Live data from Hacker News

How Did Our Medical Notes Become So Useless?

blogs.jwatch.org

11–20 of 206 posts

Re: How Did Our Medical Notes Become So Useless?

#11

I strongly agree that EMRs are making this problem worse, not better. And doctors seem to hate quite ubiquitously the extra amount of documentation they have to do. While there is a lot of evidence in some areas that EMRs have improved quality of care and patients' lives, I don't think this is one of them.

I was working for a large multi-state HMO during their transition to a major EHR (I'll let you guess, since I do not speak for either). I have a background in IT and was a systems consultant for a number of years.

On paper, I could get a relatively uncomplicated chest pain case from the ER to the hospital unit with all the orders for workup ready in 45 minutes.

With the EHR, we had abominations like double medication reconciliation and poorly customized order sets that ballooned my average admit time to almost two hours. And I was among the fastest. (I should note I am told these issues have improved, but it took years.)

Given that there was so much other stuff to do now and that ordering had become a nightmare of lookups and checkboxes, physicians under time pressure are going to economize where they can. Where they do is in the documentation, which is not generally reviewed and won't by itself prevent the patient from getting where they're going.

Now move this to an outpatient office where patient loads have not lightened and it becomes magnified.

It's a point of pride that I don't copy-paste my notes, but I have the luxury of being mostly administrative these days and most of my patient contacts are in a hyperspecialized clinic where I can do things like prewrite most of the note even before I go in a room. But it's killing primary care and it's probably making things worse at the very point where it needs to be made better.

Re: How Did Our Medical Notes Become So Useless?

#12
This EHR data problem is something I've pondered for a bit.

One "simple" solution is to have departmental standardization of note format with thoughtful inclusion of what fields are typically pertinent. This doesn't solve the problem of care transitions but it might help standardize review in a hospital context.

The other thing that I've been pondering is something resembling a formalized data structure and language for note taking. For example, diagnosis X based on Y Z. Other probabilistic diagnosis A ruled out because not B not C yes D. Reduce free form notes to be as sparse as possible. Also there should be a reference system to point back to other notes / lab values / imaging which when clicked will bring up that data. Finally, a timeline which charts pertinent diagnoses, lab values, and changes over encounters. I'm not sure how viable it would be given the complexity of notes that my physician colleagues have showed me / what I've seen in research, but I'm curious.

Re: How Did Our Medical Notes Become So Useless?

#13
The old school method of sticking the charts to the foot of the patient’s bed has the same pleasant properties that using sticky notes on a board for tasks does.

Anyone that’s struggled with JIRA and just said forget this due to tool impedance will have a good idea of how painful this is. In hospitals I almost never see charts pulled up except on daily rounds. Sure nurses are great and smart people and usually remember everything, but they also work hard long hours and the cost of mistakes can be very high.

Re: How Did Our Medical Notes Become So Useless?

#14
There's a recent New Yorker article by Atul Gawande covering this from a slightly different angle: https://www.newyorker.com/magazine/2018/11/12/why-doctors-ha...

He puts much of the blame on the generalization of computer systems, i.e. that the notes have to be readable by all sorts of staff and need to be systematized to accommodate that.

Re: How Did Our Medical Notes Become So Useless?

#16

My Primary Care Physician is unable to speak coherent sentences. I'm half-joking, of course. The guy is top-rated, elected head of the state association. He's widely-regarded as a combination of both brilliant with diagnostics and good with people. He just can't complete a sentence when we meet. Why? Because he's got some pad he carries around that takes up all of his attention span. He comes into the room, sits down…

It's a shame too, because this sort of nonsense is driving people to go to doc in a box and urgent care type operations.

Re: How Did Our Medical Notes Become So Useless?

#18

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

A while back I had a doctor where you could access everything via the online portal. I don't think some of the employees there realized that as there was some truly shocking stuff in there. One thing I learned was that anything I said which could possibly be misconstrued in a negative light was noted in my record as if the negative connotation was accurate.

Re: How Did Our Medical Notes Become So Useless?

#19
post #10

Medical notes are largely fiction IME. You should request all your medical records from any doctor you have seen and start demanding they correct them. You will be shocked at the lies they tell about you. You will be even more shocked down the road when you find out how these lies can hurt you.

In the US you're legally entitled to your medical records too but every time I've done it the response is always defensive, ie "why do you need them", "send me the doctors information and I'll fax it to them myself".

every time I've done it the response is always defensive, ie "why do you need them"

I was asked this once after requesting mine. I flatly said "I don't", and waited. The person on the other end of the line was clearly thrown off by this, probably expecting something they could dish out a canned response to, hoping I'd give up. It was obvious from their voice they were scrambling for what to say to that.

A bit of rigmarole later, I had my medical records.

Re: How Did Our Medical Notes Become So Useless?

#20

Medicine seems like a technological wasteland. They put "notes" into text boxes and call it "using computers". I wish I had both CS/SE experience and Medical experience so that I could understand what keeps this field in the 1970s. I have suspicions.

The regulations are outdated (fax is considered secure communication, as I've harped on before.) There's no patient visibility into these systems, so they don't see just how outdated and broken they are. I think that the biggest problem is this relentless focus on the short term-upgrading systems will cause problems now even if in the long run they'll pay huge dividends. Sort of similar to how medical professionals work extremely long hours with inadequate sleep.
Post reply on HN