You can write, but you can't edit

I'm thoroughly enjoying this month's edition of Annals of EM -- partly because of some challenges to current practice, with some research that's up my alley... but mostly because it arrived on my day off.

One article on lab turnaround times has a brilliant editorial accompanying it. Some background: I've been fascinated by charting since medical school, and this memorable post from MedPundit on the evolution of charting stayed with me as I tediously documented findings and thought process on my patients.

Nowhere is documentation more verbose than in the electronic ED. The late, great Cheerful Oncologist blog once hilariously remarked upon this problem:

It was the most amazing thing I had laid eyes on all summer. I sat mesmerized, scrutinizing page after page until finally I heard a voice asking if I was alright...

Later, while driving home, my thoughts drifted back to that emergency room report. It wasn't the facts in the case that captivated me; the patient's illness was serious but manageable, and he had improved since his admission.

It was the macros used by the E. R. doctors and nurses in their typewritten report that were stunning. They spilled over the pages, neatly stacked into parallel lines, all created to prove conclusively to any skeptics that at no time while physically present in the emergency room did the patient receive anything less than perfect care. The result was a repetitive - nay, interminable, tedious, irksome collection of about a hundred paragraphs that contained just under ten percent factual information.

The rest was just a pile of crap that I inferred was placed there for the sole purpose of vexing malpractice lawyers.

Don't get me wrong - I understand the importance of careful documentation of the events of the day inside a hospital or medical office. I get it when I'm told to leave good records of what I say to my patients. It's just that in this particular case the result is an unintentionally hilarious narrative. Let me illustrate by providing an example of a visit to a local hamburger joint, as chronicled by the restaurant's risk management team:

"The client, who walked into the lobby on his own power, had no signs of distress. He was promptly escorted to the nearest counter by staff member One. He completed this ambulation without injury. The client was asked how he felt before the Staff Member departed. The client said he felt fine, but did complain of a feeling of hunger in the vicinity of his abdomen. He was promptly examined by the staff member and found to not contain any foreign objects protruding from his abdomen or chest.

"The client placed his order for a hamburger, large fries and medium coffee. He did not show any signs of distress while waiting for his order, and was checked on by staff members One and Two at 1457 hours and again at 1502 hours. The client did not fall down at any time during his wait, but he did show brief signs of distress upon hearing the score of the Cardinals-Cubs baseball game, which was being broadcast from a nearby radio...

It goes on and on. Some ED information systems are better than others in shielding practitioners from the malpractice malarkey that creeps into charts (by highlighting freetext material, key findings, assessments and plans -- while pushing the checkbox stuff off to the periphery, at least while the patient is still in the ED).

But while we bemoan this excess verbiage, it's not often we wonder what else is at risk. That's why I enjoyed Dr. Peter Viccellio's editorial piece on hidden costs of computer systems, excerpted below:

The electronic medical record has become a tidal wave in emergency medicine. Templates. Checklists. Computerized physician order entry. Time stamps. All entries ending with "side rails up." When one walks into such an ED, it is rather typical to see most of the staff with their nose in a computer. With many hospital systems, there’s a wonderful opportunity to take a minute to chat with your colleagues as you await completion of your sign-on, to check to see if labs are back yet, knowing that you’ll be back to your seat to check again in a little while. (At my institution, the simple act of logging on consumes about 30 to 45 minutes per physician per shift.) Of course, much of this is improved by a robust tracking system (which, uniquely, is a system that works for the physician, rather than vice versa). Many places have implemented computerized physician order entry, or some tortured version of it, and would do well to adopt suggestions such as the ones outlined in the Guss et al article.

The human transaction costs of all these interactions with the computer have, oddly, been largely ignored.
Large groups of health care practitioners typically spend countless hours devoted to the design and maintenance of the system. Time spent at the computer writing notes, entering orders, and looking up lab results is time away from the bedside. The burden of clerical activity has shifted to the nurse and physician. We enter the orders. We seek out the results, often buried in multiple systems. We type our notes. We print out our discharge instructions and prescriptions.

From personal review of a number of templated charts, several things are readily evident. First, there is a struggle between free texting (which is very time consuming) or simply fitting the patient to the template and ignoring the variances. Second, a lot of sprained ankles are curiously getting their pupils checked and their bellies examined by both the physician and the nurse. Some evidently believe that any box left unchecked is an invitation to a supervisory reprimand. The third, and most important, has to do with the ultimate content of the chart. It no longer tells a story (yet, at the same time, takes pages and pages to do so).

The explosion of information in the record, much of which is drivel, succeeds in defeating the primary purpose of an electronic medical record, ie, to tell the story in a meaningful way. It is ultimately a record designed for coding and compliance, not to portray the battle of the patient. When an ED visit for a cough, with diagnosis of pneumonia, consumes 17 pages of print, something has gone awry. (Or perhaps things went awry when pulmonary edema was no longer considered an emergency unless there was a documented family history, social history, and 10 reviews of systems.) Unstudied is the impact a template may have on critical thinking. Being led through a series of checkboxes is very different than the unrestrained and loosely structured improvisation between the physician and the patient. Will the physician have more or less "Aha!" diagnostic breakthroughs when guided and constrained by a template? Will it alter content, the exchange, the clues of body language, the personal interaction, and the diagnostic considerations for better or for worse? Where will we find the time? Whatever its impact, we can at least be sure that more boxes will be checked.

What do these comments have to do with the Guss et al work? Improving flow is centerpiece of their efforts. Although these interventions decreased lab turnaround time for specific labs, were the patients any better off? Did they get out any faster? The article is unfortunately silent on these matters. The context of the study is one in which all efforts are channeled through a computer, and most of this effort depends on those on whose time the patient would consider most valuable. After a pound of flesh for the coder and a pound for the compliance officer, what’s left for the patient? It’s great for the clerk that we now log on, enter orders, type notes, get results, print discharge instructions, and even carry our own telephones. Some of us are doing our own billing as we work.

We need to critically measure the true value of systems that potentially double or triple the amount of work required away from the bedside. Like the electronic medical record, computerized physician order entry itself has not quite been the Grand Panacea as originally envisioned, with production of its own set of errors and time-consuming processes. We don’t really have it "right" yet.

Agreed. But while ED information systems have so far been geared toward maximizing documentation (with an eye toward limiting liability and maximizing billing) new efforts are underway to make computer charting more efficient, and at the same time support decision-making. It will take effort and much trial-and-error, but fortunately, computerized charting is a platform that, by its very nature, lends itself well to research.