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.

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