Once I lost a hammer. It was a tool I earned in my youth while working to finance my education. It taught me to respect the tools I use in my work. On a past occasion (30 years ago), I wrote how doctors should view their tools: a major one being hospitals. My hope was that practicing doctors would work to influence those institutions for the better. Oh, such were the dreams of my youth. Hospitals are now conglomerates operated by boards and individuals steeped in the profit motives common to all corporations. These are boards and individuals who are far removed from our Oath. They are focusing on the growth and profit for the corporate owners, not on a profit to benefit the community, patients, employees, operations and doctors that it serves. It is a tool that I believe is lost for the lifetime of most current doctors. Now a newer tool already widely used is my current concern: the electronic medical record.
This story begins with my Apple IIe. No, it actually begins much earlier than that. It begins my senior year in high school. An opening in my class schedule allowed me to choose a class of my choice. I chose typing. As a result, I had the advantage of being able to type in college, medical school and even now. My time in high school was before electric typewriters and computers. Since I could type, buying my IIe let me explore the world of computing. It was great fun and allowed me to explore simple basic programing, even writing a program for the interpretation of blood gas test results. Within a short time, professional programers were producing much more sophisticated versions. My skills were in the medical, not the computer field. I need not burden you with the progress in the computer world.
As my medical practice matured, my use of computers kept up with their ability to make life easier. My specialty practice needed quality reports to keep its referring physicians informed as did my work interpreting hospital studies. The computers of the 90’s and since, allow for the creation of these. More ominously, the financial aspects of medical practices began to require computerization. Progress in technology and increased control over fees and payments by outside businesses and government required more and more computerization. Then, a little more than a decade ago, the electronic medical record appeared. It first was a way to organize the doctor’s medical files, but integration with the financial aspects of practice rapidly followed. The electric, digital medical record was born. Hospital and medical practices, with significant government encouragement, widely adopted the electronic system. Use became mandatory for some.
“Open the Pod Bay doors, Hal.” Requested astronaut Dave Bowman.
“I’m sorry, Dave. I’m afraid I can’t do that.” Responded Hal, the 9000 Computer
“The X system does not allow that. I think you can work around it. You will need to go to the ‘order’ tab, then the ‘misc’ tab. That will get the dropdown menu for other items. It is probably listed there.” The support staff cheerily reviewed for me. Their acceptance of the complexities of the digital medical record is probably based upon their knowledge of its inner working. Most of the staff were born after my IIe was manufactured. Raised with and around computers, their acceptance of these difficulties is as understandable as it is disturbing. Though their followup comment indicates dependency on a higher authority, “Sharon, Medical Record X’s representative, can probably help us with that. I will reach out to her. I can have something for you in a few days.” This interaction has become more and more common when a doctor working for a large group or organization runs into issues with documenting, placing orders or communicating with their patients.
Don’t misunderstand me. They are trying to be helpful. They definitely know more about the X electronic medical record than the physicians do. What is irritating is their acceptance that it is the holy grail of records. Their entire lives have been during the computer age. It leads them to accept all its faults and I suspect, to not fully understand why just a few more clicks to memorize and perform does not leave me happy. What happens when the business Medical Record X changes the clicks, deletes the item or task needed or I forget the clicks? I am back to square one.
“Dave, this conversation can serve no purpose any more. Goodbye,” concludes Hal when it tires of discussing opening the pod bay doors with Dave. Hal has made a decision and it will not change. Dave will be left in space. Dave using human ingenuity ultimately finds an alternate way back into the space craft.
Recently it was announced, company X had added an upgrade that some of the support staff were using. It is a program to change a prepared patient message to a calmer more comforting tone and words. We were told it has helped improve the patient’s perception of a few of the staff messages where it has been used. How does it work? A message is prepared. You ask the program to review it. It does, and then changes how the message is phrased and addressed the patient. Red flags flew in my head. Is it the first step in eliminating the human contact in medical care? For example, just feed the result of a test to the system and it prepares and sends the message. Will it be become similar to the multitude of robo calls, messages and commercial computer chats to which we are now exposed? Yes, I am being a bit paranoid. At the least, it does indicate some of the support staff need to improve their communication skills.
“Just what do you think you’re doing, Dave?” Hal asks.
“Dave, stop. Stop, will you? Stop, Dave. Will you stop Dave? Stop. Dave.” Hal attempting to stop Dave from deactivating it.
Hal’s finial vocalizations, “I’m afraid. I’m afraid. Dave. Dave my mind is going. I can feel it. I can feel it. My mind is going.”
