16 ms·

How Did Our Medical Notes Become So Useless?

252 points by mrestko 8y ago

ivraatiems 8y ago
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.
- classichasclass 8y ago
  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.
  - Scoundreller 8y ago
    What is a “double” medrec? And what initial electronic order sets were implemented? Did the organization not just implement (as best as possible) the previously on-paper order sets? It’s not a perfect approach (you can do things with an online form that you can’t do on paper and vice-versa), but it seems like a good approach to avoid (more) mass confusion on Day1.
    - brokenmachine 8y ago
      > What is a “double” medrec? I think that's when you need a second doctor to approve orders for another.
- Scoundreller 8y ago
  I’ll shoot: what extra documentation has to be done on an EMR that isn’t necessary on paper? Has the “standard” been to document X, Y and Z, but providers felt (rightly or wrongly) that documenting those things is unnecessary, so they didn’t, but now they have to and it’s easily auditable? Is the problem the medium or the implementation?
- peo939 8y ago
  The fundamental problem in my opinion is that these EMRs were forced on providers and hospitals rather than emerging organically by choice. I fully support the use of EMRs as some ideal, but it should emerge as the best option not as something that was forced. The result was a lot of EMR systems that would have never been adopted if there wasn't added pressure from government regulations. I strongly believe that EMRs would look pretty different if they were adopted organically without regulation. It's really astounding to me that the elephant in the room of healthcare regulation isn't discussed more in public discussions of cost. As a result we end up with EMRs where the tail wags the dog, lack of transparency, lack of competition, lack of choice, etc. etc. etc. I keep hoping the weight of the edifice will cause the thing to implode as it becomes so obviously unsustainable, but it's as if more regulation just births more regulation.
arielweisberg 8y ago
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.
- limeblack 8y ago
  Yes at least with paper they were typically tied to one hospital. Now with Epic they are basically automatically pulled over.
  - cordite 8y ago
    The product for this is called Care Everywhere for epic to epic transfers. An example handout from Yale New Haven Hospital about it: https://projectepic.ynhh.org/Epic%20Newsletters%20and%20Fact%20Sheets/FAQ%20Care%20Everywhere.pdf https://projectepic.ynhh.org/Epic%20Newsletters%20and%20Fact... You can also find out more about cross-vendor interchange at https://carequality.org/ https://carequality.org/
- rhcom2 8y ago
  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".
  - isaacdl 8y ago
    This is interesting, and I didn't know it! Does it include everything (doctor's notes, etc.), or just whatever your doctor/organization wants to include in your "official" medical record? I'd like to do this myself, but I want to understand what I'm actually entitled to so I can be prepared if they push back.
  - limeblack 8y ago
    Same experience. Try requesting through a Psychologist or case worker I have had success with that.
goldcd 8y ago
In (the UK at least) your medical notes follow you as you sign on with a new GP (General Practitioner - first point of medical contact for anything non-urgent). Now knew this theoretically happened, but was quite bemused to see it happen in practice. I rescued a rat from the silken-jaws of my pseudo-homicidal cat, and the ungrateful rodent bit through half of my finger - I thought it would be sensible to have a checkup/shot. I've only got a hazy recollection of what shots I've had when, so my notes were consulted. Seemingly, according to my paper notes produced from the cabinet, 40 years ago "I was an adorable wee thing" (aged 2).
- jermaustin1 8y ago
  That's amazing. I guess, in the US, we only started tracking patients recently. I had to call and have my old records faxed from my old GP in Texas to one in New Jersey, and then again from that GP to my NEWER one in New York. Earliest record was from when I was 7, since neither my mother or I remember who my pediatrician was before then.
  - limeblack 8y ago
    I disagree on this stance. If you were diagnosed with depression when 13 but no longer depressed its nobody not the doctor, the nurse, the IT staff jobs to know this unless you choose. You have everything from Psychology/Psychiatry notes to overdose records that many health staff can pull up from almost any computer. EDIT: Remember many jobs disqualify you from the job if you have any past psychiatric treatment. Even if you are in your 40s Psych drugs at 13 are a disqualifier. "Paying cash" is what some doctors have resorted to. http://www.idealmedicalcare.org/75-med-students-antidepressants-stimulants/ http://www.idealmedicalcare.org/75-med-students-antidepressa...
    - jermaustin1 8y ago
      I could be wrong, that's why I said I guess. It was just based on my personal experience in switching doctors a couple times when I moved away from my home town.
