Why Do We Document?

A guest blog by Donald Kamens, MD, FACEP, FAAEM- Enjoy!

Any physician, and certainly any emergency physician, may have scratched his or her head over this question at one time or another.  I can remember, not only in my early years as an ED doc, but also during a period in which I ran an office as a youngster, the way in which notes were made.  "Cough.  Sounds like bronchitis.  Try antibiotic xyz; see in a week."  For the office, those were even more words than were commonly seen.  And for the ED, where the "chart" - from beginning to end- was handwritten on NCR multiple paper, it was not much different: :Chest pain; EKG - acute anterior ST elevation- admit to CCU."  Sure, I'm dating myself, as it was before the cath lab(!) and the presence of computer terminals at every desk.  But some of you remember, and the rest...well, you are just going to have to take our word for it!

Now, it is of value to ask: "how did all this get started?"; "Why does so much of my time and energy go into creating documents?"; "I could be using those resources to communicate with patients, discuss care, consider and think about the interventions and treatments being applied.".  If one looks historically, several fundamental purposes for putting pen to paper existed throughout the centuries in which medicine, as a science and as a profession, came to exist.  Always however, those purposes were for communication.

At bottom, a physician was communicating to himself/herself.  When the patient returned- if the patient returned- there would thus be a note to refresh the memory on what was previously thought, and what was done.  Some physicians, and I knew a few, made no notes(!).  Their memory was of a class by itself, and each of their patients was like a personal family member whose whole history lived in their minds and hearts indelibly.  Rare birds, these were, and certainly quite extinct.

Those practitioners who worked in larger offices wrote also to communicate with a partner or associate who may wind up caring for the patient at another time.  A good rationale, and sometimes, when considered, required seven or eight words, instead of just two.

And then there were the needs of research.  Research always required the accumulation of more data, and so those thus engaged needed to document more fully.  We can attribute a good deal of the foundations of our medical knowledge to those who, like William Harvey some 400 years ago made copious notes.  And yet even he admonished "not to enter into too much detail".

If only Harvey's prescient counsel could be followed today.  for what do we have?  It has run amuck.  Why?  Well, any of us think that the first incursion was ascension of malpractice defense.  Malpractice litigation appeared for the first time in the US during the middle to the end of the 19th century(JAMA. 2000 apr 5;283(13):1731-7.  NJ Med. 2003 Jul-Aug;100(7-8):21-5.  http://jama.jamanetwork.com/article.aspx?articleid=192559.  Nevertheless, it was really only in the 20th century that defense of such litigation became a day-to-day consideration for physicians.  As a result of the underlying process, records were subpoenaed, notes were scoured by plaintiffs attorneys, and physicians were called-to-carpet for omissions or commissions of words rather than omissions or commissions of action or inaction.  Note the result, the word became the foundation upon which litigation was built.  Hence, attention to words became an effort-requiring part of keeping the center of one's practice free, or relatively free from the efforts of these to extract money from a realm which was once quite purely and completely devoted to caring for patients.  Note that what was once a few word note, became, defensively, a more extensive pronouncement, sometimes a diatribe.  All in defense of some anticipated litigation.

On the heels of this incursion into the formerly somewhat word free realm of medicine, came a new demand for justification of reimbursement from third party payers, in particular CMS-Medicare.  Here, physicians were formerly jotting down just a bit, now writing with a view toward building a potential defense, and along comes various forms of pay-for-performance initiatives, such as DRGs and others to really crank up the word requirements.

Thus "performance" Was tied to what was written down, noted, charted.  Ad the medical record, thus became the reflection of medical activity.  Whether it was accurate or not, is another matter, still if it was not written, "it was not done".  And if it was not done, it was not paid.

It does not take much therefore to see why we document, and thus how the EHR has become the now centrally increasing mechanism for creating a record upon which the life of a practice will ultimately rest.  A good record=a defensible record.  A good record=reimbursable record.  Hence we document to keep our heads above water, but whether we do so, truly, for the sake of good patient care, is really another question entirely.

In the end, we do the best we can, within the circumstances in which we exist.  So we will likely be documenting on every patient, and perhaps wincing a bit along the way.  Still, in the modern practice of medicine it is as necessary as air and water to survival.  So make the best of it.  Look for ease of use.  Employ paper, if you can get way with it.  But if not, simple user interfaces are a key to a good life in the ED or clinic.  You should never need to spend more than a few minutes after a shift to complete your days' documentation.  If so, find a fix.  Documentation of patient care is a beast that has evolved out of control for many decades, but wrestling with it is something we have to do  in a way that tames its excesses, and keeps it rue purposes in perspective.

PRACTICE, PRACTICE, PRACTICE!

How much education and practice is necessary to perform on cue on a daily basis consistently over the years?

