January 9, 2009

The Chart Is Dead, Long Live The Chart

I. In the Annals of Emergency Medicine appears a short article called, The Chart Is Dead- Long Live The Chart.

The article explains how the chart has regressed from a place to write down thoughts and ideas ("writing as thinking") to a fee extraction device, simply templates specific to reimbursement guidelines, and not the delivering of care.  This means that the chart does not aid in the work of the clinician; I'd add that it actually becomes the work.  The chart is dead.

Summarizing some of the author's, and my own, observations:

  • Default terms and ideas which go/don't go into the chart-- so all charts look pretty much the same.  There is barely anything in the record that distinguishes one patient from another.   It's as if privacy laws are superfluous.
  • Unreliability of the information. On day 3 of a hospitalization, does "+SI" mean he really had SI, or is that just there for the insurance?   Does PERRLA mean P+E+R+R+L+A, or just "Patient had two Ps?"  This isn't a comment on clinical rigor.  Let's assume doctors are doing a thorough job regardless of documentation.  The question here is that since PERRLA doesn't actually mean P+E+R+R+L+A, why document it at all? Who are we really trying to fool? 
  • Research by retrospective chart review is therefore invalid.  It is unreliable, misleading, and worse than useless.  Please read that 100 times.
  • The shadow chart-- and any resident will know exactly what this means.  "Sign outs" or "the list," three lines long per patient but substantially more focused and useful than the entire actual chart.  Often, information is there that would never  dare be included in the regular record: "mother likely borderline as well."  Lawyers have no idea what they're missing out on; and, here's a secret-- the sign outs are usually typed on the same ward computer.  Let fly the subpoenas.
Since doctors believe the chart to be a billing form or evidence in a malpractice case, they are not using it as a diary of clinical care.  The irony, of course, is that both insurance companies and lawyers pretend that it still is the very thing that they have caused it not to be.

II.  How did it come to this?

Another article in the Annals of Internal Medicine, entitled "The misinformation era: The fall of the medical record"  also criticizes the uselessness and unreliability of the chart.  The author observes that clinicians are often afraid to document things that might upset the patient:

Physicians have become cautious of writing that a patient is paranoid, flirtatious, hypochondriacal, verbose, or homosexual. Possible demeaning comments about the patient's manner, dress, speech, level of education, and intelligence are also omitted. 
If flow-chart medicine is what we strive to practice, than let's imply dispense with charts-- and doctors-- fire up the Hippocratobot, and start billing Medicare.  Otherwise we're going to need to accept that, in order to be effective, a doctor is going to need to know even the things which are "irrelevant," precisely because they are not.  And he's even going to need to write them down somewhere.

The rest of the article will resonate with any clinician:

In view of the flagging integrity of medical record information, it is particularly galling that medical records have been accorded such authority in our society. Physicians may spend as much time with records as with patients. Medical records dictate whether and how much physicians and hospitals are paid... Records determine our patients' insurability, job qualifications, credit ratings, disability awards, and retirement. They are central in malpractice litigation...

...But to restore the integrity of the medical record is more difficult. The manipulation of chart information physicians go through to protect private information about patients from public view and to satisfy the cost-control regulations are demoralizing and degrading to medical professionalism. This subterfuge will continue until confidentiality is restored to medical records and the regulations are revised to accord with the realities of practice, rather than requiring clinical medicine to be a mechanistic clockwork technology. In the meantime, all medical record information should be regarded as suspect; much of it is fiction.
Boy, things are getting worse.  Actually, no: this article was written 20 years ago.

III.  So if things have been this bad for a while, what is the real problem?

The charts haven't gotten worse, our ability to think has gotten worse, the chart now simply reflects that.   I know we believe we chart differently than we practice or think, but the two are very connected; what you write causes you to think a certain way.  Since we are not writing down dating history, therefore we are not thinking about dating history, it becomes secondary.  We're instead thinking about about "mixed episodes."   Get it?  We're trying to reduce "dating history" into a symptom cluster.    What's on our minds first is Lipitor and LDL, and only secondarily quit smoking and eat better, because we document Lipitor and cholesterol, our charts contain places to write those down.

"But isn't LDL important?"  See? You've been contaminated also.  The number is meaningless beyond low, normal, and high; and those three have relevance only as they correlate to other pathologies.  But you have information bias, you feel like you need to know the actual number, you feel like it tells you something, you feel like "normal" isn't informative enough.  And I'm telling you "normal" is more informative because your mind is not cluttered with the uselessness of "one hundred and nineteen."

Knowing that certain info should go into the chart (Lipitor) causes you to think about that primarily.

The second problem is this: the doctor is required to do two entirely contradictory things.  First, he is supposed to do what he thinks is best for the patient.  Second, he is asked to document the facts of his prosecution.

No one looks bad if they don't write, "told to eat carrots."  But you look sloppy if you write ""LDL high." 

