EMR

The Pain and Inflammation of Documentation

My previous two posts lamented the incredibly bad the documentation I get from a local hospital is.  In truth, the documentation I get from everyone is terrible.  Seldom does it tell me what I actually want to know, and if there is useful information it is buried in an avalanche of yada yada.  The main reason for this is that documentation is driven by our ridiculous payment system, which requires us to follow arcane rules to generate notes that justify the obscure codes we submit for money from the payors.  This is the reason for much of the gibberish.  These rules, combined with computers\’ ability to quickly and efficiently generate drivel (see also The Entire Internet) are the hot house and Miracle Gro for meaningless words.  Sprinkle the rules on a computerized medical record and stand back!  Useless words and codes will spew out at you like milk from the mouth of an overfed baby.

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Computerized Epic Failure

Good news: my local hospital has the fanciest, newest, coolest computer system (costing major bucks, of course) and now is routinely sending me \”transition of care\” documents on my patients.

Bad news: they are horrible.

Seriously, we get several of these documents per day and often can\’t figure out what the document is about.  On the bright side, sometimes after taking 10-20 minutes of looking through the 12-14 page document, we do actually gain some useful information.

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Ask Dr. Rob: Medical Wreckords

Dr. Rob:  

Long-time reader, first time writer!  I want to know why it is that my doctor makes me pay to get my own medical records.  It seems like since they are my records, they should be free to me!  Can you explain this to me?

– Lucy in Texas

Thanks, Lucy, for asking such an astute question that is near and dear to my heart.

There is, in fact, a simple answer as to why doctors don\’t want you to lay hands on their medical records, Lucy.  It\’s the same reason you don\’t want your son\’s underwear after his first semester in college (known to have broken autoclaves):  they stink.

Why do they stink?  It\’s complicated.  The best way to see this answer is to look into the past.  Way back.

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Personal Tech

When I say we need more tech, I am not saying we need more computerization so we can produce a higher volume of medically irrelevant word garbage.  I am not saying we need to gather more points of data that can measure physicians and \”reward\” them if they input data well enough.  The tech I am referring to is like that I used regarding my father.  I want technology that does two things: connects and organizes.  I want to be able to coordinate care with specialists and to reach out to my patients.  I want my patients to be able to reach me when they need my help.  Technology can do this; it sure did for my dad.

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Crazy Ideas

A patient calls or emails me with a problem.  I talk with them over the course of a few days, using whatever form of communication works best.  Eventually, they need to come to the office to be seen – either for something needing to be done in-person (examination, procedure, or lab test), or because of

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DIY

There was a hole in the wall of our bathroom that was a painful reminder of a bad encounter with a plumber.  Yes, that hole has been there about a year, and it has been on my to-d0 list for the duration, daring me to show if I inherited any of the fix-it genes I

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