Friday, November 23, 2012

An unintended consequence of electronic medical records

A few years ago, we doctors kept handwritten charts about patients. Back then, it sometimes seemed like we spent half our time walking around looking for misplaced charts, and the other half trying to decipher the handwriting when we found them. The upside was that if I did have the chart in front of me, and I saw that someone had taken the trouble to write something down, I believed it.

Unfortunately, this is no longer the case. The advent of electronic medical records has been a boon to patient safety and physician efficiency in many ways. But it has also brought with it a slew of “timesaving” tricks that have had some unintended consequences. These tricks make it so easy for doctors to document the results of standard exams and conversations with patients that it appears more and more of them are being documented without ever having happened in the first place.

For instance, doctors used to have to fill out a checklist for every step in a physical exam. Now, they can click one button that automatically places a comprehensive normal physical exam in the record. ...

Hospitals received $1 billion more from Medicare in 2010 than they did in 2005. They say this is largely because electronic medical records have made it easier for doctors to document and be reimbursed for the real work that they do. That’s probably true to an extent. But I bet a lot of doctors have succumbed to the temptation of the click. Medicare thinks so too. This fall, the attorney general and secretary of health and human services warned the five major hospital associations that this kind of abuse would not be tolerated.

And then there are the evil twins, copy and paste. I’ve seen “patient is on day two of antibiotics” appear for five days in a row on one chart. Worse, I’ve seen my own assessments of a patient’s health appear in another doctor’s notes. A 2009 study found that 90 percent of physicians reported copying and pasting when writing daily notes.

In short, reading the electronic chart has become a game of looking for a small needle of new information in a haystack of falsely comprehensive documentation and outdated, copied text. Why do we doctors do this to ourselves? Largely, it turns out, for the same reason most people do most things: money.

Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down. And the rules for what we have to write are Byzantine: Medicare’s explanation takes 87 pages.
--Leora Horwitz, NYT, on a result of lowering the cost of supplying medical documentation