The IDI-Odyssey of Medical Records.

In today's leg of our Idiots Odyssey through healthcare, I would like to take a look at medical records and how our current attitudes and legal positions are not only non-productive, but can be potentially harmful to the patient. Let's step back a few years. I'm sure many of you remember High School or College Biology class. Remember those notebooks you kept recording the data of all those life changing experiments and original research? Well, that element of recording basic scientific process is the basis of the medical record. In the days before Medicine became "Evidence Based" (that deserves a posting all by itself), physicians would record their interactions with patients, reactions to certain therapies and just general observations. These notes were considered the personal property of the physician and the contents were as tightly guarded as trade secrets. For one physician to get ahold of another's medical records was akin to Apple or Microsoft planting spies in the others company, in other words, industrial espionage. Fast forward a few years, the medical records evolved into a tool for providers to communicate during the transfer of knowledge say when a patient was referred from their primary Doctor to a specialist. The notes were very much written in "Medical-ese" and anyone outside the business would have a somewhat difficult time understanding them. Not so much trade secrets anymore, but a useful tool for the transmission of knowledge. Then, as society changed and the legal system began delving deeper and deeper into the function of medicine, the legal medical note began to be viewed with more scrutiny. I feel I should point out here that this was the period of time when translating the language of medicine from a means of communication among individuals who spent their lives dedicated to their science to a language understood by the masses truly began to complicate issues. When one is taught the art of the physical exam, how to take an extensive history and develop a feel for the health issues of an individual, there is a standard of care. Medical notes (and Nursing notes for that matter) used to be "charting by exception". There was a medical standard and you only had to write down what was outside the norm. So, lawyers being lawyers who appear to be incapable of functioning without every detail being covered minutely, began to demand that EVERYTHING needed to be written down. The end result was a LOT of very useless information being put in a Medical record, forcing the reader to search for useful information in a see of flotsam and jetsam. It should also be noted that the escalation of medical costs beyond the finances of the average individual coincided with the entry of lawyers into medicine FOR THE SAFETY OF THE PUBLIC. So, this brings us to our current times, not only does the legal system force Providers to waste HUGE amounts of time documenting to C.Y.A, it now means that needless testing and delays are being done to practice DEFENSIVE MEDICINE. Thus ordering tests which can be both costly and sometimes dangerous because they don't want to risk a law suit if their medical knowledge is incorrect. (Generally, it is not!) Additionally, with the advent of the electronic medical records, ease of access and oversight of the whole medical process is greatly enabled. Initially this might sound like a good idea, but it really isn't. First off, when medical records are requested from another provider, the receiving clinician often receives what is know as a "DATA DUMP". A 2-3 day stay in the hospital can easily translate into well over 100 pages of information, 95 of which are completely useless to transferring care of the patient. The rest results in a dangerous pile of useless information which may include ONE important line, easily overlooked, that may be a key to the patient's future health and treatment. So now let's say that all of the clinical record is scanned into a computer. Generally, these are stored as PDF files. Nothing but pictures that cannot be filed, sorted or searched. With the ease of transfer of data, a patient can have literally hundreds of pages of records, all of which the provider is legally responsible for and none of which is useful. "Now where is that Cat Scan done 6 months ago?" Computers are great at storing information, they are horrible at presenting it to the user at appropriate times. Enter the insurance company. They want access to these records also, Frequently, it appears, for no other reason than to delay or deny care. I have seen insurance companies deny an entire Emergency Visit, ambulance ride and testing because what originally appeared to be a heart attack ended up being indigestion. (Talk about MONDAY MORNING QUARTERBACKING) This is dangerous because patients no longer have faith the service they are paying for will support them when a real emergency does present itself. Also please keep in mind that the individuals who make these decisions to approve or deny payment are now second guessing the training and education of highly committed and educated health care professionals, while they themselves frequently only have a high school education. Now let's take a look at the complications of the Electronic Medical Record and the Patient. Current health standards require that a patient be given access to their medical records, generally through a computer "portal". I am going to contend (while some may disagree) that patients do not need to know everything in their record. Knowing without understanding can actually be dangerous. First, consider the internet. Anyone can go to any search engine and look up every disease known to man and a few more that only exist on the internet. ANYONE can read a medical textbook and get a lot of information from it. If that was all there was to practicing medicine, I could give you a list of books, give online tests to see if you understand the material and send you a medical diploma. We do not go to school to learn Medicine, Nursing or any of the other healthcare professional licenses that people hold FROM A BOOK!. I heard the following statement the first day of Nursing School and the first day of my Physician Assistant/Nurse Practitioner programs: YOU WILL TEACH YOURSELVES THE MEDICINE, WE {the teaching faculty) WILL TEACH YOU HOW TO APPLY IT!!!!!! Too many people grab ahold of some medical fact about their health, research it on the internet, fail to consult a professional, try to treat themselves or demand certain therapies from their providers. THIS CAN BE VERY DANGEROUS and ruin any hope of a productive relationship with your Provider! Now for what I feel is the biggest danger of all. Under current guidelines, we are working towards a system where the note needs to be completed and handed to the patient at the time of the appointment (Currently, the time limit is 3 days.) This is a problem in several areas: 1) the provider is now required to make a snap judgement on diagnosis and treatment. Frequently, there is a need to do research, review the records, obtain other information or just plain think about it for a while. 2) Since the patient will be reading EVERY word in the medical record, certain thoughts WILL NOT BE RECORDED. Trust me, the patient does not WANT to know every time I consider a potentially fatal diagnosis while performing a workup. We have DIFFERENTIAL DIAGNOSIS for a reason, what is most likely, what is most fatal and the priority of working up several differentials at once. Also,certain concerns will never make it into the record. Let us say I have an elderly person with a family member in the exam room. The family member satisfies Federal Privacy requirements to have access to the patients chart. Now let us say I suspect some form of abuse, physical, financial or other, but may need more time to get to know the family dynamics. I'm not going to document that for a couple of reasons. First, when the family member reads of my suspicions, they may just not present for care anymore, certainly not helping the person at risk. Secondly, there is now huge room for conflict in the office, potentially leading to legal actions for slander or violence. We already have patients calling up and yelling at us because they don't like the diagnosis we gave them (for many reasons). To a large extent, the public, the law and insurance companies are demanding access to information that they really do not understand how to process, how to apply it or see what kind of impact any single piece of information has. It is the job of the providers to educate and inform, help the patient understand what is important and what is not. Medicine is not a bunch of statistics that can be applied to all circumstance. People are INDIVIDUALS! It is an art of understanding and caring. It is the responsibility of the patient to find a provider they can work with. Sometimes a difficult task when insurance companies search for the lowest cost provider to provide care at the lowest standards to the most people possible (CATTLE CALL). So the next time you go to a Dr's appointment, and the provider spends the entire visit with their back to you, typing into a computer, please realize that the system that was supposed to provide YOU with quality medical care has devolved to a check box mentality with DATA ENTRY being to most important part of your visit. I guarantee, some day, no amount of data entered into a computer will be adequate. Maybe the next step is a camera and microphone in the room, recording all of your visit and an insurance adjuster giving immediate input as to the future of your healthcare. Have a nice day, more as the IDI-Odyssey of 21st Century Healthcare continues.