    - 8y ago
DanielBMarkham 8y ago
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 -- and there's this struggle for his attention that I watch play out. It usually involves a lot of verbal grunts. "So we've got this .... er.. .. and it looks .. hmmmm. .... So this is...." This could go on for a bit. Eventually we get to either a statement or a question. Frankly I'd think the guy was having some sort of mental issues if it weren't for the facts that 1) he used to be fine before they all started carrying around pads, and 2) he's fine outside the clinic. I really hope that the tech community has helped make healthcare better. It's certainly had an impact.
- Spooky23 8y ago
  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.
- nradov 8y ago
  Some provider organizations hire medical scribes to sit in the exam room and do real time EHR data entry so that the doctor can focus on the patient.
- mikekchar 8y ago
  Maybe not relevant for you, but one thing that has helped me with my doctor is that the first thing I do when I go in is sum up what happened in our previous couple of visits. My doctor doesn't have enough time to prep for my visit. I mean, he should, but he doesn't (been there, done that). So I give him the executive summary to speed things up. I visit my doctor a lot, so he now trusts me to give him accurate and useful information.
SL61 8y ago
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-hate-their-computers 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.
deleted 8y ago
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User23 8y ago
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.
petermcneeley 8y ago
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.
- jlamberts 8y ago
  In my experience, it's a combination of a couple of things. First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high. Second, the field is currently dominated by major players such as Epic, so its pretty important to be compatible with them, but they don't really have an incentive to open up their ecosystem since they have such a stranglehold on the market. Finally, a lot of medical folks have been burned by technology in the past, and, in my experience, often view a lot of the tech they have to use as an insurance and government mandated evil, rather than a way to make their lives better. Not to say things can't be improved, but there are a lot of factors that make it more difficult than a traditional B2B or B2C product.
  - deleted 8y ago
    [deleted]
  - nradov 8y ago
    The Epic ecosystem is actually pretty open now. They have multiple web service APIs with full documentation, and even provide a developer sandbox you can use to test client applications. https://open.epic.com/ https://open.epic.com/ Epic also has an app store. You can write your own SMART on FHIR apps, then deploy them inside the EHR with full access to patient data. https://apporchard.epic.com/ https://apporchard.epic.com/
    - arkh 8y ago
      The full FHIR standard can be a lot at first sight https://www.hl7.org/fhir/ https://www.hl7.org/fhir/ but I'd recommend anyone having to store names, addresses or contact information to check how they do it. The last example for names is always fun: https://www.hl7.org/fhir/datatypes-examples.html#HumanName https://www.hl7.org/fhir/datatypes-examples.html#HumanName
Thriptic 8y ago
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.
- roywiggins 8y ago
  Epic provides progress note templates: http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABDU/-k-vLlIHj5M/s1600/epic+screen+shot.gif http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABD...
- nradov 8y ago
  All large hospitals and clinics already have standardized note formats. For care transitions the HL7 C-CDA 2.1 Continuity of Care Document (CCD) format works pretty well. Modern EHRs can export a summary of a patient's chart in that format. Some data may be lost in translation but usually it works fine. But there are often still technical obstacles to transporting a CCD from one provider to another. There are existing formal code systems for notes: CPT, ICD-10-CM, RxNorm, CVX, SNOMED-CT, etc. Those are helpful for billing and analysis purposes, but they can't replace free form narrative text for most clinical use cases.
- sxg 8y ago
  Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4 acuity (there are 5 levels, with level 5 being ICU-like care). I looked into how the billing level is determined, and I found this article explaining how components of the notes are tied to billing levels [1]. Basically, by including 6 elements to the physical exam rather than 5, you can bill at a higher tier. There are several other areas that are tied to billing like this, including the family history, social history, etc. My PCP had completely filled out her standardized note to include every little detail I had mentioned—many of which were totally irrelevant to my current issue. I talked to some other physicians about this, and I learned that hospital departments use their standardized notes to include as much detail (i.e. bloat) as possible so that physicians can bill at higher tiers since billing is tied to the number of details included in the note. [1] https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-bt4 https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-b...
qrbLPHiKpiux 8y ago
Doc here - spot on. 25% of my day is typing, reading, deciphering, referencing. I waste so much time not providing care.
- notabee 8y ago
  I just want to say that I'm happy to see one of y'all on here. If doctors and engineers were to collaborate together directly to fill in each others' domain knowledge gaps instead of buying crap software from companies with poor incentives, some truly amazing things could happen.
  - JshWright 8y ago
    It's not as uncommon as you think. I'm both a paramedic and a developer for an EHR, and we have a number of other medical professionals (including a physician) in various product related roles.
