Fluff Kills

Even though it resulted in accusations of an insecure ego, I am glad that I kicked the hornets nest in my previous post.  This discussion made me realize something that has been bothering for a long time.  Now I know what is so painful about medical records and what causes medicine to be so difficult to practice.  It\’s something most clinicians like myself have accepted without question (albeit with a few complaints).  It takes a huge chunk of time out of my day and causes patients\’ problems to be overlooked.  What is it?  Fluff.

Fluff Kills.

When I say fluff I refer to the packaging-material of medicine – the information that surrounds, obscures, and dwarfs the really useful information.  By fluff I mean the thousand words it takes to obscure a picture.  By fluff I mean E/M coding requirements, lab panels, and unhelpful descriptions of specialists.

You see, one of the biggest impediments to good medicine (which is not possible much of the time) is not the lack of information, tools, or good minds; it is the lack of communication.  Patients are batted around from doctor to hospital, from specialist to PCP, from lab to pharmacy like shuttlecocks but the information that goes between the providers is wrapped in so much fluff that much of it gets ignored.

But I am not just a victim of fluff, I am an expert at generating it as well.  Ironically, the tool that is key in the drive to improve communication between providers has also enabled the production of vast amounts of fluff. Yes, campers, I am talking about EMR.  EMR\’s are veritable fountains of fluff.

Let me illustrate.  I recently saw a patient who was doing very well.  We discussed medications and some side-effects he was having, and made a plan on how to deal with this.  I gave him about 20 minutes in the visit, but it was mainly social chat.  Here is the note I generated by my EMR for that visit (HIPAA Compliant – don\’t worry):

Now the truly useful information is highlighted:

The rest is fluff. I count 750 words in this document, 700 of which are fluff.  This is a healthy patient, but sick patients have much larger notes.  I suspect the fluff to pertinent ratio (I\’ll call this the fluff index) is similar in most notes.

The reasons this fluff exists are numerous:

  • Fluff protects against lawsuits (sometimes).
  • Fluff allows us to code at a higher level because fluff proves we worked harder.
  • Fluff has a remote chance of containing truly useful information so we keep it all around \”just in case\” (which means fluff is just like the cardboard boxes in my garage).
  • There is a long tradition of fluff.  The correct use of fluff is rigorously taught by medical schools, with harsh lectures laid upon students and residents who fail to include enough of it.
  • Fluff is lazy – instead of weeding out pertinent information, I send a bunch of fluff.
  • Insurance companies seem to want more fluff (as does the government).  Doctors who grow tired of fluff end up charging less than those who master fluffing.  The best doctors don\’t make the most money; the best fluffers do.

There are lots of locations of fluff in our system besides the notes in my records:

  • The 20 Gazillion ICD-9 and CPT codes are almost 100% fluff.  They don\’t help with care.  They don\’t help with communication.  They simply take more time and obscure what is actually important.
  • Radiology and other procedural reports contain a ton of fluff (as illustrated in previous posts).  The radiologist uses 200 words to say the word \”normal\” (that is a fluff index of 200 for those of you keeping score).  The cardiologist uses 500 words to say an echocardiogram is normal.
  • Lab tests are not ordered individually, they are ordered in panels (again, as stated in previous posts).  This means that for me to get useful information, sometimes I have to order 20 pieces of fluff for every 1 piece of useful information.
  • Nurses are experts at fluff too.  How many of nurses\’ notes in the hospital are written, never to be read again?  Hospitals, however, seem to have found a way to charge for fluff (I think they tack it on in the $10 charge for the Tylenol).
  • Notes from specialists are mostly fluff.  Specialists mysteriously want to tell me the past history of the patient I sent to them.  Somehow they feel I might not remember the person I referred.  It\’s OK, though, I always skip through that part completely and just read the impression and recommendations, but it would be much easier to not have the fluff.
  • Old records are have a 10,000 fluff index.  They are the fluffiest thing there is, with 1-2 items useful out of the entire record.  I don\’t need the last 10 mammograms.  I just need the last one.

This may sound like I am making light of the problem (pun intended), but as I said before: fluff kills.  People die because doctors spend so much time picking at and making fluff that they don\’t pay attention to patients.  Fluff does not help.  It doesn\’t help that I have to look through 50 different codes for \”neck pain\” to figure out which one will be paid for by the insurance company.  Fluff makes doctors\’ communication so difficult, that most doctors choose to ignore what other doctors have said (it takes too long to find meaningful information in the fluff) and instead almost always start from scratch.

