Wednesday, August 28, 2013
A patient calls or e-mails me with a problem. I talk with them over the course of a few days, using whatever form of communication works best. Eventually, they need to come to the office to be seen, either for something needing to be done in-person (examination, procedure, or lab test), or because of the advantages of face-to-face communication. At the visit, I not only deal with one problem, but there are other issues needing to be addressed. Finally, after the visit, follow-up on the problem continues until it is either resolved, or at least is not causing much trouble.
So how do I document that?
In the past I would’ve had a clear structure for the “office visit” and separate “encounters” for the documentation of the communication done outside of the office. The latter would be done largely with narrative of the conversation, and some direct quotes from the patient. The former, the “office visit” would include:
• A re-telling of the story of the “chief complaint” and what’s been happening that caused this encounter to be necessary.
• A sifting through other symptoms and past-problems to see if there is any information hidden there that may be useful.
• A documentation of past problems (already in the record) to support the thought process documented later in the visit.
• An overview of the physical exam, again to support the decisions made as a result of the visit.
• A discussion of my thoughts on what I think is going on.
• A telling of my plan on how to deal with this.
• A list of any advice given, tests ordered, medications changed, prescriptions written, and follow-up as the details of that plan.
• A signature at the end, attesting to the validity of what is contained in the note.
But here’s the problem: it’s not real. I don’t make all of my decisions based on the visit, and the patient’s story is not limited to what they tell me. Details may be left out because they are forgotten, questions aren’t asked, or things just haven’t happened yet. This signed and sealed unit of care, represented as a full story, actually represents only fragments of the story, of many stories actually, and only as a moment on the continuum of the patient’s care.
But there it stands, the office visit, the center of the patient’s medical record. It is what my past life defines as “health care.” But for me now, it is an anachronism: an old-fashioned idea that has nothing to do with my present reality. My care is no longer episodic, so why should my records be? I no longer need “visits” as units of commerce, and no longer need “problems” as the goods for which I am paid. This took me quite a while to figure out, and has me making some radical (crazy?) changes to how I think about care.
1. Stop artificially defining units of care from my perspective.
The “office visit” is a unit defined from the physician’s perspective. This may actually undermine a clear thought process, though, fooling me into believing I’ve finished something that isn’t complete. Instead of breaking care into a temporal unit, why not define it another way:
1. The narrative – what is going on with the person. The patient narrative goes over their lifetime, some of which happens in my office. Narrative would best be a combination of patient input and my observations as a third-party. My job is not necessarily to do the narration, but to guide it by asking questions and to prioritize that which I think is most salient. Each “problem” may have its own narrative, but those lines often blur, as the chronic disease causes depression, and both the chronic disease and depression lead to fatigue and increased pain. How do you divide those? Do you need to?
2. The investigation – both through my questions, examination, and through tests I order, I work to solve puzzles. The patient wants me to make sense of confusing parts of their narrative, so I step in and investigate. Tests are ordered for a reason, and exams are generally problem-driven. One of the most important “tests” to do is to wait and see what happens. Sometimes stories only become clear as they unfold, and it is my job to know when it’s best to do nothing other than wait and observe.
3. Interventions – medications, lifestyle changes, education, and procedures are what most people think of when they define “health care.” Yet these are entirely driven by the narrative and investigation. They add to the narrative and often become part of the investigation, but they never stand alone. Well, they shouldn’t stand alone, despite the fact that they are what doctors are largely paid for in this country.
4. Destinations – what are our goals? What is the goal of the patient in the bigger sense, and what are our goals for individual narratives? The destination is the entire purpose of the doctor-patient interaction. The patient doesn’t like their destination and I am called on to help them go somewhere else, or they just want to be sure they are not inadvertently going to a bad locale.
Can I do a record based on these categories? If I do, would it end up as a crazy jumbled mess?
2. Find strings to tie the pieces together.
Each part of the record of care is tied together in different ways, with different things that they share with the other pieces of information or narrative.
1. Diseases – these were referred to as “problems” in my past life, a euphemism if there ever was one, but part of each record is usually devoted toward the prevention, treatment, or management of disease. Narrative, investigation, intervention, and destination could address these aspects of disease.
2. Symptoms – these also (perhaps more appropriately) were listed as “problems” in my past life. They are how health directly impacts the patient. Symptoms may or may be related to a one or many diseases, or may be mysterious.
3. Risks – These are sometimes determined by choices of the patient (smoking, drinking) or not (family history). The reason we at all care about smoking or family history is the risk they confer.
4. Events – Big events, such as heart attacks or motor vehicle accidents can result from or cause disease, but they are tied together in a temporal way. In the same way, an office visit is a temporal way to tie together interactions with a patient on a given day. (I didn’t say it’s entirely bad to consider visits as units; it’s just bad to only define them that way).
5. Situation/Environment – What’s going on in the other areas? Is the person getting a divorce? Is it allergy season? Is there a flu epidemic?
6. Population factors – some narratives, investigations, interventions, and destinations can transcend a single patient. My ability to see the population as a whole will help me to give better individual care.
Where does this lead?
What does a record in such a world look like? I can’t say I’ve come to a clear idea, but there are some things I’ve started doing:
1. Treating narrative as a separate entity – Whether communication happens via secure message, on the phone, or via email, narrative is narrative. It is the fuel that propels good communication (my listening to it) and by which proper care is given. Lumping narrative with the other areas tends to artificially categorize it. The result is a separate documentation of narrative from exam, intervention, etc. in the record.
2. Tying narrative and the other areas together using things they have in common. I have started using diseases, symptoms, risk factors, and events as tags, tagging narrative, consults, lab results, medications, and anything else with these fathers (so I can see all conversations, examinations, lab tests, consults, hospitalizations, etc. related to a person’s diabetes, for example, or seeing all other parts related to a specific medication).
3. Allowing free-flowing use of tags to give me different views of the same parts of the record. In general, the more perspectives one has when looking at something, the more accurate the picture. This means tagging needs to be simple (perhaps automatic) and robust. It also means that I need to be able to quickly get those views when I (or the patient) need them.
4. Working with the patient to come up with a destination – an overall plan of what they expect to get out of my care.
5. Going over the progress toward those destinations on a regular basis.
6. Making all of this fully available to my patients. This assures the accuracy of the information and keeps it focused where it should be: on the person for whom this whole system is built.
Sounds crazy? Sometimes I wonder. But then I look at what my past life as a doctor involved, and what “care” was defined as, and I begin to grin. That was crazy. This is simply being myself, which, for once, doesn’t seem so crazy.
After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.
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