    - notabee 8y ago
      I know that EHR companies surely employ both engineers and medical professionals, but are they able to freely innovate and explore, or are they bound to top-down bureaucracy with, as another responder mentioned, misaligned incentives? The kind of thing that I imagine would be a fully open source, open standards implementation that could allow easy portability of records between all providers.
  - TheCoelacanth 8y ago
    I have a feeling it's more a case of misaligned incentives than just that people with the right knowledge are not involved. Medical professionals are certainly one set of stakeholders that EHR developers consider, but I'm almost certainly they aren't the ones given the highest priority. I would bet that billing, legal compliance and protection from accusations of malpractice are all given a higher priority than actually being able to effectively treat patients.
- robmiller 8y ago
yumraj 8y ago
My kids' pediatrician was part of a small office, which merged with a larger office that is affiliated with a large hospital and hence uses EPIC. She used to take hand notes on paper and was quiet efficient when she was with the smaller office. After the move I have seen her struggle with EPIC, and then recently hire a medical transcription service and be followed by a person taking notes so that she can focus on the medical stuff. And, of course I have no idea if the quality of her notes has suffered.
- organsnyder 8y ago
  Believe it or not, Epic is one of the more provider-friendly solutions out there, according to many providers I've talked with (I work in the healthcare software industry).
  - JshWright 8y ago
    Epic _can_ be not as awful as some (it's still a far sight from "friendly" in my opinion). The problem is that it's highly customized in each installation, and the vast, vast majority of them "customize" it in very provider-unfriendly ways (tons of irrelevant required fields for billing, etc). Even in the best case scenario though, it's a lot of clicking around to find clinical information that may be relevant to a patient (which means it can often go unnoticed).
samsolomon 8y ago
I've done a good bit of thinking about medical note taking. To me it's a little odd that hospitals are the ones who keep this information. I'd think that the records should belong to patients—it's about them after all. And that the patients would provide access to doctors or hospitals. Right now I've got a personal medical journal that has things like: * Sickness - Date Range and Notes * Flu Shots - Date * Injuries - Date and Notes * Observations - Date and Notes * Blood tests - Date and Photos of Tests Before my yearly checkup (or if I have to visit a clinic) I review the last entries and open them on my phone incase my doctor wants to see any of them. It works well enough for me, but seems like there could be a ton of opportunity for improvement. I'd love to have a system where my doctor could be notified and comment on new notes or events. Also the ability to bring in my scale, run tracker and other fitness data.
- mikekchar 8y ago
  One thing I like about Japan, where I live now, is that every time I get a test done (and unfortunately I've had a lot of them recently), they send a copy of the results to me. I have everything my doctor has. He also writes personal notes for himself, but usually they are descriptions of symptoms when I complain about stuff. I could write them down too (and maybe I should), but those are his personal notes just to remind him what was going one when I visited him. I don't need access to that, as far as I'm concerned (although he shows me what he's writing and sometimes I even ask him to show me what he's written on a previous page).
- davycro 8y ago
  Notes intended for patients would have a different form than notes intended for doctors. Unfortunately medical records achieve neither. My notes are bloated with information needed to bill the maximum amount from the center of Medicare services, which ultimately hurts all parties. The bloat obscures critical information from other doctors. Patients are unable to read a meaningful account of their care, and are charged more for worse services.
- mikecsh 8y ago
  The problem with this is that a very small minority of patients are that diligent or reliable, for various reasons (dementia, forgetfulness, disinterest, mental illness, low IQ, substance abuse, not realising the information is required, brought in by ambulance unconscious and peri-arrest, etc.). Here in the UK patients do have responsibility for some records - notably anticoagulation records and maternity / child health records. I have seen literally one patient present with their anticoagulation record. I have lost count of the number of patients who come to appointments without their maternity notes or child health notes. Even trying to get an accurate medication history from a patient is near impossible and we end up having to look at past hospital discharge letters, call their GP, or look on shared record systems to try and piece together what they are taking. I'm all for patients "owning" their records but they must be held in a way that is accessible when needed regardless of human variabilities.
nathan_long 8y ago
One "solution" is sometimes to use speech-to-text. The mangled results would be hilarious if they weren't frightening.
- egillie 8y ago
  I know some places have scribes (often students), and I wonder why they aren’t more common given how valuable doctors’ time must be
VikingCoder 8y ago
1. Money 2. Legal liability (CYA) 3. We don't use outcome-based medicine
- skwb 8y ago
  1. There's an old saying in healthcare that patient care is always first, but money is a close second. 2. Sort of yes, but I've heard it more time from managers who use it more of an excuse for not wanting change rather than it being a legitimate argument (i.e. from people with little to no legal training). 3. This is changing slowly. The Affordable Care Act and it's little known cousin MACRA have started to shift the entire system (albeit slowly) towards more outcome based measures, primarily through Medicare. Major payers are following in their steps. Not happening overnight, but any major healthcare executive sees the writing on the wall and is taking these considerations into account for their investments. [0]. https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/ https://www.healthaffairs.org/do/10.1377/hblog20180810.48196... [1]. https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/ https://www.healthaffairs.org/do/10.1377/hblog20180810.48196...