In other words, the medical chart is a college application: here's what I did, to the best of my embellishment, knowing that you don't care about what I actually did, but rather about the things you think are important-- all of which I did only because that's what you want from me.  Can I get paid/dismissed now?

IV.  You're kidding, right?

No.  Maryland State Board of Physicians v. Eist, 2007.

A man-- not a patient-- complains to the Medical Board that Dr. Eist overmedicated his wife and son (Eist's actual patients), which caused (supposedly) his wife to become psychotic and the boy extremely anxious.

The Board, trying to get to the bottom of it all, told Eist, and I'm quoting,

deliver immediately upon service of process a copy of all medical records of [the wife and son]; treated at your facility; which materials are in your custody, possession or control.

His response was, and I'm paraphrasing,

bite me.

Slow down, Souter, Eist is right: the complaint was filed by the husband-- he's not the patient; and he was in the process of divorcing his wife and demanding custody of the kids.  Get it?  No?  Once the Board gets the records, the man would then be able to demand those records from the Board as evidence for his custody hearing: "my wife isn't fit to care for her kids."

Well, the wife eventually allowed Eist to release the records to the Board, so he did.  In thanks, the Board slapped him with a $5000 fine for not having complied immediately.


What do you think Eist wrote in that chart that he didn't want the husband to see that-- and this is important-- the husband couldn't have obtained from other sources? The husband has  empty prescription bottles in the house; he has insurance bills.  He knows she went to a shrink. Do you think Eist was doing dream work with her, and documenting it?  Of course not.

The state board, in its brief to the Court of Appeals, argues that the lower courts failed to weigh appropriately the state's need for patient records when investigating alleged medical misconduct and the doctor's ethical requirement to preserve patient confidentiality. The records sought from Eist concerned primarily the drugs and dosages prescribed by the physician, data which medical agencies routinely collect as part of their compelling interest in protecting the health of all residents who seek medical care, the board states.

The Board itself expected there'd be nothing useful in the record.

Eist's, and all doctors', dilemma is this: if he has written what he really wants to write in the chart, and the husband gets hold of it, he's damaged his patient and can even be sued for doing so.  So he shouldn't give the Board the records.  On the other hand, he's punished for not giving the records-- because the Board expects that he/you are smart enough not to put anything in those records, so why wouldn't you give them up?

So then why would he/you write something in the chart that, if it fell into the wrong hands, could damage your patient?  You wouldn't.  Are we supposed to honor the confidentiality of medical records but assume they can be read by anyone at any time?  Apparently yes.


Doctors have to document for billing and for malpractice, but at the same time not so much that it would damage the patient in the event of accidental disclosure.  If these are the things on his mind as he is writing the chart, it is impossible for these things not to be on his mind as he practices medicine.  To the exclusion of other things.   It's not just that it takes up time; it completely changes the way you think.

Example:  They'll write in a progress note, "Lipitor 10mg PO qd."  But they'll write that information also in the section called "Medication Record" and also photocopy the prescription.  But no doctor would ever write only "Lipitor" in the progress note, because that seems incomplete.  Try it, see how weird it feels.  Is triple documentation useful?  No.  But it triply reinforces that that information is very, very important, while things you don't write down-- "needs to eat two carrots a day and one less donut"  is less important.

How we chart makes us worse doctors.

VII.  "It maybe makes you a worse doctor, but you're a jerk anyway.  I'm not like that.

Let's all agree that I am not a person short on thoughts.  But I notice in my own practice that I don't think about things which are later obvious to me when I'm listening to music not writing in a chart, because my pattern is to write certain things down.

Life is one big Stroop test.  Don't read the words-- just say out loud the colors you see:


It is very hard to attend to what you think is important when you are faced with competing informaion.  Note that the only way to really succeed at this task is to avoid reading the words.

These are just stupid colors and words.  Do you really think you can block the effect of thrice documented Lipitor in your practice?

VII.  What's coming?

Easy answer that no one will like.  Since it is evident that chart serves no useful purpose to the clinician; and it only serves a negative, or limiting purpose vis a vis insurance and litigation, and it adversely affects the way we think about patients and the way we treat them, it will, inevitably, be abandoned.  What will replace it?  The only thing that is objective enough to serve both science, billing, and forensics:   video.

Which is another reason why I am retiring.


My workaround for this prob... (Below threshold)

January 9, 2009 12:26 PM | Posted by Dr Benway: | Reply

My workaround for this problem: write a program to automate as much of the documentation as possible.

I do like hearing, "LDL=119" rather than, "LDL normal," because people say "normal" when they haven't actually checked the results. In my head, I translate the 119 to "normal."

But for every action there's a reaction. Thanks to the database, third party payers now demand crazy buttloads of useless info. It's like everyone is autistic and unable to grasp the larger picture.