Dave completed his mission without Hal. Following Dave’s guidance, maybe we need to disable X. No, that would be like doing away with the car, a terrible thought. Without the automobile, modern society would crumble. There are cars made to go 180 miles per hour and travel through deserts and mountains with ruts for roads, but few will purchase them and even fewer use those features. Unfortunately, the typical electronic medical record system comes with the 180 mile per hour and off-road options. Unlike the car of your choice, you are more a passenger than the driver of the record.
Those options on the electronic record are controls that constrain the medical practice to conform to insurance and government standards. We should recognize the dangers of its controlling nature. It is very similar to government. Governments have an essential role in allowing a free society to flourish and too much government results in tyrannical control. In our era, China, North Korea, Cuba and Russia are good examples of too much control. The computer has an important, almost essential role in medicine, but when controlled by self-interested parties, it can become tyrannical.
As the ultimate users, doctors, and maybe patients, need to police the features included in the computerization of the medical record. Let’s not buy those controlling features. Remember, your role in most systems will be that of passenger, not driver, and it is going to be a long, frustrating, expensive ride.
*From “2001, A Space Odyssey,” a movie by Stanley Kubrick released in 1968 to mixed reviews. Now considered one of the greatest and most influential films ever made. These quotes are taken from a section of the movie on a space voyage from Earth to Jupiter where Hal, the human like computer controlling the flight and the space craft, has lock the human astronaut out of the space craft and refuses to let him back in. You see, Hal had made a mistake and could not admit it. How very human like.
Yes, yes, Winston, I have heard about the new medication approved by the FDA. It has been heralded as the first drug approved for the treatment of Obstructive Sleep Apnea. “Is it so?” you ask. It is, but as an infamous man once said, “It all depends on what the definition of is, is.”
The approval is the FDA giving it an indication for use in obese patients with moderate to severe obstructive sleep apnea. With that approval, it becomes the first medication to have an indication for use in Obstructive Sleep Apnea. This is the fact that has been in multiple news outlets and led to many questions of sleep doctors by our patients. It is important to know more about the details.
The approval followed a multi-million dollar, manufacture sponsored study that was published in the New England Journal of Medicine (NEJM). The study focused on using the weight loss drug in obese individuals with Obstructive Sleep Apnea. Unsurprisingly, the weight loss induced by the medication resulted in improvement in the apnea condition. The treated patients were compared to those treated by diet alone who lost little weight during the study. It was not compared to other weight loss drugs. The article received wide acclaim and attention.
What was known about excessive body weight, weight loss and Obstructive Sleep Apnea before this study? I have an interest in the subject and have followed the work in the field since seeing my first patient with sleep apnea while serving in the Army. He was thin as a rail, by the way. Current knowledge is that we know slightly more than half of all newly diagnosed apnea patients have problems with their weight. We know that of those patients who experience significant weight loss, apnea is eliminated in 18-20% of the obese patients. The others are usually improved, but apnea is not eliminated.
My review of the NEJM article can be summarized briefly. The drug causes weight loss (previously known) and the weight loss improved apnea in many with it. Does it work any better than weight loss by any other means: diet, counseling or other weight loss drugs? Who knows? The study does not address the issue. Does it improve apnea over and above the effect of losing weight? Who knows? The study does not address the issue.
What did the article do? I don’t think it provided any new information. It most likely – I speculate here – influenced the FDA to add the Sleep Apnea with obesity indication to the medication’s approved usage. I suspect that the several million dollars spent for the study resulted in far more notoriety and media attention than any amount of advertising money could buy. Additional facts for you to consider are the cost of the medication and the duration of treatment it requires. A quick Internet search shows it to cost between 900 and 1,000 dollars a month on a well-known discount site. The duration of treatment is potentially life long.
No Winston, it is not proven to be a drug for apnea: just another very expensive drug for weight loss.
I am sorry to go on like this Winston, but let’s face it; we are all concerned with our image. It is a basic human trait. Doctors are not immune. When I last wrote, my feelings were running high regarding the reports all doctors are responsible for completing. I stressed the importance of topic or idea segmentation to improve communication, but good communication requires much more.
All reports need more than just the appropriate formatting. What do we include? Of course the type of report dictates its contents. Test interpretation results, by their nature, report the data generated. Hopefully, these are skillfully separated into pertinent presentations or discussions of individual parameters. For the tests performed, a summation of the results should follow with any appropriate, suggested next steps.
