Sunday, November 20, 2011


GIGO,part 2, Medical Records


Part 2 of "The Medical Record"

"Garbage in, garbage out", GIGO, is a term that computer geeks have used since the early days of computer mainframes in the 1950's. Computers make impressive charts and graphs. Computers make impressive data displays. If the information entered is wrong, so is the output.

I am concerned about the methodologies used to enter data into the electronic medical record. While the old handwritten chart was prone to human error and illegibility, the new record seems to magnify the errors and present them legibly and authoritatively.

I currently have a patient in the hospital admitted (as most are) through the emergency department. The ER is the first department in the hospital to have doctors and nurses notes computerized. In the very first doctor entry in her chart, the ER doctor's note, in the very first paragraph, she is described as in "no distress and well hydrated", as well as being "grey, comatose, and with dry mucous membranes" (a cardinal sign of severe dehydration). How can she exhibit all these contradictory findings?

The answer is twofold: templates and checklists.

Of course, in the end, it is the responsibility of the physician to ensure that that notes are not only sensible, but truly reflect his observations and understanding.

The computerized record, however, allows and enables, if not encourages, GIGO.

There are far too many men who have medical records recording their pelvic exams and make note of their previous hysterectomy, as well as women who are recorded as having normal testicular exams. Why? Surely, not because of an epidemic of hermaphroditism, but, rather, a rash of checklists. GIGO.

Despite the epidemic of obesity, and the documentation of patient weights, the record nearly always describes the individual as "well nourished". Why? Surely not because of a hesitancy to label the 400 pound patient as obese, but, rather, templates. GIGO.

Templates push square patients into round descriptions.

Checklists enable clickety-click instead of thinkety-think.

I fear that we are becoming unthinking extensions of our technology. The nursing tech recording vital signs enters a temperature of 95.3 into the computer without a second thought, and without a gaze at the flushed red flesh or a touch of the feverish forehead. GIGO.


The Design of the Medical Record

The Design of the Medical Record
Part 1

The hospital medical record has existed since hospitals began. There are ancient Greek archives of Hippocrates' "Cult of Aesculapius" whose temples were the sites of the first recorded gathering places for care for the ill: primitive hospitals. Hospitals have evolved far in the past two millennia. The medical record evolved.

There was a revolution in hospital care that occurred in the sixth decade of the twentieth century, following WWII and the Korean War. Surgical care had progressed by leaps and in-patient medical care was progressing rapidly. The medical record evolved to serve as documentation and communication tool.

At the end of the sixties, the growth in hospital care was exponential. The entire scope of the medical record was carefully studied and intentionally designed. To a very great degree the medical record was standardized across America. The medical record as a tool of documentation and communication reached its pinnacle in the mid seventies.

The hospital medical record consisted of the following elements:
• Demographics
• Emergency room record
• History and Physical
• Physicians' progress notes
• Nursing notes
• Vital signs
• Consultation notes
• Procedure notes
• Laboratory reports
• Imaging reports
• Therapy reports
• Doctors' orders
• Discharge summary

A separate section of the chart held consent forms.

Each of the elements had its own tab in the binder. Other than the lab and imaging reports and the demographic face sheet the entire chart was hand-written. In some institutions, the doctors and nurses charted in the same progress note section. Sometimes the entire physician documentation, from emergency room, H&P, progress notes, and consultations were all in a single tab, written and stored chronologically sequentially.

What was most striking about the chart was the rigorous way that physicians and nurses documented their observations and their assessments. In particular, physicians delineated their diagnostic thought process and their therapeutic decision making. Everything was communicated and available in a well organized chart.

Granted, there was vast variation in compliance with this model. Physician poor handwriting was already a hackneyed joke. Some doctors just did not respect the value, beauty, and sanctity of the medical record.

The "problem oriented record", formulated by Dr. Weed, and adopted by the entire medical community in the late sixties was at the heart of the structure of the medical record. The chart contained a standardized PROBLEM LIST, with dates of onset and dates of resolution of each problem, with the problem described by the "highest degree of resolution". A problem initially listed as "abdominal pain" might later be resolved to "acute peritonitis" and later to "acute sigmoid diverticulitis with localized peri-colonic abscess". Each progress note referenced the problem list.

The progress notes were in the now famous SOAP format, summarizing the patient's subjective reporting, the doctors' (or nurses') objective observations as well as pertinent laboratory or imaging data, the professionals' assessment of each problem and a problem oriented plan.

The notes were sequential and clearly told the story of the hospitalization. The structure facilitated communication and decision making.

The initial "history and physical" had a structure that dates back to the early twentieth century. It was a careful record of the patients presenting complaint, a detailed history of the present problem, a summary of the past medical and surgical history, as well as family, and social data. A "review of systems" systematically reviewed the patients current reporting of any symptoms not clearly relevant to the presenting problem. Then came a structured comprehensive examination report, followed by a review of all the lab or ancillary data available at the time of admission. Next, the patient's condition was carefully analyzed in the assessment: the problem list was here generated. The preceding data was synthesized and a tentative series of diagnoses recorded. The thought process was delineated. The assessment was followed by the plan: how the doctor intended to proceed with treatment and diagnostics. The rationale was described.

