Thursday, March 8, 2007

Documentation Hassles - The Chart before the Horse

Last week I visited a relative in a circular ward in an academic health center. In the middle of the ward’s central circle sat a dozen nurses, doctors, and aides. I did not see any medical students, but it was hard to tell because everybody was wearing blue hospital garb. Most people in the inner circle wore no name tags.

No Eye Contact

As I entered the ward, nobody raised their heads or made eye contact, or showed other signs of recognition. I saw no health care personnel visiting patients in their rooms, listening, looking, checking, and examining. During my three hour visit, I saw no evidence of nurses and doctors working in tandem at patients’ bedsides, the sine qua non for clinical efficiency (see tomorrow’s blog on the “The Business Case for Hospital Case Management.”)

Eyes Glued to Computer Screens

To computer screens all eyes were glued. All hands were clicking computer keys, either entering or retrieving data with that omnipotent mouse. They were feeding or extracting information from that omnivorous and never-forgetting data-eating and data-spewing monster called the electronic chart, now more properly dubbed the electronic medical record.

The Chart Ritual


This experience reminded me of when I was a Duke medical student. A red-headed intern with a sense of humor oversaw students. Before rounds he would pull all the charts, review each, and begin his recitation, “This three day-old chart presents without a urinalysis, a CBC, and a chest x-ray.” His tongue-in-cheek message was that a completed chart superceded the patient.

Today this ritual is more important than ever, for everything in this fast-paced fee-for-service world, must be entered, charged, coded, and documented by computer, lest something be overlooked, a diagnosis missed, or an attorney discover a sin of omission.

Data entry has thus become King of the Ward, Supreme Ruler of the Dark Data Domain, and health care professionals have become data entry serfs. Nurses are now the chart police and paper tigers. They spend more time policing and prowling through the chart than nurturing, observing, and caring for patients and collaborating with doctors.

Test First, Talk Last


A fellow intern, now an internist who hangs out at a teaching hospital, tells me in this technological age, interns and residents believe technology testing – CT and MRI scans, echo studies, blood tests – takes precedence over the medical history and physical examination.

Present day monitors of medical students must be intoning, “This three day chart presents without a full technological workup.” The nurses are part of the parade and conduct chart rounds of their own, a task most would rather disown.

A Closing Verse.

Putting the chart before the horse,
is doing first what’s better done later,
putting charts first as a matter of course.
saying to patients, “See you later alligator.”

Treating the chart before the person
has become an obsession and a curse.
I believe it is only going to worsen.
To me it is medical care in reverse.

“Please,” clerks say, “fill out this form.”
You’ve done countless times before.
Still you fill in the blanks and conform,
with data given too often heretofore.

This obsession with documentation,
has to do with payer compensation,
with multi-layered administration,
ending with endless data collection.

When you go through hospital admissions,
it gets worse, time spent on paperwork.
on what are to be your payment conditions.
It is quite enough to drive you berserk.

But for me what is absolutely disconcerting,
is the complete lack of human eye contact.
Total attention to the computer is diverting,
as if you were not even there in actual fact.

Computer hypnosis mesmerizes doctors too.
They sit glued behind that infernal screen,
treating the chart as if it were really you,
acting as slaves to that flickering machine.

So you doctors obligated to give care,
lift up your eyes and open your ears.
Listen to nurses, patients, and visiting folks.
They take precedence over digital strokes.

4 comments:

Val said...

What a terrific, and eye-opening post. The poem was great (loved the last verse "digital strokes"). As a resident I always complained bitterly that 90% of my time was spent with the charts, and 10% with the patients. Did I choose to shorten my notes to spend more time with patients? No, unfortunately I had to protect myself from attending criticisms that I head left something out... and indeed I had, but it wasn't part of the record.

DrWes said...

We've said it many times before, but never as cleverly. Thanks for the great post.

Richard L. Reece, MD said...

Your comment about me being clever brings to mind this poem, The Clever and the Good, by Elizabeth Wordsworth.

If all the good people were clever,
And all the clever people were good,
The word would be nicer than other
We thought it possibly could.

But somehow, 'tis seldom or never
Tht two hit if off as they should;
The good are so harsh to the clever,
The clever so rude to the good!

Richard L. Reece, MD

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