Allen Iverson of the Philadelphia 76er's basketball team gave his famous version of the value of practice: "If I can't practice, I can't practice man.  If I'm hurt, I'm hurt.  I mean...simple as that.  It ain't about that... I mean it's... It's not about that... At all.  You know what I'm saying I mean... But it's...it's easy... to, to talk about... It's easy to sum it up when you're just talking about practice.  We're sitting in here, and I'm supposed to be the franchise player, and we in here talking about practice.  I mean, listen, we're talking about practice, not a game, not a game, not a game, we talking about practice.  Not a game.  Not, not... Not the game that I go out there and die for and play every game like it's my last.  Not the game, but we're talking about practice, man.  I know I'm supposed to lead by example... I know that...And I'm not... I'm not shoving it aside, you know, like it don't mean anything.  I know it's important I do.  I honestly do... But we're talking about practice man.  What are we talking about?  Practice?  We're talking about practice, man. [laughter from the media crowd]  We're talking about practice.  We're talking about practice.  We ain't talking about the game. [more laughter]  We're talking about practice, man.  When you come to the area, and you see me play, you see me play don't you?  You've seen me give everything I've got, right?  But we're talking about practice right now.  We talking about pr..."


The reality of medicine is that it takes endless practice, education, simulations, added on to experience to perform up to par on a daily basis.  The more prepared in advanced one is, they are ready to deal with most problems in an organized fashion.

Having an epiphany of insight in a stressful moment is a rare, cosmic occurrence and can not be relied on.  Bottom line, even though most of us are competent, experienced professionals we should Practice, Practice, Practice!

Merit Badge Medicine

In Mel Brooks' 1974 Western Blazing Saddles, he famously misquoted the line, "Badges?  We don't need no stinking Badges!".

In medicine, there is always a debate on whether a provider needs ACLS, ATLS, PALS, etc. to be qualified to obtain employment.  these particular cards have created a "cottage Industry" that relies on new and recertification participants to keep the ball rolling.

There is a need for constant education and preparation, but whether obtaining these certificates imply high quality and standardized abilities is another matter.  The education program is also based on guidelines and opinions that are not necessarily evidence based.

Everyone should know the guidelines who practice Emergency medicine, but do not necessarily need a card or merit badge to affirm ability. 

ACLS (Advance Cardiac Life Support) has come a long way to simplify the process for non-clinicians by eliminating the complexity.  They have also learned that retention of the information is so limited they have installed the KISS (keep it simple stupid) approach to get people to participate.

Providers with board certification in their respective specialties should be encouraged to stay up-to-date, but not necessarily required to have a "Badge".

EHR Blues...Co-authored by Dr. Donald Kamens

Upon reading even just a few of the thousands of review articles on the Electronic Health Record- EHR, it is quite reasonable to conclude that most clinicians would prefer paper.  Why?  The details are many, but the overall impression one gets is that providers do not really see value in performing tasks that are predominately secretarial especially when their already overstretched time could be more effectively spent on actual clinical matters, like communicating with patients and staff, decision making, care consideration, and real-time research.

Unfortunately, though, an unanticipated secondary tier of clerical tasks accompanies most newly deployed EHR modules, and these wind up, of course, in the physician's to do box.  Particularly within modules for order entry (CPOE) and chart documentation, such overhead generates excessive demands on provider attention and effectiveness.

At many institutions, un-navigable interfaces trigger
frustrations and administrators react by throwing more staff at the problem.  Therefore, we now see an increasing number of extra personnel (medical assistants, physician extenders and scribes) carrying laptops, tablets, and smartphones, but not bandages and IV fluids.  Because there is a tendency to sweep EHR deployment shortcomings under the rug, they tend to live beyond conscious recognition, and instead within some hypothetical virtual promise, in a time soon to come.

Thus, while hires may -  on the surface - seem to be made to help provide better overall care, the intrinsic, systemic demands placed on a mouse & keyboard ED staff, by far exceed those placed on a pen & paper staff.  Indeed, logic says that a staff whose workflow and process has improved above that of pre-EHR times, needs correspondingly fewer personnel.  Right?  However, inadequacies in EHR design and performance, and the  necessity of complex workarounds to accomplish simple basic tasks, have instead added to the workload, and have done so beneath the surface, in an almost unconscious plane of operation.

So, since costs tend to reside in an unconscious plane, the ED department will likely not recognize the source of the issues for what they are: generated by the very presence of the EHR, itself.  Moreover, no EHR vendor intends to clue your department in on this.  After a while, one becomes accustomed to extra medical staff, as they become embedded features of the landscape.  Has anyone said that the cost of medical care has gone down since the advent of EHRs?  No Way!  Rather, it is continuous, in the other direction- up, always up.  Hence, a few minutes with pencil and calculator can show that the cost of (staff) adoption to meet EHR practical use will soon exceed the billions in incentives directly paid to physicians for EHRs adoption through meaningful use.  In the end, therefore and sadly, a loss.

