Your life may depend on my wonkiness

“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 masters craftsmen, medical quality is subject to the whims of individual patients and professionals. EHR’s 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 payor they already have access to, I may just give up, allow my self 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 payements, 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 non-sensical medical practices designed around forms and incentives rather than efficient, data-driven care.

 

2 Comments

  1. I agree 100%. Electronic records are a miracle if the better part of your career has been spent trying to read handwritten charts. Electronic records are an expensive distraction if there is no consistency in the systems, they can’t “talk” with one another and they are only used to make lists of lists that need more staff time than it would take to transcribe a page of illegible orders.
    If we need more regulation to keep the system running, then regulate compatibility and consistency in the EMR within in systems as well as through out the country. I worked for Kaiser Permanente who has been using EMR long before it became a buzzword, but even they have components within their systems that don’t talk with one another. Lab orders/results may not integrate with patient visits, home health reports have a separate path, inpatient records run in one reality and outpatient notes another and notes by nursing and call centers may not integrate with physician paths. Without integration the whole project is a waste of time and money. In this instance the “free market” of EMR isn’t easing the work but making it more time consuming.

  2. asthmadoc

     /  November 21, 2012

    Good point. however keep in mind several points:
    1) Doctors, if they are to carefully read every dictation, generally tend to have to do this on their “own unpaid time”, say , 9PM at night. Its a matter sometimes of carefully reading every dictation vs going home and actually seeing your children. Pilots generally do all aspects of their jobs on paid time, including paperwork.
    2) Pilots have their work hours capped; which includes all paperwork. Physicians are often doing paperwork in off time late at night, as per #1
    3) Physicians often have to do CME, board exams, other training and certification on their own time, and paying their own money. Pilots generally have all of this paid for by their employer and it can be done on salaried time.

    Perhaps self-employed physicians still have “no excuse” , but for employed physicians – if employers want physicians to be more like pilots, they must do something about the above issues.

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