One morning this week I was chatting with a few physicians in our medical staff lounge. “Did you see this?” one of them asked me. I looked to see that someone had tacked up a paper on the bulletin board that was from the “A Piece of My Mind” series in the Journal of the American Medical Association. The writer was lamenting the fact that since the implementation of electronic documentation, many clinicians, especially trainees, were abusing the “cut and paste” function to make their notes repetitive, lengthy, and unreadable. The doctors present with me in the lounge were unified in their belief that this new ability to repeat every fact about the patient in every note was making the record less usable.
I replied to my colleagues that I had seen and read the piece and that I had mixed feelings about it. While I agreed with the author’s basic lament that the regurgitation of information was not helpful, I was bothered by the tenor of his writing. You see, he was a teacher of the people whose work he was criticizing, and he also appeared to be blaming the creators of the electronic record for the fact that his work of patient care was becoming harder. I thought that he was in the “victim box”. He was going to write about this problem so that some great power would fix it. He did not appear to be willing to take any action to help improve the situation.
In 1994, which was also a time when people were talking about healthcare reform, Dr. Donald Berwick, then the President of the Institute for Healthcare Improvement, wrote a paper in the same journal in which he proposed 11 worthy aims of clinician-led reform. One of the aims was recording only useful information only once. Dr. Berwick realized then, and it is ever-more true today, that in an electronic record it is pure waste to record the same thing twice because in a database after the first recording the information can be displayed whenever it is needed. He knew that not only is the second recording of the same data element wasteful, but it creates an opportunity for error like we have with multiple allergy or medication lists in the paper record.
In both the paper and the electronic record there is the potential of waste and patient safety issues. Most of us believe that the benefit that the electronic record gives in making the information available everywhere trumps its failings. But I am in agreement with the author of the JAMA piece that we have to stay vigilant to prevent the creation of a record that is less usable because of its repetitiveness.
But what about Dr. Berwick’s notion of clinician-led reform? At GBMC, our clinicians are making marvelous improvements from doing standard work in the use of central lines to stop infections, to creating order sets to increase the use of evidence-based strategies, to extending office hours, and yes to implementing electronic records so that what the primary care team knows about a patient is available to the ED Team when the patient needs help. Our doctors and nurses haven’t looked to a higher power to make these improvements so we shouldn’t be looking to some higher power to change the recording habits of our junior or not-so-junior colleagues. We should get in action to record only useful information only once! This is my problem with the JAMA piece. Why did the author write the piece before he had sat down with his team to change their work?
What actions might you take to make the patient’s medical record more usable and safer?
A GBMC Icon is Recuperating
Git Merryman, the indomitable “Mr. G” of the Volunteer Auxiliary, who has greeted and helped so many of our patients from his post in our main blood drawing station, has been recuperating from a significant illness at GBMC. Git told me that it would be ok for me to mention this fact in the blog. He is very grateful for the wonderful care he has received from our physicians, nurses, therapists, housekeepers, food service workers, and others. We are grateful for all that he has given us and I can’t wait to see him back at his post!