what is driving this phenomena. When one actually writes a note, they need to think about what it is they are writing. Now we cut and paste and click on predetermied text that takes away alot of this thought process. I almost don't bother to look at the physical exam anymore in EMR records since it is quickly becoming unreliable and I honestly do not believe that all the items described have actually been performed. Same can be said for what seem to be shorter and shorter descriptions of the present illness. But time is finite, and if you need to spend it clicking off all the items to fulfill meaningful use, then something else needs to be sacrificed. That has always been my concern that our devotion to the EMR (which certainly has good attributes) will sap time and attention away from the things we all know are important to good medical care.

I will say as well that the current systems seem to have been designed more for the buisiness end of medicine and assuring upcoding improved capture of billable services; not to improve clinical flow or decision making. Hopefuly this will change over time, but I am not holding my breath.

Anonymous said...

You give the perfect example of value based purchasing. Why should a resident get credit with a poor performance? By that same token, why should a hospital or provider get paid for poor performance? The new database supervision program by the ACC code named PINNACLE will allow CMS to 'see' whether a diagnosis of AS has supporting documentation such as a murmur in the physical exam. The possibilities are limitless. Until hospitals and providers are threatened with decreasing reimbursement, this low quality care will continue.

Anonymous said...

Doesn't matter if it's paper or electronic. If you are going to fake your assessment, it's a statement of the particular person not the means of record taking.


Tim Hulsey, MD said...

SCRN said, "If you are going to fake your assessment, it's a statement of the particular person not the means of record taking."

Just goes to show, you can be dishonest in any medium. Honesty has to be the basis every endeavor, even medicine. Unfortunately, it is not a widely held value in the government, from where our regulation comes.