Most medical reports are the results of our direct interaction with patients. Histories, physicals, consultations, progress notes, surgical reports and summaries of clinical notes are examples. While these reports are segmented in a long defined manner, they are often subject to abuses of several easily identifiable types.
The segmentation of doctors’ reports summarizing patient interactions is over 50 years old. New physicians are trained to segment their reports. Traditionally, such reports are divided into the chief complaint, history of the present illness, past medical history, medications, allergies, system review, physical examination, available test data, analysis, impression of the potential diagnosis and the plan for the patient’s future. It seems a lot, and it is, but it is what we do. A great deal must be accomplished in the time we allocate to meet with the patient.
Changes in the notes documenting patient interactions have been suggested in the past few decades; most notably the problem oriented segmentation of such reports. Segmenting reports to specific problems has been suggested to improve the identification and analysis of each problem. These approaches have has varying degrees of acceptance and have definitely improved communications of information. But abuses creating reports continue.
In reports, the all-encompassing segment on analysis is too frequently a single paragraph where the facts of the case are reviewed, an appropriate diagnosis assessed and recommendations presented. When prepared by a thorough physician, this portion of the report will be subdivided as appropriate for the facts of the case to discuss each individual item. The specific recommendations will be provided separately.
There are common techniques used in creating these reports that stand out as inappropriate when overused. I refer to the users of these techniques as the ‘filler’, the ‘ black and white,’ and the ‘obfuscator.’
A ‘filler’ delights in computer generated reports. At the appropriate place in his report, the ‘filler’ will copy and paste entire test results, consults, radiology or laboratory reports into their own. Another common filler technique is to insert a computer generated medical list completed by a nurse or assistant that is so easy to do and so official looking. All the while, to the educated eye, the presentation is screaming that they couldn’t identify what was important from the inserted report so they just included it all in their own. You can almost hear them say, “Look at my impressive comprehensive report.” Certainly the lengths of the reports are impressive. I recently received a consultation on one of my patients where the doctor used the filler technique to the maximum. The dictated computer report was 16 pages long.
The person using the ‘black and white’ approach is the binary report creator: lots of data and no nuances. The ‘black and white’s’ history will include yes and no answers for symptoms, give number results for standard questionnaires and closely follow current medical guidelines. This is particularly true for any therapeutic recommendations on the reports.
The ‘obfuscator’ will fill their assessments with facts and lengthy discussions of potential diseases and conditions, while not providing a consensus on issues of concern to the patient. Could it be they do not have an opinion, do not have a clue or just do not want to express an assessment of the patient’s issues? Maybe it is a “look how smart I am” assessment.
All of us use these techniques to some degree in our reports. Most medical reports tend to be repetitious and dull, but like a story, they can benefit from a logical progression in the presentation and understandable writing. Brevity, to a point, leads to clarity of communication.
I am sorry to go on like this Winston, but let’s face it; we are all concerned with our image. It is a basic human trait. Doctors are not immune. When I last wrote, my feelings were running high regarding the reports all doctors are responsible for completing. I stressed the importance of topic or idea segmentation to improve communication, but good communication requires much more.
All reports need more than just the appropriate formatting. What do we include? Of course the type of report dictates its contents. Test interpretation results, by their nature, report the data generated. Hopefully, these are skillfully separated into pertinent presentations or discussions of individual parameters. For the tests performed, a summation of the results should follow with any appropriate, suggested next steps.
Most medical reports are the results of our direct interaction with patients. Histories, physicals, consultations, progress notes, surgical reports and summaries of clinical notes are examples. While these reports are segmented in a long defined manner, they are often subject to abuses of several easily identifiable types.
The segmentation of doctors’ reports summarizing patient interactions is over 50 years old. New physicians are trained to segment their reports. Traditionally, such reports are divided into the chief complaint, history of the present illness, past medical history, medications, allergies, system review, physical examination, available test data, analysis, impression of the potential diagnosis and the plan for the patient’s future. It seems a lot, and it is, but it is what we do. A great deal must be accomplished in the time we allocate to meet with the patient.
Changes in the notes documenting patient interactions have been suggested in the past few decades; most notably the problem oriented segmentation of such reports. Segmenting reports to specific problems has been suggested to improve the identification and analysis of each problem. These approaches have has varying degrees of acceptance and have definitely improved communications of information. But abuses creating reports continue.
