It’s a New Year, and welcome, 2023!
When I still practiced clinically, I once got a job as an emergency physician at a brand-new hospital. I was really excited, because I recognized the opportunity for our department to develop our own best-practice culture. I was hoping the staff would gel in an environment of cooperation, with the sole goal of taking the most excellent care of all patients. Sadly, it did not come to fruition, and once bad habits became ensconced, it was all but impossible to rectify the situation.
We have a very important opportunity right now to re-evaluate bad habits in the medical record, throughout the healthcare system, and I hope we don’t squander it.
I ended last year with a project reviewing hospital documentation to see if readmissions had been causally related to index admission. It almost didn’t happen, because they allotted half an hour per record. Depending on the duration of the hospitalization, the charts ranged from 400 to 4,000 pages long! The documentation I needed to make my determination likely represented 20 pages. The narratives and conclusions of the emergency department (ED) note, history and physical (H&P), and the consults, progress notes, and discharge summary and discharge medications were usually all I needed to decide whether the standard of care had been met – and whether the second hospitalization was avoidable.
Slogging through the medical records was frustrating and time-wasting. I know you all know what I am talking about, because this phenomenon, born of equal parts modern technology and laziness, is ubiquitous. Here are a few irritating examples:
- The text only prints on the left half of the page, making everything literally twice as long;
- The past medical history list includes numerous irrelevant, outdated, and/or redundant entries (someone should be tasked with curating and maintaining the past medical history and/or problem list to ensure accuracy);
- Irrelevant family history;
- Medications and lab tests with details, instructions, or explanations that are unnecessary or not useful (e.g., “narrative: The APTT is commonly used to monitor unfractionated heparin and direct thrombin inhibitors. The APTT test is generally insensitive in monitoring low molecular weight heparin or danaparoid.”) If I don’t know what AST stands for, I should either not be looking for the results, or I can Google it to determine that it is aspartate aminotransferase, previously known as SGOT;
- Medications or labs displayed over and over and over again in the record (do we really need these?);
- Social history with entries that do not provide any information, e.g., “not on file.” Line after line of possible ways a person could partake of tobacco (e.g., smoking, chewing, vaping) answered in the negative is just wasted scrolling if the patient doesn’t use tobacco! And:
- Social determinants of health (SDoH) data gathering, which is important, but can take up an entire page if each one is explored.
It is also a travesty that many of these items are visible when reviewing the medical record in an electronic format. Had I designed the electronic health record (EHR), I would have enabled potentially irrelevant or rarely needed details to be made available only upon request. Instead of displaying pages and pages of explanation without usable data, I would make it available on demand by clicking an active link. As a clinician, I don’t care that “the following orders were created for panel order. Please view results for these tests on the individual orders.”
But it is not always possible to view the chart in the EHR. Payers do not have access; auditors are not always granted access. I am not sure if the hospitals really print out these records and then scan them in, or if the technology just processes the chart into a PDF. Whichever it is, it is a waste of time and possibly trees (forests!) Searching is primitive, and often not functional.
On Jan. 1, 2023, the physician professional fee update took effect. The CPT© Evaluation and Management guidelines changed to only consider medical decision-making or time as the determinant for level of service. The goal was to reduce the burden of documentation. In two weeks, I will focus on this, but this shift should give rise to a revision of templates in the system. While the IT folks are doing that, perhaps it would also be a good idea to address some of the other aspects that make the EHR so bulky and end-user-unfriendly. Here are a few examples:
- Have text occupy the entire page, from left to right;
- Purge all ICD-9 codes, once and for all;
- Have someone who reads and uses the information give feedback on fonts. There are often so many different fonts and sizes that it becomes impossible to tease out what are important and what is background noise. Important text should be findable;
- Make it possible to default to all negatives without expansion (e.g., “No smoking, drinking, or illicit drug use” as opposed to “Tobacco use: Smoking status: Never smoker; Smokeless tobacco: never used; Vaping use: Never used;”
- Have a radio button for SDoH for no concerns. This doesn’t mean the questioner can’t ask; it just means that if the answers are all negative, you don’t need to list each one as being negative. In fact, make the default “all negative except…” and then the computer can display the only positives;
- Consultant documents should specify their specialty. If I am looking for the cardiologist’s opinion, having a document titled “consult” is not helpful. “Cardiology consult” would be. If I have a PDF that I can search, typing in “cardiology” could find the latter;
- Consider what presentation suits your organization’s needs best. Is it more helpful to have everything in chronological order, or to have the entries grouped together? For instance, I personally would prefer to see provider notes (in chronological order) to include the ED, admitting H&P, consultations, daily progress notes by all providers, and discharge summary in one section, the nurses’ notes in another section, the medications in another; and
- Maybe the computer can alert someone that a lab result, radiology impression, or other study result has already been embedded in a document, so that providers have to consider whether they really need to incorporate it into TODAY’s entry, too.
I think your organization should collect the stakeholders who generate and those who use the medical record, and they should conjointly decide what needs to be present, and in what format. The electronic medical record is no longer in its infancy. In fact, I think it is exiting its “terrible twos” stage and growing up. It is time that we encourage it to do so, and arrange for it to help us do our jobs.
Our primary concern is patient care, and the medical record in its present state does not always advance that objective.
Next time, we will consider what opportunities the evaluation and management (E&M) revisions offer us, and what changes need to be made to providers’ documentation. It is time for the entire medical record to get an update.