American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, November 12, 2014

The pain and inflammation of documentation

I recently lamented the incredibly bad the documentation I get from a local hospital is. In truth, the documentation I get from everyone is terrible. Seldom does it tell me what I actually want to know, and if there is useful information it is buried in an avalanche of yadda yadda.

The main reason for this is that documentation is driven by our ridiculous payment system, which requires us to follow arcane rules to generate notes that justify the obscure codes we submit for money from the payors. This is the reason for much of the gibberish. These rules, combined with computers' ability to quickly and efficiently generate drivel (see also The Entire Internet) are the hot house and Miracle Gro for meaningless words. Sprinkle the rules on a computerized medical record and stand back! Useless words and codes will spew out at you like milk from the mouth of an overfed baby.

When I started my new practice, one which is outside of those rules, I was excited about the possibility of actually documenting based on patient care. I asked myself, “What would a patient record look like if the only reason for it was for patient care?” It was a compelling question; one which I undertook in earnest to answer over the past 18+ months. Much of the reason for the downturn in my blogging volume is that I've spent an incredible number of hours working on a charting system that did exactly that. It has sucked out a lot of my creative juices, leaving me only the mental energy at the end of the day to play solitaire on my iPad.

Undertaking this endeavor had taught me an important fact: documentation in itself, without the stupid rules, is still really painful. As many bells and whistles I put on my computer system (I recently put a “coffee break” button on we can press when we want to take a break), it still is difficult to generate good documentation.

Notice the coffee cup between the exit and address book icons

This is what you get when you press on that coffee cup!

Why? Imagine having to go through each day and keep track of every conversation you have with people. Imagine trying to not only have meaningful interactions with people and to make good decisions about important things, but to make sure all of the facts were accurately documented in a form that will be useful in the future. Imagine too that you had to do this with all of your emails, phone calls, and text messages you have with people. This is a real pain in the gluteus maximus!

Add to that the joy of patient confidentiality (and our dear friend HIPAA) along with the gobbledygook we get from other practices and hospital documents, and things get really tough. Not only do I have to find a place for each of the pieces of “documentation” I get from hospitals, consultants, and old records, but I also need to go through them and pull out the bits of useful information and put them in as “structured data.”

What, you may ask, is structured data?

Structured data is information that is sorted so the important stuff can be gotten to easily. Some structured data are numbers (like a blood pressure or blood glucose), some are words (like mammogram reports, heart exam findings, and pathology reports), some are dates (date of last colonoscopy, flu shot, or office visit for diabetes), and some are images/documents (like a picture of that rash you had in July, or the video of accident you had with the golf cart that got posted to YouTube). Not all data should be structured (it gets way more confusing that way), just the stuff you might need later on.

You see? Gluteus maximus acquires trauma and inflammation. It is really hard to document things well, and human nature means that by the end of the day you've spent your time doing things and not documenting it all. It's really hard to be diligent about this stuff and not require a double espresso Adderall latte with a valium mojito chaser.

Still the process I've been trying to build has several strategies to make this better:
1. Focus on office workflows to make sure important things get done. When I order a lab test, I need to make sure that it gets done, we get the report, the report is sent to the patient along with a plan, and then a follow-up interval is determined. This needs to be baked into any record system a doctor uses. There are lots and lots of these kinds of workflows that need to be automated.
2. Make the record a collaborative record. There is one person with far more at stake than the folks in the medical office: the patient about whom the record is about. I have yet to implement, but my plan is to give people the ability to see and edit their own records in a way that maximizes accuracy. When a person goes to a consultant, why not have them enter it into their record? When they get results back from another doctor or hospital, why not let them at least notify me in the record that this happened? Accurate records are far more important to patients than anyone else, so why do we keep them out of them (and why the hell do we charge people for their own records??)?
3. Embed communication tools into the record itself. Why have an email or voice message transcribed into a record system? Why not just have the email message go right to their record? Customer relations management programs already do that, keeping track of all communications with each customer. Why doesn't an EMR do that?
4. Use other common tools, like timelines, task management, and tag clouds, to make data easier to understand and compile. There are lots of things done in other information systems that are painfully absent from medical records. Why, for example, don't we have a medication timeline for each patient that has start and stop times overlapping with things like symptoms, lab tests, etc.

I am not saying that documentation will become any more fun than cleaning a cat's litter box, but if we gain enough from the tool, we will use it better. Right now medical records are caught up in the vortex of codes, ACOs and meaningful use. Getting out of that vortex is only step 1 in the process. I've been busting my butt (more gluteal inflammation, sadly) to get something that does even a small part of this. I'm getting closer, but of course I have to build that new record while also seeing patients each day and properly documenting each encounter.

I'll go into more detail as things develop, but I think I need to stand up for a bit.

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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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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