In reports, the all-encompassing segment on analysis is too frequently a single paragraph where the facts of the case are reviewed, an appropriate diagnosis assessed and recommendations presented. When prepared by a thorough physician, this portion of the report will be subdivided as appropriate for the facts of the case to discuss each individual item. The specific recommendations will be provided separately.
There are common techniques used in creating these reports that stand out as inappropriate when overused. I refer to the users of these techniques as the ‘filler’, the ‘ black and white,’ and the ‘obfuscator.’
A ‘filler’ delights in computer generated reports. At the appropriate place in his report, the ‘filler’ will copy and paste entire test results, consults, radiology or laboratory reports into their own. Another common filler technique is to insert a computer generated medical list completed by a nurse or assistant that is so easy to do and so official looking. All the while, to the educated eye, the presentation is screaming that they couldn’t identify what was important from the inserted report so they just included it all in their own. You can almost hear them say, “Look at my impressive comprehensive report.” Certainly the lengths of the reports are impressive. I recently received a consultation on one of my patients where the doctor used the filler technique to the maximum. The dictated computer report was 16 pages long.
The person using the ‘black and white’ approach is the binary report creator: lots of data and no nuances. The ‘black and white’s’ history will include yes and no answers for symptoms, give number results for standard questionnaires and closely follow current medical guidelines. This is particularly true for any therapeutic recommendations on the reports.
The ‘obfuscator’ will fill their assessments with facts and lengthy discussions of potential diseases and conditions, while not providing a consensus on issues of concern to the patient. Could it be they do not have an opinion, do not have a clue or just do not want to express an assessment of the patient’s issues? Maybe it is a “look how smart I am” assessment.
All of us use these techniques to some degree in our reports. Most medical reports tend to be repetitious and dull, but like a story, they can benefit from a logical progression in the presentation and understandable writing. Brevity, to a point, leads to clarity of communication.
Yes Winston, I am very opinionated about writing medical reports. Any document in medicine has a purpose for being created. Those purposes have evolved as well as the manner in which the information is generated. The types of reports have multiplied. My obsession with the creation of reports occurred as a result of a coping mechanism during my career’s evolution.
Once trained as a medical doctor, I was slow to make a decision on what to do with my career. My basic introduction to medicine had, by my own choice, been one of exposing myself to multiple fields. Once I selected internal medicine, it was shortly thereafter that I decided to concentrate my work in the field of lung diseases. With good fortune, ambition and fate, a short five years later I found myself in charge of the Pulmonary Function Laboratory at Walter Reed Army Medical Center.
My post graduate medical training at county, university, veteran and military institutions was designed to train me to be a medical doctor in the specialty of lung diseases. My knowledge of physiology was good for a pulmonologist, but almost superficial for my added job responsibilities. I set a goal to learn the field at a deeper level and was able to progress greatly over the years while I held that position.
On the practical side, tests were being done daily. Doctors from numerous specialties and clinics were ordering tests of lung functions and a report had to be generated for each. It was my responsibility to oversee the creation and quality of a large number of those reports. After leaving the military, I had similar responsibilities at a cardio-pulmonary specialty hospital for an additional 16 years. During the following 20 years, my reports were limited to interpreting sleep tests. Throughout my career, I have been responsible for an extremely large number of medical test reports.
In those early years I was progressively learning more about the details of my work. In my training and previous experience, I was exposed to reports which consisted of consolidated paragraphs with a signature at the end. As I learned more about the physiological aspects of our studies, I would segment portions of my reports to review each one in more detail. Over time, my reports became multiple, small descriptive paragraphs with many sections. At the end, I would summarize the results briefly.
As my knowledge increased, the report format evolved. I was separately analyzing and reporting each group of measured parameters. By doing so, their relationships were clearer and abnormal parameters were more readily identified. Constructing the report by simply separating each parameter analyzed, insured that the interpreting physician reviewed all the parameters and improved the communication of important results to the requesting physician.
Now, after 50 years working in this field, I am struck by how many respected doctors and physicians do not use such a format. Their single paragraph reports appear congested and chaotic when read, making it difficult to identify important numbers and features.
And yes Winston, our clinical reports, consults, progress notes and similar communications benefit from clear thinking and organization. It does not matter if the report is for other physicians, for your future reference, for insurance review or for the patients; a compartmental organized report demonstrates a thorough analytical analysis.
A medical report is a window on the organization and thinking of the professional who prepares it. A segmented, organized report communicates better and ensures attention is paid to each aspect of the subject. Continuous paragraphs of summarized facts suggest a chaotic, unorganized mind.
