Wednesday, September 03, 2008

Our Most Expensive Typing Pool

With the advent of the Electronic Medical Record, the world's most expensive typing pool has been born.

Just look at all of the nurses, medical students, residents, pharmacists, social workers, physicians' assistants, nurse practitioners, and attending physicians from all corners of the medical globe tic-typing away each morning, noon and night. Sit at a table next to this remarkable typing pool and all you'll hear is: "click-click-click-click-click-click-click-click-click-click-'sh*t'-click-click-click-click-'dammit'-click-click-click-click-click."

Each morning, without fail, there's one or two individuals circling the computer terminals waiting for access to these electronic monetary portals, like children waiting to grab the last chair when the music stops.

But what are they typing?

Here's an example (actual typing in bold):

.id (name, sex, age entered automatically from what clerk has entered at Central Registration) referred for (enter your chief complaint here).

.pmh (At least four pages of Past Medical History spits out when this is typed - the original work was completed by the patient's poor primary care physician, neatly organized, but never to be updated again - hey thanks, Dude!)

.psh (Another page of Past Surgical History is dumped into the note in a fraction of a second, the information kindly entered by a newbee medical student or overachieving resident, or in some rare cases, that gracious primary care physician - hey, you guys are the best!)

.cmed (Another page and a half of the current medications, their dose, prescribing physician, half of which come from self-generated 'CYA' hypoglycemia orders are also self-generated in the interest of 'safety')

.all (The patient's allergy list)

.soc (The patient's Social History regurgitated in detail, with helpful information like "wears seat belts," "does annual self-examinations", and "coffee consumption" all, of course, provided by the patient's primary care physician pain-stakingly entering this highly critical information for the purposes of satisfying "quality initiatives" and Medicare billing requirements - I mean, aren't primary care physician's the best?)

.fam (One line of "Mother died of CA" automatically spits out (previously entered by the hospitalist - bless their soul - so that billing to Medicare can go from Level 4 to Level 5 for the rest of the health care team. Way to be team players!)

.ros (Spits out a canned review of systems, always appended with "All other systems negative.")

.vs (Automatically enters vital signs here, automatically generated by automated pneumatic blood pressure cuffs, digital thermometers, and pulse oximetery machines)

.exam (Enters doctor or nurses's pre-canned exam, edited as needed to they can remember what the patient looked like - unfortunately, this portion of the typing takes the most time and requires the person to surrender their precious computer terminal to actually talk to the patient and examine them.)


EKG: (Put your best guess here)

Cut and paste CXR results here.
Cut and paste echo results here.

And here, some erudite proclamation of an interpretation of the problems is carefully typed. This, you see, is the only thing people will read. The rest above is for Medicare and has been added repetitively and identically by countless other individuals, all whom enter the same content to assure achieving the maximum amount billed by law for their services. Not that any of it is read, mind you, but it'd better be there, lest the Medicare auditors descend on your facility.

Plan: The other portion of what is really read. This takes a bit longer to enter, too, since the doctor spends much of the time scrolling back up the note to see if the medication recommended will interact with the multitude of medications spit out by the ".cmed" dot-phrase.

I wonder what the effect of such automatic generation of notes will have on the next generation of doctors. Will they actually process what is entered, or merely become highly-efficient typists and plagiarists in the never-ending quest to become more "efficient" health care providers?



Anonymous said...

As a provider working in a tertiary care facility since the 1990s when electronic notes were started at the VA I can already tell you that the many of the newer housestaff do NOT process what they copy.

I recently saw an H&P done by a resident which essentially said "PMH per EMR". They didn't even bother to import the problem list or cut and paste from someone else's note.
Nor was there a med list in the H&P; see EMR again was noted. This pt had chronic LBP and was on whopping doses of long acting narcotics (not mentioned anywhere in the H&P) Not a minor oversight when the pt is on the cath table, hasn't taken their usual AM narcotic dose and needs buckets of morphine to control his pain.

I have also seen cards fellows OVERLOOK the fact that pts have contrast allergies. They are using the EMR to import data and forget or neglect to actually review what they have imported.
Have seen this error twice recently. Have seen similar problems with coumadin... routine cath, just hold the coumadin without really evaluating why the pt is on the coumadin. e.g.: "Oh, gee, he's had recurrent DVT and PE?, I didn't realize that."

Graham said...

That's pretty sad. Why can't the EMR generate all the macros for them so that they don't have to type those . commands?

Anonymous said...

I like the progress notes that list automated information like "distal pulses intact" in a patient with an amputation and that daily report on 2/5 strength in the dorsiflexors in a patient who has recovered all strength. This may pale with some of the exams documented on patients - very reliable individuals who tell me they never took off their clothes and that the doctor never actually touched them.

Anonymous said...

Don't forget about how many medical transcriptionist jobs are taken away from the hard working professionals when the reports are done this way!

Bill Cast, M.D. said...

In the end, you get what you measure. As long as outcomes and payment are evaluated by tick-lists, the EMR auto-fill feature will work overtime. On the other hand, I believe we can count on software program advances increasingly to "pull" relevant data for summation. Until then, we all read the consultants' conclusions first.