Tuesday, October 16, 2012

Thanks, EMR Mandate, for the Useless Office Notes

     "What happened at your oncology appointment last month?" I asked my patient.
     "Don't you have the report in your chart?"
     I found it:  seven single-spaced pages.  I studied it carefully, while the patient stared at me.  I was struggling to figure out what the oncologist was saying, or thinking, or planning to do with the patient.
     "What did he say?" I asked again.
     "Isn't it in the chart?"  the patient countered.  He wanted my interpretation.
     So, I read through all the pages, most of which reiterated information from prior notes--stuff I already knew:  his medications, past medical problems, the type of cancer, allergies to medicines, results of prior tests.
     One page was full of things like:
     "Eyes:  System reviewed, all negative."
     "Ears, nose, mouth, throat, neck:  System reviewed, all negative."
     "Endocrine:  System reviewed, all negative."
     "Abdomen:  System reviewed, all negative."
     Another page listed all the labs that had been done in the past year--but not the most recent ones, which I needed to see.
     Another page was documentation of a physical exam--but it didn't seem to apply to my patient, who was right in front of me.  Instead, it consisted of items from a drop-down menu, most of which were irrelevant, if not downright dumb.  The psychiatric exam, for example, stated:  "Affect normal;  follows commands;  appropriate behavior."
     Follows commands?  Were we talking about a dog?
     The cardiovascular exam stated:  "Regular rate and rhythm, S1, S2, no murmurs, rubs or gallops."  But--the patient has had a heart murmur for years, and it's pretty loud.  Had I made a mistake?  I listened to his heart--same 3/6 murmur as always.
     "Did the doctor lie you down, and push on your abdomen while looking at your neck?"  I asked.
     "No, I was in the chair the whole time," he said.
     That meant the part of the report that said "No JVD" was something from the drop-down menu, too--easy to click, but not a part of the actual exam that day.
     I kept flipping the pages, reading--and re-reading--words that amounted to balderdash.  Then I saw the section I needed, "Impression."
     What's your impression, Mr. Oncologist?  What's going on with my patient's cancer?  Has it come back?  If so, where?  If not, how should I keep an eye on him?  And what do you propose, if anything?
     My patient was getting nervous.  It was taking me so long.
     "So, what does it say?"  he asked.
     It's often the case that patients come to a family doctor to get a translation of what the specialist told them--this was one of those times.
     I have the blasted report in front of me as I write this blogpost, hours later, but I still can't find answers to my simple questions, nor is there in the seven pages of verbiage anyone who resembles the patient I know, or information about his actual condition.
     The last page of the report is a bunch of superfluities like:
      "E & M.  This excludes teaching time and all billable procedures."
     "The above plan has been discussed with patient." 
     "Greater than 50% of the time spent in this patient's care was face-to-face time spent in counseling, evaluation, and coordination of care for his cancer."
     "I personally reviewed the pertinent medical records, laboratory data, and radiographic images."
     So many words, so little meaning...
     Once upon a time, in a fairy tale land, I could pick up the phone and talk casually with an oncologist--w'd have a chat about our patient.  We'd put our heads together, and come up with ideas about what might work, based on who the patient was and what he might want.  I'd learn a thing or two about cancer trials, new medicines, treatment successes.
     Sometimes I'd catch up on a few other patients, too, or "run a new patient by" the specialist, to see if it was an appropriate referral.  The specialist would thank me.  It was all very cordial.
     Once upon a time, the notes I got from specialists were a paragraph or two long, loaded with meaning, containing exactly what I needed to know to answer a patient's questions, allowing me to proceed in tandem with the treatment plan.  The patient was better off.  Doctors had sensible correspondence with one another, using abbreviated nuggets of information. We had time to see lots more patients.  We saved a ton of paper.  And we loved what we did.
     Alas, those days are lost and gone forever.

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