This week I learned that a patient admitted to my care several months ago was charged with first degree murder about a year prior. Not in the referring records, probably as the info might induce some bias against the patient.

What's the latest euphemism for HIV+? I've been writing, "immune deficiency."

It's dangerous to note too many problems in the record. Every problem has to match some intervention --never mind that no effective intervention might actually exist.

A not-too-bright Asperger's youth in an RTF indulged in some mutual masturbation with a pre-adolescent boy. The funder wants him in "sex offender treatment."

I said, "The sexual behavior is merely one of this boy's many problems. He has no internal motivation for following social norms. He could care less about school. He has poor impulse control generally. He throws tantrums to get what he wants. Individual or group counseling specifically concerned with sex won't make any difference."

The funder said, "Well, we really feel this problem needs to be addressed."

I said, "The only intervention I'm aware of that has some success at protecting the community from sex offenders is conviction in a court of law. Thus, it's unfortunate that the charges against this boy were dropped in favor of "therapy."

The funder said, "Ok, but let's get him in sex offender therapy."

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This is excellent. Thank yo... (Below threshold)

January 9, 2009 12:41 PM | Posted by Maria: | Reply

This is excellent. Thank you.

(Are you really retiring now?)

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Between this sort of thing,... (Below threshold)

January 9, 2009 1:48 PM | Posted by Fargo: | Reply

Between this sort of thing, the chart as a sort of procedural weapon against care providers, and seeing a doctor say "could care less" when he obviously means "couldn't care less" really confirms my general plan of avoiding the medical industry unless a bone or organ is sticking out somewhere it shouldn't be. I'm not saying it's a good plan, or even a rational one, but it sure does reduce the bullshit quotient.

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What if the doctors kept th... (Below threshold)

January 10, 2009 5:36 PM | Posted by Anonymous: | Reply

What if the doctors kept their own private journals on patients? Where they could write things that they judged really important? Would they have the right to keep them private? They wouldn't necessarily write down the patients names...although I suppose that takes way too much time when your schedule is full

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Do you mean 'process notes?... (Below threshold)

January 11, 2009 4:39 AM | Posted, in reply to Anonymous's comment, by Ellie: | Reply

Do you mean 'process notes?'

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"What if the doctors kept t... (Below threshold)

January 11, 2009 3:37 PM | Posted by Dr X: | Reply

"What if the doctors kept their own private journals on patients? Where they could write things that they judged really important? Would they have the right to keep them private?"

Private practice psychotherapists often keep private or personal notes that are not part of the official record. These do not have to be disclosed even when a patient signs a request for release of records. These notes could be subpoenaed, but there is no requirement to keep these notes, no one but the clinician would know of their existence and, ordinarily, personal notes are not available either to patients or insurers.

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"Between this sort of thing... (Below threshold)

January 11, 2009 4:51 PM | Posted by jaineage: | Reply

"Between this sort of thing, the chart as a sort of procedural weapon against care providers, and seeing a doctor say "could care less" when he obviously means "couldn't care less" really confirms my general plan of avoiding the medical industry"

I suspect that the word 'cleave' torments your soul. How could they let a thing like that happen?

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I actually rather enjoy cle... (Below threshold)

January 12, 2009 8:43 PM | Posted, in reply to jaineage's comment, by Fargo: | Reply

I actually rather enjoy cleave, despite the dual meanings. Things like that are resolved contextually, and are firmly part of the messy gooball we call english. Similar to "seal" or "bow".

No, homonyms I can accept, because we've been taught them and there's little use in trying to edit a language retroactively. Spelling and grammar errors are ok; I mean we all make mistakes, just don't let it get out of hand. Like that semicolon there. Does it belong there? I have no idea.

Now things like "the point is mute" "intensive purposes" "could care less" and not knowing whether to use "to" "too" "two" or "2" are just signs of a failing in reading comprehension. Learning is the only natural gift we have, as a species, yet we seem to strive to use it as little as possible. A willful ignorance. That is what torments me.

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This sort of bureaucratic e... (Below threshold)

January 14, 2009 1:44 AM | Posted by Alexandru: | Reply

This sort of bureaucratic exercise seems to me useful to alleviate guilt and anxiety at a societal level: limiting liability (practitioners' anxiety), providing a feeling that everything is just (malpraxis can be punished) and measurable (predictable, less anxiety due) etc.

That the other popular solution to these is organized religion...

The need for charts arises from the fact that many view medicine as a threat, rather than an opportunity to live better and longer. If earlier many people died of trivial causes it didn't pain them as much as dying of things they *think they understand and actually don't*. Hence the need for control, by means of bureaucratic procedures (or are they rituals?).

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Howdy there I like your Wor... (Below threshold)

January 23, 2010 9:46 PM | Posted by Axel Pittman: | Reply

Howdy there I like your Work

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