This is not to say there is no value in EHRs.  There is indeed some, and there is certainly promise.  Yet, to put the rate of progress directly on the backs of practicing physicians makes no sense whatsoever, especially when the big-picture for the US, includes major systemic health-care overhaul.

 

In areas such as data collection, decision-making, and legibility, a (very) few EHRs hold promise to make things better, in comparison with care currently able to be provided with just pen and paper.  That's a problem, because it trades current quality of health care for future promises that do not have guaranteed benefits.  Doing so isn't necessary.  Yet with quality EHR offerings slim, and pressure to choose high, physicians are correspondingly impaired in their ability to discern what's best for them within what is available.  As a result, most initially attracted by meaningful use monies have found it simply not worth the effort.  Of course, administrators and those who oversee healthcare from a governmental level will think differently.  Nevertheless - and this is a key point - most persons responsible for selecting clinical systems, are themselves not providers, have never directly provided medical care, and never will provide medical care with their own, medically trained, hands.  That's like turning over car design to a group that rides bikes to work every day.

 

Indeed, after all the effort made with meaningful use, and all the billions spent, there is minimal substantive evidence that quality has improved or that efficiencies have been achieved.  Meaningful use activities may look good from a statistician's viewpoint, but very few of the processes that necessarily tag-along with EHR implementation have practical function in the real world.  For example, handing a patient a paper copy of a CCD*, together with 12-pages of discharge instructions, serves little purpose.  Not surprisingly, many clinicians simply do not even know what a CCD even is - nor should they need to know - any more than we need to know the underlying formatted structure of the receipts we sign in restaurants and retail merchants.  Each format is different from the next, and even though the data elements are identical, we commonly just scan for the bottom-line, whether paying at a restaurant, or understanding what actually happened with a patient.  In the case of a patient "represented" by a CCD, chances for successful electronic transmission and succinct presentation of the "bottom-line", are marginal, if at all present.

Over the last few years,, the rush to implement EHRs in time to get meaningful use money has forced hospitals to make decisions based too fully on financial considerations, instead of on finding practical, real, solutions to improve care.  This has led to user (physician) angst and chronic end-user (patient) uncertainty.

 

Institutions have also tried, not-surprisingly, to solve long-term efficiency issues with computer-based solutions that don't address underlying issues.  For example, an electronic bed board may say that room 222 is ready to be cleaned, but if the system cannot assist housekeeping personnel to get there in real-time, the patient destined for that room - once cleaned - is still taking up a bed in the ED.

 

Turning providers into "data jockeys" has created cumbersome workarounds (some quite creative) to offset what was lost from the inherent benefit, simplicity, and efficiency of paper and pen. 

 

But, there is hope.  Perhaps the media will one day say about meaningful use, what Elwood said to Jake in the Blues Brothers (1980), "It wasn't a lie, it was just bulls**t."  With costs increasing and reimbursements under constant scrutiny, there will be in the future a huge push to have an end-user friendly electronic health record with all the fancy artificial intelligence features to save money and eliminate inefficiencies.  Let's hope it really succeeds the next time around.

* The CCD (Continuity of Care Document) is one of several electronic templates proposed by standards organizations to enable interoperability (electronic sharing and reuse) of medical information.  The CCD (as well the CDR, the CDA-R2-CDA, and others) has been constructed to standardize and facilitate rapid transmission of a summary of the patient’s recent course and current condition, readily showing vital signs, family history, plan of care, and so on.  The CCD, however, is not considered the best formulation by everyone. There have been multiple CCD releases over the past decade, all the while trying to establish a standard format into which an EHR can automatically input a summary of the medical history, and output the CCD as an HTML-type document that can be sent to, and read by, other EHRs.  Hence, again in theory, any CCD should be electronically transmissible between differently constructed EHRs, installed by different vendors, and operating cross distances.  Achieving this would be something like building standard fuel pumps for automobiles, so that no matter what the engine happened to be, fuel-pump replacement on a Mercedes would be the identical to that on a Ford. 

Wikipedia says:  “The patient summary contains a core data set of the most relevant administrative, demographic, and clinical information facts about a patient's healthcare, covering one or more healthcare encounters. It provides a means for one healthcare practitioner, system, or setting to aggregate all of the pertinent data about a patient and forward it to another practitioner, system, or setting to support the continuity of care. Its primary use case is to provide a snapshot in time containing the pertinent clinical, demographic, and administrative data for a specific patient.^{[1  ]    “}

 

The Lucey Disease

My associate has recently come down with a new syndrome related to extensive interaction with the Electronic Health Record.The symptoms are an overwhelming desire to shout expletives, when distracted the data he is inputting is now located in the wrong place!