Fluff also costs a bunch of money.  For an administration staking its legitimacy on reforming healthcare while cutting cost, cutting fluff will have the greatest impact on care.

Here is what I would like to see as a physician:

  • Let my notes be about care, not fluff.  Make my goal keeping patients healthy, not keeping fluff-obsessed coders happy.
  • Let me order only what I need.  I want to be able to order a Hemoglobin, Platelet count, and WBC count when I get a CBC.  If I need to drill down further, then let me do that; but I don\’t want to have to wade through fluff.
  • Focus on efficient communication.  Doctors are so immersed in the fluff culture that they fluff each other all the time.  The purpose of notes needs to be for communication.  Connecting EMR systems could be a god-send, as communication would be much easier; but it could be a door to the pits of fluff hell as well.

I feel sorry for patients who get their records from me.  It\’s not that they are bad records – they are better than 99% of doctors (we have been on EMR for 13 years).  But they are totally engulfed in fluff – this makes important information very difficult to find, and some is even wrong.

I had a patient today who got a copy of a note I had written.  He got very upset when he noticed some past indiscretions that were listed in the present tense.  He is now more mature and beyond this behavior.  The note no longer represented him – instead casting him on a negative light.  He was mortified; it felt as if an old wound had been opened when he saw the record.  The inaccuracy was there because I spend most of my time in the chart generating fluff, and so have little time to ensure its accuracy.

I was embarrassed and apologetic.  He understood why it had happened (and I quickly fixed it), but the whole event made it clear that I spend far too much of my time wading through and generating fluff, and far too little time taking care of people.  I hate this about our system.

Fear the fluff.

33 thoughts on “Fluff Kills”

  1. FEAR THE FLUFF — I think I’m going to make that my new motto.
    Fluff — 1000 pages on healthcare reform
    Fluff — writing in my nurses’ notes the same things that the previous nurse wrote, just changed around & said differently; but how many ways can you say “the baby is peeing & pooping & doing a good job learning to eat”? Most of the stuff I write is fluff.
    Health care reform = fluffectomies ??!!!

  2. FEAR THE FLUFF — I think I’m going to make that my new motto.
    Fluff — 1000 pages on healthcare reform
    Fluff — writing in my nurses’ notes the same things that the previous nurse wrote, just changed around & said differently; but how many ways can you say “the baby is peeing & pooping & doing a good job learning to eat”? Most of the stuff I write is fluff.
    Health care reform = fluffectomies ??!!!

  3. I am a coder, and have to agree!I get sick of sifting through the fluff to find the things to code…all the while seething at the fluff that is thrown in that makes the reimbursement go up when it has nothing to do with the stay. If we don’t pick it up, we’re “undercoding” and “missing reimbursement.” I hate that the focus is on the “bottom line” more so than health care…that’s why I’m getting out of coding by studying to be a cancer registrar! Cancer registry seems to be much more about studying and fighting disease than money 🙂

  4. I am a coder, and have to agree!I get sick of sifting through the fluff to find the things to code…all the while seething at the fluff that is thrown in that makes the reimbursement go up when it has nothing to do with the stay. If we don’t pick it up, we’re “undercoding” and “missing reimbursement.” I hate that the focus is on the “bottom line” more so than health care…that’s why I’m getting out of coding by studying to be a cancer registrar! Cancer registry seems to be much more about studying and fighting disease than money 🙂

  5. “Fluff-obsessed coders”… LOL, even from one of them! This is exactly why I find myself so often thinking I wound up in the “wrong” part of the healthcare system; I wanted to be the one doing great (and at times perhaps not so great) things for people as a physician and I wound up coding, which at times makes me want to tear my hair out in utter frustration because there are just too blasted many rules and regs…and for what? All about the money, which is precisely the part I always said I didn’t give a rat’s behind about! Grrrr….how is it possible that you can make me laugh and yet simultaneously stir up a bit of the rage? Too weird….

  6. “Fluff-obsessed coders”… LOL, even from one of them! This is exactly why I find myself so often thinking I wound up in the “wrong” part of the healthcare system; I wanted to be the one doing great (and at times perhaps not so great) things for people as a physician and I wound up coding, which at times makes me want to tear my hair out in utter frustration because there are just too blasted many rules and regs…and for what? All about the money, which is precisely the part I always said I didn’t give a rat’s behind about! Grrrr….how is it possible that you can make me laugh and yet simultaneously stir up a bit of the rage? Too weird….