Procedure notes and surgery notes had standardized structure and were included in the sequential flow of the chart.

At the conclusion of the hospitalization, a discharge summary was prepared, summarizing the entirety of the hospitalization.

In the design of a medical record for a new medium in a new millennium, the computerized medical records of the twenty-first century, it is incumbent on the creator to, at the least, maintain the working structures of the paper chart. Since no model has ever proven as valuable as the problem oriented record, it would seem obvious that the design of the electronic record should facilitate the production of an equally valuable record. Perhaps the high structure of database technology could even renew the values of the ideal record that have been lost, abandoned, or made sloppy by the past four decades of medical evolution. It is surely offensive and wrong for the system designer to impose models of data entry, recording, and retrieval that fit some model of program design, but that do not promote a medical record model that has been time honored by the medical profession.

Many forces in society, primarily government and financial institutions (third party payers) are placing tremendous pressure on the medical profession to conform to a model of medical practice that is foreign to our science and our traditions. It is fully acceptable for the medical record to serve as a tool for those forces if and only if the principles and values of the practice of medicine are not thereby compromised. Since the same forces are driving the institution of the electronic medical record, it is incumbent on the designers of that tool to honor our medical record.

Tuesday, November 01, 2011


Health Care Reform Epiphony

When I was in medical school I had friends in law school. Late in our first years of training in our chosen fields, I had an epiphany. It was not at all about the information that we were learning, it was about the thought process. The medical students were being taught to think like doctors and the law students to think like lawyers. Both professions are, in most ways, about problem solving. There was a major difference in the problem solving processes taught.

In medicine we gather data, our history, physical exam, test results, and exploration. Along the way we are juggling the data and fitting to patterns. At some point we prescribe or perform a procedure to attempt to fix the problem. If the fix fails, we regroup and try again: gathering data, pattern fitting, trying to solve. All the human players are on the same team, the doctors, nurses, technicians, as well as the patient and the family: the enemy is disease or dysfunction afflicting the patient. Precision and speed are essential. Caring and compassion are essential as well.

In law the process has a different flavor. Although there is information gathering, the process is adversarial. There are winners and losers, and the battle goes to not necessarily to the best solution, but to the the best fighter. Perhaps justice is served, but all the combatants are bloodied. Surely there are "principles of law" that are based on millenia of sorting of human civilizations' wranglings with conflicts between people. But the lawyers thought process is taught about the minutia and techniques that win the battle, not for what is right, but how to win.

I watched as my law student friends became lawyers: arguing their points with ferocity and skill. I watched as my budding medical colleagues became expert in data analysis and complex human bio-psycho-social systems.

Tonight I had another epiphany.

It has been the in last forty-five years, and particularly the past thirty, that health care delivery has shifted and declined. I blame the decline on the shot-gun wedding of government/business with medicine. Under duress, medicine was forced to accept governmental intervention and control and subsequent business interference. The intrinsic thought process of physicians is incompatible with the legalisms of government and the imperatives of the marketplace. The medical model has been supplanted by a business model and legal process. I fear that the new generation of physicians will be taught to think like businessmen, lawyers, and politicians. I see it already.

My generation of physicians are retiring early, unable to practice as the physicians they were molded to be. Few physicians appreciate the interference and control of Medicare and the myriad insurers. The adversarial relationship is foreign to us: it just does not work for us. We are forced to argue with representatives over even the most trivial things.

This morning I was making rounds at the hospital. I needed to write orders, write a progress note, and obtain written consent from a patient for her blood transfusion. I had to search through racks of ninety-six (I counted) different forms to find these three sheets. Of course, half the chart information is not paper, but is in the computer. Despite the computerization there are over one hundred required forms. Thirty years ago there were less than half a dozen forms in the chart. Forms and paperwork are part of the legal mind-set, not the medical world.

I believe the ever-rising cost of health care and the ever-declining esteem and honor of my profession is a direct result of the spawn of that wrong-minded marriage.


Halloween Scary Medicare Letter

I received the thick envelope from Medicare today. They are demanding I repay them because they erroneously overpaid me. The letter details the rules and regulations regarding the necessary repayment. It details my rights for dispute (but makes it clear that such appeal is hopeless). It details the penalty of 10.875% interest on the amount due if not repaid within thirty days. (I assume this is an "annual percentage rate", but it never says that. By gosh! It could be a daily or monthly rate!) If I do not pay by December 3, 2011, they will withhold all my Medicare payments. I am allowed to make an extended payment plan, and I am allowed to certify that I am bankrupt or unable to pay because of other financial difficulty (three more pa ges to so certify).

And then there are the listings of the overpayments.

There are sixty-two incidences where they overpaid me, from February until June of 2010. The amounts of overpayment range from one cent (really! eighteen of the errors were less than a nickel!!) to whopping $1.04. The average amount is forty cents.'

So I am immediately sending them back the $24.63 they demand as soon as I am able (TODAY!) lest I incur the wrath of this bureaucracy!

Their rules. Their error. Their threats. Their ridiculous recouping of this pittance.

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