When reviewing the condition, it is characterized by calm demeanor that explodes into frustration, anxiety, stress and the use of inappropriate language in the clinical setting.

The individual is confused and frustrated by the less than simplistic navigation, complex interfaces, and inability to remember the last known "work around".

This diagnosis could not be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM).  It is used or relied upon by clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmaceutical companies, the legal system and policy makers.

However, treatment has not been well studied but reassurance, back-rubs, and electroshock convulsive therapy seem to ameliorate the symptoms.

Can a Physician Run a Business???

Physicians have run small businesses for years with varying degrees of success.  Success can be identified multiple ways: 1. Financial; 2. Personal Satisfaction- being a good doctor; 3. Psychologically Rewarding- ego gratification; 4. Etc.; 5. Etc.

Physicians are excellent at providing good medical care and excellent at thinking that this automatically translates into productivity, process improvement, patient satisfaction, financial reward, and efficiency.  They mold their practices, so that everything works reasonably well, according to their personal vision of how it ought to function.

With the continual addition of more rules, the Affordable Care Act, meaningful use, and higher costs of keeping practices open, many offices are closing.  Whereas, the application of some sophisticated guidance from outside consultants could help.

Physicians may consider hiring such consultants, and often their first recommendation is to create a "Business Plan" representative of the physician's, or practice's goals. Such a plan is corporate-speak for an organizational strategy to achieve those goals, and is customarily laid out on paper.  However, many doctors, if they have a structured overall plan, often maintain it solely within in their own minds, if maintained at all.

Decisions always have to be made for that plan, and therefore always evolving to keep up with the ever-changing practice environment.

Examples include:

1. What Electronic Health Record works for this practice?
2. Is the meaningful use incentive funds worth it?
3. What computers to purchase?
4. How many providers are necessary- physicians, NP, PA, medical assistants, voice activated technology?
5. Do we staff to demand- right number of people at the right time of day?
6. What malpractice to choose- my bias is the least expensive with the lowest limits of coverage acceptable-?
7. Should we perform labs and x-rays in-house or partner?
8. Should we do our own billing?
9. What about ICD 10?
10. Do we accept Medicare and/or Medicaid?
11. How do we get credentialed with payers?
12. How much do we market or advertise?
13. Do we rent, lease or purchase space?
14. Should we sell out to the hospital to eliminate 1-8- what happens after the 2- year honeymoon period?

These are complex questions with no easy answers.  Best decisions in this regard are always made when time is taken to get sufficient data and advice before making adjustments.  But even if decisions are made to change practices, changing behaviors is not so easy, no matter what the facts, or realities of the particular care setting say.

Wisdom is not always easily acquired, and one should carefully listen to those both within and outside of the particular workplace in question.  Optimizing one's practice through small incremental steps with limited investments can be richly rewarding.

Search Engine Optimization

Being technologically impaired according to my offspring, I never understood the mechanics of how Google, Bing, and other search engines know how to deliver advertisements in my mail as well as different web sites I visit.  The term for this process goes by the acronym SEO (search Engine Optimization). 

SEO is accomplished through keywords on which searches are initially based.  On the other hand, after the keywords themselves are injected into the mix, there is the rank given to the website, which determines whether it will appear on the search results, and where on the returned links it shows up.  Larry Page, one of Google's founders, first introduced the concept of rank; hence, the first algorithm used for ranking was called Page-rank(though many have mistakenly thought it meant to reference web-page rank).  Rank, in essence, determines the "popularity" of a given site for the keywords submitted.  Popularity is determined through complex formula that analyze not only how many hits a site has, but also how many other webpages link to the site receiveing the ranking.  Industries have appeared over the last decade that promise to increase ranking and improve hits on a website.  Hence search results, in general, must be viewed with a measure of skepticism, as with any advertising.

The following is a description of an optimal EHR having multiple keywords within the content.

The EHR is being used in hospitals, emergency departments, urgent cares, family practice and specialty private offices to fundamentally change work flow and processes.  The EHR contains databases, charting systems for physicians, physician assistants, and nurse practitioners, nurses, and support staff.  CPOE (computerized order entry), patient education, e-prescribing, report generation, and tracking board.   The database has the ability to scan in outside document or attachments in the record, which can be imported to the contemporaneous patient encounter.  The medical record should be voice activated technology and ICD 10 ready.  It should also be able to send secure faxes with reports to the private medical office.

The Practice Management side contains registration, real-time insurance eligibility checks (extremely important with the initiation of the ACA (Affordable care act), scheduling, medical coding assistants (an estimated level of service), billing with revenue cycle management, and multiple efficiency and reimbursement reports.  The data should be backed up redundantly in the cloud to allow instant update.

In the modern world the internet both watches and has a great influence on your potential behaviors.