  7. Healthcare reform? Maybe it should be called Fluff Care Reform!! Sounds like health car needs a “fluffectomy”, but so does the Health Care Reform Bill, over 1000 pages…Here is some fluff from the Health Care Reform Bill. I think (?) this is related to the end-of -life fluff that is making the news:

    (From page 426 of pdf copy)
    ‘‘(E) An explanation by the practitioner of the
    continuum of end-of-life services and supports avail-
    able, including palliative care and hospice, and bene-
    fits for such services and supports that are available
    under this title.
    ‘‘(F)(i) Subject to clause (ii), an explanation of
    orders regarding life sustaining treatment or similar
    orders, which shall include—
    ‘‘(I) the reasons why the development of
    such an order is beneficial to the individual and
    the individual’s family and the reasons why
    such an order should be updated periodically as
    the health of the individual changes;
    ( Section ii, referenced above, page 427)
    ‘‘(ii) The Secretary shall limit the requirement
    for explanations under clause (i) to consultations
    furnished in a State—
    ‘‘(I) in which all legal barriers have been
    addressed for enabling orders for life sustaining
    treatment to constitute a set of medical orders
    respected across all care settings; and
    ‘‘(II) that has in effect a program for or-
    ders for life sustaining treatment described in
    clause (iii).

    WOW

  8. Healthcare reform? Maybe it should be called Fluff Care Reform!! Sounds like health car needs a “fluffectomy”, but so does the Health Care Reform Bill, over 1000 pages…Here is some fluff from the Health Care Reform Bill. I think (?) this is related to the end-of -life fluff that is making the news:

    (From page 426 of pdf copy)
    ‘‘(E) An explanation by the practitioner of the
    continuum of end-of-life services and supports avail-
    able, including palliative care and hospice, and bene-
    fits for such services and supports that are available
    under this title.
    ‘‘(F)(i) Subject to clause (ii), an explanation of
    orders regarding life sustaining treatment or similar
    orders, which shall include—
    ‘‘(I) the reasons why the development of
    such an order is beneficial to the individual and
    the individual’s family and the reasons why
    such an order should be updated periodically as
    the health of the individual changes;
    ( Section ii, referenced above, page 427)
    ‘‘(ii) The Secretary shall limit the requirement
    for explanations under clause (i) to consultations
    furnished in a State—
    ‘‘(I) in which all legal barriers have been
    addressed for enabling orders for life sustaining
    treatment to constitute a set of medical orders
    respected across all care settings; and
    ‘‘(II) that has in effect a program for or-
    ders for life sustaining treatment described in
    clause (iii).

    WOW

  9. re. end of life discussions:It is frustrating to me why this has become an issue. Of course we need to have end-of-life discussions with people! People need to prepare. I have had patients who would never have wanted extensive things done who didn’t voice it clearly and ended up being kept alive when they wouldn’t have wanted to go through things. It’s about autonomy.

    It’s a shame that this has been turned into a political weapon, as it turns a very important issue into a scare-tactic for “death panels.” Ironically, many Republicans have been the biggest proponents about end-of-life discussions (one is a senator from my state).

    The worst-case is upon us with the debate on healthcare: the fear-mongers are using any lever they can to scare us away from change. In this case they are using misinformation.

  10. re. end of life discussions:It is frustrating to me why this has become an issue. Of course we need to have end-of-life discussions with people! People need to prepare. I have had patients who would never have wanted extensive things done who didn’t voice it clearly and ended up being kept alive when they wouldn’t have wanted to go through things. It’s about autonomy.

    It’s a shame that this has been turned into a political weapon, as it turns a very important issue into a scare-tactic for “death panels.” Ironically, many Republicans have been the biggest proponents about end-of-life discussions (one is a senator from my state).

    The worst-case is upon us with the debate on healthcare: the fear-mongers are using any lever they can to scare us away from change. In this case they are using misinformation.

  11. I believe fluff also exists because it makes people look “smart”.
    “Look at me. I’m a doctor and went through Med School and I am so smart. Blah Blah Blah. I’m fluffy and I know it.”

    I like pink fluff. If you don’t know what that is, google it.

    Now I’ll shut the fluff up.

  12. I believe fluff also exists because it makes people look “smart”.
    “Look at me. I’m a doctor and went through Med School and I am so smart. Blah Blah Blah. I’m fluffy and I know it.”

    I like pink fluff. If you don’t know what that is, google it.

    Now I’ll shut the fluff up.

