There were stacks and stacks of old medical records from the 1950’s, 60’s and 70’s. A seemingly endless commentary of the medical history of a small community in West Tennessee.
All for perusing at my leisure.
All of it a study in old school doctoring.
There were one page hospital summaries. There were two line office visits (“S. Throat - Pen VK IM”) and an occasional dictated noted on adhesive paper placed in the chard. A whopping five lines of dictation.
There were a few bills. Office visits were two to five dollars. Hospital bills were less than a page and actually made sense of what was charged. Insurance? It paid the nominal fee the doctor billed with no need of the levels and codes of today.
Occasionally there was a smudge on the paper chart from the fountain pen ink. The doctor’s fountain pens of that era were narrow and very firm so that the carbon paper in hospital charts could pick up the handwriting. This would lead to smudges from the cuff of the shirt or coat.
This was the kind of medicine where the doctor usually knew the patient since birth, had a schedule but it was only a rough estimate because anyone who walked in was seen and that usually meant forty to fifty patients a day (no quality surveys calling patients afterwards asking if the doctor was on time), the doctor would scribble or dictate a brief note to serve as a reminder for future reference, and nobody outside that medical office saw any patient’s medical record.
See the patient, assess the patient, treat the patient, somehow without the aid of a cell phone, know when to go to the hospital for the patient.
Move forward to current medicine. Seeing the patient has almost become an interruption to the data collection that is necessary for the billing, insurance and government. (That’s until the insurance makes a decision to change coverage and the patient has to move on to a new physician.)
The focus, the thoughts, the line of thinking and listening must be constantly interrupted with a second thought process of entering it into a computer or being certain to collect enough data points to satisfy the chart auditor who will question the level of coding and billing sent to the insurance or government agency.
It isn’t just chest pain. In the language of ICD-10 coding it is R07.2 Precordial pain, however it could be R07.82 Intercostal pain, but could be R07.9 Chest pain, unspecified, but “that code is usually denied for lack of specificity so use R07.1.” Oh, okay, got it.
Oh, wait, did I click on the right box for the test I was wanting…..? Oh, I better look at the patient again so they think I’m not looking at the computer all the time while in the room with them. I’ll get a bad review on the customer survey for not making eye contact and appearing engaged.
Is this having an impact on patient care? In a recent survey of physicians published in 2015 in the Mayo Clinic Proceedings, physician burnout has clearly risen in the past year. Overall the number of physicians reporting at least one symptom of burnout has risen from 45% to 54%.
In a similar survey, Medscape, an online source of medical information, data and news for medical professionals, polled 15,800 physicians from 25 specialties. Their data suggests that “physician burnout” (ICD-10 code Z73.0) has reached a critical level. They defined burnout in the survey as “loss of enthusiasm for work, depersonalization, and a low sense of personal accomplishment.”
The top causes of burnout were noted by Medscape as bureaucratic tasks, working too many hours, and computerization. However, in the 45-65 year old demographic, computerization was the leading cause of burnout, by far.
The 45-65 year old physicians? They are the ones who usually have settled into a community and are the backbone of the medical system. They don’t get too excited about new trends until they are dependable trends.
Why is this? First, I believe it is because physicians do not train to be data collectors or typists. Sure, some level of documentation needs to be done to preserve continuity of care, reasoning for the treatment plan, discussion of risks and thoughts of alternative courses if needed, but that shouldn’t require a parallel thought process along with the medical thinking that is critical to getting a patient the best care.
Do judges and lawyers do this? No, they have stenographers. Do executive’s do this? No, they have assistants.
Second, most, but not all, electronic medical records are designed by computer programmers listening to physicians tell them what they need. Some of the programs are better than others, but there is a world of difference in describing how to play a chord on the piano and actually playing it. The same goes in medicine.
There is an enormous industry now based on the data collected on patients from vital signs (your insurance company knows if you are fat), to refill compliance (your insurance company knows if you are slack), and now even to the number of steps walked per day (your insurance company knows if you are lazy). This isn’t going to change.
Always remember, politicians never give up power and companies never give up data. They both crave more.
Therefore, there is a vast and gaping canyon separating where we are in medicine and where we need to be with computerization. Surprisingly, the solution for this is in its infancy, possibly pushed into the forefront by the Affordable Care Act’s requirement for Electronic Health Records.
First, physicians need to get back to being physicians. They need to be able to listen, watch, look, interact, see subtle changes and think completely about the patient. After all, it is about the patient.
Second, scribes (assistants who accompany the doctor into the room) should be utilized to fluently know the computer system, know how to transcribe the doctor-patient encounter in real time and collect the data that is required in modern medicine.
Third, it simply is time for better computerized medical records. When I was in high school we would write programs in Basic Language on our sizzling fast Apple Macintosh computers. I ventured into the visual programming of mathematical equations forming graphic designs. It was cutting edge stuff to write for several days and see a colorful display of symmetrical lines as the result. My friends caught on and I moved on to the Hi-Res graphic programming. It took forever to write that code.
Now, I can create graphic art on my iPad with a free app and moving a finger across the screen. It is simple. It is intuitive. It allows me to focus on the art of design and not the netherworld of data architecture.
Someone, somewhere, needs to design the same intuitive system for physicians to use in medical care. Whoever that is deserves the financial windfall it will bring and the heartfelt appreciation of the physicians who might just not abandon their profession in their prime.
After all, it is the art of medicine, not the architecture of medicine.
Eric J. Littleton, M.D. (@DrEricLittleton) is a Family Physician in Sevierville, TN. His office is in the UT Regional Health Center Sevierville at 1130 Middle Creek Road. Topics covered are general in nature and should not be used to change medical treatments and/or plans without first discussing with your physician. Send questions to askdrlittleton@gmail.com
