I’m lost, but I’m making record time.
– A pilot, somewhere over the Pacific Ocean
The other day I was reading the printout of an electronic medical record of a patient transferred to our practice. The record reminded me a lot of my Aunt Tillie. Aunt Tillie was the aunt whom everyone would avoid at family gatherings when I was young because the minute she started talking you could be sure of two things: first, that it would be a long time till she stopped talking, and second, that most of what she had to say simply was not relevant to what anyone was interested in hearing. She was interested in what she was interested in and seemed to care little about the needs of anyone else in the room.
The patient in question was 32 years old and had gone to an emergency room for headache and chest pain. Headache and chest pain can be challenging problems, but there are still certain things in both the history and on physical exam that are relevant and informative. It was hard to find those things in this medical record. After a relatively short history of present illness (HPI) that said my patient had presented with 1 day of headache and chest pain. The HPI on this record took up less than three lines. The assessment scales went on for over two pages. When we see records like this, driven by a system that desires to document every question or scale that every possible insurer might be looking for on every possible patient, we fear that common sense has died.
Among the extraneous information in the EHR was a Morse Fall Scale score. The Morse scale and point system were carefully laid out with the actions to be taken at various levels of risk, from bed in the lowest position to when to use skid-proof slipper socks. Then the Braden Scale for Predicting Pressure Sore Risk was recorded, followed by the Domestic Violence Score, complete with indication of whether the patient was under immediate threat and whether police, social services, and mental health professionals were notified. There also was a pain assessment that was filled out with an area indicating that the patient and her family were instructed to tell someone if her level of pain changed. Seriously. The pain assessment scale was located right after the suicide risk assessment and the depression scale, presumably because if the depression assessment occurred any later in the visit the patient might have scored higher out of desperation.
The death of common sense is neither pretty nor fast. As we fill out scales that answer neither evidence-based preventive health interventions nor meet the current needs of the patient, we have become concerned that we, as physicians, have chosen a path that seems to be the clearest – including all possible questions on all possible patients – but is actually fraught with peril.
We have become so concerned about not missing any potential source of reimbursement and protecting ourselves from any source of liability that our visits take longer and our focus has become distracted from the real problems that patients bring to us. By so doing we end up not accomplishing our goal of maximizing reimbursement because we move slower through our visits, filling out information that is not meaningful to either patient or physician. We also do not protect ourselves from liability when we are distracted by the need to fill out irrelevant information and are subsequently left with less time to get through the important parts of our visit, leaving us to take a less detailed history than we might otherwise have performed.
In 1995, Phillip K. Howard wrote a book about the legal system, The Death of Common Sense (Random House). In it, he argues that the desire to have clear rules that allow uniformity in the operation of law has resulted in a system that is inefficient and “precludes the exercise of judgment.” Mr. Howard argues that, no matter how detailed, laws cannot anticipate all of society’s needs. He goes on to state that “law can’t think, and so law must be entrusted to humans and they must take responsibility for their interpretation of it.”
We find a similar case to what Mr. Howard described to be occurring in medicine today. Patients present as individuals, with complex problems that require well-trained clinicians who can prioritize among the many concerns and determine which algorithms of diagnosis and treatment are appropriate to a given visit on a given day. When each visit follows a rote format, no visit follows the format that best serves the patient.