  13. I agree. “…to actually fix this problem we all have to somehow come together.”
    My point is that the fluff that ALL politicians put into 1000 page bills is a symptom of problem that no one is stepping up to address. The fluff breeds misinformation, because no-one can understand (or interpret) the words the same way. In fact FEW people (politicians included) read the words that they are arguing against, or for, because they don’t understand the fluff.

    I will try to avoid the hint of politics in future posts. ?

  14. I agree. “…to actually fix this problem we all have to somehow come together.”
    My point is that the fluff that ALL politicians put into 1000 page bills is a symptom of problem that no one is stepping up to address. The fluff breeds misinformation, because no-one can understand (or interpret) the words the same way. In fact FEW people (politicians included) read the words that they are arguing against, or for, because they don’t understand the fluff.

    I will try to avoid the hint of politics in future posts. ?

  15. christophil, MD

    You want to clean up records…start by only documenting what you actually do! Let’s call chart fluff what it actually is, lies. Did you really go through that full review of systems? Yet your point and click EMR says you did. Look at a 99214 office note and ask yourself how much is fact and how much is fiction. Fear the fiction.

  16. christophil, MD

    You want to clean up records…start by only documenting what you actually do! Let’s call chart fluff what it actually is, lies. Did you really go through that full review of systems? Yet your point and click EMR says you did. Look at a 99214 office note and ask yourself how much is fact and how much is fiction. Fear the fiction.

  17. Drummed into me during any decent training I’ve done…If you haven’t documented it, it hasn’t been done…this includes negative findings…AKA fluff!

    P/C: broken finger nail.
    O/E: full body assessment normal.

    Where do we stop???Full body MRI and then the radiologist can write the full report and save us some time? Still we’d have to document all bodily functions are normal. It’s a case of finding a happy medium between this extreme and the other common with the Dr’s I work with.
    “PC: Foot. Px NSAIDs”

  18. Drummed into me during any decent training I’ve done…If you haven’t documented it, it hasn’t been done…this includes negative findings…AKA fluff!

    P/C: broken finger nail.
    O/E: full body assessment normal.

    Where do we stop???Full body MRI and then the radiologist can write the full report and save us some time? Still we’d have to document all bodily functions are normal. It’s a case of finding a happy medium between this extreme and the other common with the Dr’s I work with.
    “PC: Foot. Px NSAIDs”

  19. Yes, we do ROS every time. We have the patient fill one out on a laminated sheet, then I hold it and go through the symptoms with the patient.
    I put nothing in there that I haven’t reviewed. No fiction.

  20. Yes, we do ROS every time. We have the patient fill one out on a laminated sheet, then I hold it and go through the symptoms with the patient.
    I put nothing in there that I haven’t reviewed. No fiction.

  21. christophil, MD

    Does that work for the exam too? The point is that much of the filler in charts is fiction ( you know the old WNL= we never looked).

  22. christophil, MD

    Does that work for the exam too? The point is that much of the filler in charts is fiction ( you know the old WNL= we never looked).

  23. I never use WNL and try to only include things I do. I never say something “looks normal.” We are fairly careful.

  24. I never use WNL and try to only include things I do. I never say something “looks normal.” We are fairly careful.

  25. Hit there, new reader, and a Canadian, just delurking to say that I found this fascinating.
    “Lab tests are not ordered individually, they are ordered in panels (again, as stated in previous posts). This means that for me to get useful information, sometimes I have to order 20 pieces of fluff for every 1 piece of useful information.”

    All of our lab tests are our ordered individually here, except for a few very limited screening panels like prenatal ones, that every pregnant patient gets automatically on the first visit. And the govt. has negotiated with the labs to get a flat price on those panels, so it saves money.

    No wonder you guys waste so much money!

    Anyway, we waste money too, don’t get me wrong. Especially on end-of-life-care, because Doctors and politicians are all afraid to raise the subject and have the public debate.

  26. Hit there, new reader, and a Canadian, just delurking to say that I found this fascinating.
    “Lab tests are not ordered individually, they are ordered in panels (again, as stated in previous posts). This means that for me to get useful information, sometimes I have to order 20 pieces of fluff for every 1 piece of useful information.”

    All of our lab tests are our ordered individually here, except for a few very limited screening panels like prenatal ones, that every pregnant patient gets automatically on the first visit. And the govt. has negotiated with the labs to get a flat price on those panels, so it saves money.

    No wonder you guys waste so much money!

    Anyway, we waste money too, don’t get me wrong. Especially on end-of-life-care, because Doctors and politicians are all afraid to raise the subject and have the public debate.

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