Blog | Friday, November 16, 2012

Your life may depend on my diction


"This note was produced using [mega-brand] medical dictation software. While every effort has been made to insure accuracy, errors may still exist."

Really? What kind of doctor would admit in a medical chart to being too lazy or incompetent to produce an accurate record?

A lot of them. Dictations are easy to read if you are willing to confound legibility and accuracy. Dictation software is relatively cheap, and with the continued profusion of electronic health records (EHRs), dictation software allows the doctor's words to become immediately a part of the patient's chart, analogous to writing in a paper chart. In a paper chart, though I've never written a disclaimer warning of my own potential inaccuracy.

Doctors work in a safety-conscious environment on par with the best 19th century practices. If pilots worked like doctors, the sky would rain planes. Because as Americans we've chosen to maintain a medical culture reminiscent of pre-industrial guilds, with apprentices, journeymen and master craftsmen, medical quality is subject to the whims of individual patients and professionals.

EHRs are a tool that can be used to improve ourselves. Health care information entered into EHRs become potentially useful data. If I have 200 diabetic patients with paper charts, I have no easy way of seeing who is getting their yearly eye exams. If the data were entered into an EHR, I could easily produce a report that shows me the information, if I chose to.

Without agreed-upon ways to measure quality and share data, the EHR becomes a fancy toy, with amusing dictation errors. Many physicians have chosen to hold off on EHRs until their role in the system is more clear. The government and private insurers have stepped in to encourage EHR use. Medicare started by offering incentive payments which are being phased into penalties. Private insurers are demanding physicians provide them with reams of data, each company using its own data collection method. What each method has in common is the reliance on doctors to extract and report the data.

Here's the basic conflict: Medical practice needs safety, accountability, and cost-effectiveness. We also need doctors and other providers to focus on patient care. Another lesson from the airline industry is that distraction kills. The role of doctors has until now been to take care of patients, spending time with them, listening, examining, following up on tests. When I look at my desk and see piles of (different) forms from each insurance company asking me to gather and submit data on all of their patients, data which as the payer they already have access to, I may just give up, allow myself to miss out on pay incentives (i.e. pay a penalty), and miss out on an opportunity to improve the quality of care I give.

The private sector has moved in to help fill this gap with companies such as WellCentive, which offers to help doctors to gather and report data. The general idea is that to improve the quality of medical care and to hold costs down for insurance companies, doctors will purchase EHRs, pay for their upkeep and the extra personnel and hardware, and for third parties such as WellCentive to gather and report the data, all to avoid the penalty of reduced payments, penalties that for many of us aren't nearly as onerous as the process of avoiding them.

We need to use information technology to help improve safety, costs, and quality of care. But to put the burden directly on the shoulders of doctors, distracting them from patient care, is insane. If we are serious about this, the market, red in tooth in claw, is not the only solution. Until we take a systemic, serious approach to safety, cost, and quality, we will continue to have nonsensical medical practices designed around forms and incentives rather than efficient, data-driven care.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.