Saturday, September 13, 2008

Documentation Hassles - The Chart Before the Horse, Part 2

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.

The Chart Before the Horse, Medinnovation blog, March 9, 2007

The question is, which is to be master – that’s all.

Humpty Dumpty, Alice in Wonderland

I have a renewed observation to make:

Obsession with computer documentation can interfere with physician-patient-nurse relationships and distract from observing, paying attention to, listening to, and treating patients.

I offer the following personal anecdotes as evidence. I do so, knowing full well, that this “string of pearls” approach, i.e., series of anecdotes, is no substitute for data.

• In a previous blog, I described my experience on a medical ward in an academic teaching center. Nurses, doctors, and other paramedical personnel were so firmly glued to their computer screens that I found it difficult to find what was going on with my brother-in-law, who had Parkinson’s disease with pneumonia. Anonymous medical personnel on the ward, who by the way, bore no name tags, made it even tougher to find who was responsible for care. They seemed preoccupied with “treating the chart,” documenting his disease, rather than treating the patient.

• I interviewed Daniel Pallestrant, MD, general surgeon and CEO of, and he said a computer in a room placed between a doctor and his patient negatively changed the human chemistry of the encounter.

• I have spoken to VA patients and doctors regarding the VA’s vaunted “integrated” computer system that links all VA hospitals and clinics. This system represents the state of the art in computer communication and tracking systems. One patient commented, “I can’t talk to the doctor. He is always sitting behind that damn computer, typing in what I say.” Said one doctor, a plastic surgeon, “It takes me 15 minutes to do the procedure, and a half hour to enter the damn data.”

• I interviewed a well-known Florida nephrologist, a computer geek of the first order, and he complained, “EMRs are nothing but giant computer invoices for documenting events. They have no utility as devices to communicate with patients, doctors, or hospitals.”

• Paul Grundy, MD, director of IBM’s health transformation efforts, told me the story of a Danish doctor who took 2 clicks on an EMR to refill a prescription and related a similar story in the American Midwest in which the physician required 156 clicks to accomplish the same thing.

• A medical school classmate, who teaches internal medical residents, has repeatedly told me young doctors in training no longer know how to interview or examine patients, instead relying on computer-based technologies to provide the answers.

• An 82 year old woman with thromboplebitis on anticoagulants was admitted to a local “well-wired” hospital with a decentralized nursing system and rotating hospitalists for generalized bleeding. According to her companion, a nurse who had been head of a major nursing school, the experience was a nightmare, with multiple caregivers, not knowing what the others were doing and the patient being taken on and off anticoagulants, going into shock, and being subjected to a colonoscopy despite being previously dehydrated from diarrhea. Said the nurse companion, “All of this could have been avoided had people got out from behind their computers and looked at the patient.”

• On an unrelated front, my son, who has just returned to graduate school after 12 years in retail, told me, “Dad, it’s a totally different world out there. People go class with their laptops, type their notes, and don’t even listen to or look at the professor. And I can’t even talk directly to the professor. I have to communicate by email.”

I am not a computer curmudgeon, but I want to bring attention to the fact that obsession with computer documentation, no doubt engendered by the desires for
managerial measurement and tracking and avoidance of malpractice suits, can distract from patient care and commonsensical clinical observations.

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