  - VikingCoder 8y ago
    3. No, it's not. If you go in for a wonky heart, and you get some kind of imaging done on your chest, and then spot something in your lungs, they SHOULD ignore it. Outcome-Based Medicine says that's what they should do. They CAN'T ignore it. Cardiologists actively want the lungs REMOVED from the images they order, because they don't want to accidentally notice any lung nodules. That's crazy! And that's just one example. We don't know how to properly ignore the things we should. And if something IS there, and there COULD HAVE been action taken on it, then the people who looked at the images are potentially liable in court. Or at least in settlement. The whole thing sucks.
    - skwb 8y ago
      Yes, it is. You appear to be conflating my point of how healthcare is changing with regard to payment structures with clinical guidelines which tend to have potentially more subtleties. There are some areas of healthcare where it is very cut and dry what defines good healthcare management. These are where we've developed good reporting outcomes that tie closely to clinical and resource utilization outcomes from the published literature. Think of your high volume routines cases such as diabetes (monitoring of A1C)[0] and knee replacements [1] that make of a large portion of health care cases. These are certainly not covering all healthcare episodes, but represent areas where significant fat can be trimmed. With regard to your above clinical case, there are specific approaches for (what I assume is an incidental finding from a coronary CTA) reporting lung nodules and requesting follow up studies [2]. However, this represents an area where there is significant good faith professional disagreement of reporting. I will agree that high-evidence clinical guidelines are not always followed, and payment reform has not been influenced all medical professions equally. The way healthcare is delivered is changing, and is being highly influenced by national policy level decisions. [0]: https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/ https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/f... [1]: http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-Payments http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-P... [2]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/
Scoundreller 8y ago
My favourite citation from the link: “In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries” It seems that the EHR isn’t the root cause of the problem.
- jcowdy 8y ago
  I was one of the people that gathered and analyzed the data that the cited study used and can't agree with your conclusion more. Sure, the EHR makes "note bloat" easier than paper but the difference in length across different countries (using the same software) shows that note length is more a result of the environment than the tool. I think there is also a general misunderstanding of "the note" in an EHR context. The progress note is really just one aspect of a provider's documentation of a visit. Things like medications and allergies are generally indicated as "reviewed" elsewhere in the chart and yet all of this information is many times also entered into the progress note unnecessarily adding to note bloat. In the days of the paper chart the progress note ended up being the only summary of the visit and even though it's now just one piece of the visit documentation, it's still written as though it will be the only source of truth.
  - Scoundreller 8y ago
    It’s a sad situation. Unhappy users are much louder than happy or neutral users. As a result, when a non-US health provider wants to do some informal research on implementing EHRs, they mostly read a lot of angry complaints.
deckar01 8y ago
I recently built my mom a basic web app to automate building patient evaluations. She has been using paper forms with checkboxes for decades and they started requiring the info in digital format over the last few years. She had been copy and pasting from the digital version of the blank form into MS Word. It was time consuming, but still faster than typing it by hand. To be clear, a paragraph containing sentences is the format medical professionals are required to present this information in. Automating the boilerplate stuff actually gives my mom more time to type in the information that the paper forms don't anticipate and provide actual care to patients. The problem is not automation. The problem is unscrupulous executives who maximization profits at the expense of quality of service. The examples provided in this article are unethical and anyone who is caught dumping irrelevant data into important medical records should be held responsible.
leovander 8y ago
Spec. Off's [1] - Doctor enters your visit (encounter), cross your fingers that his system has the most up-to-date medical codes (e.g. snomed, cpt, icd, etc) - Doctors notes for that encounter are potentially entered as a text area in one system (u/petermcneeley). Can be notes at the encounter level or for a specific diagnosis/lab result/etc. - The codes vs free text, is what we refer to as discreet and narrative/free text. - The current IHE spec. [2] (last updated in 2015?), allows for codes to be interpreted from narrative text if a valid code is not provided. I think there are a few startups that have popped up here that are trying to make sense of the narrative text. - That same spec would be great if everyone followed it but they have to get their system to bend a little bit or throw an integration engine in front of the problem to play nicely with others. (u/nradov) - Start sending those back and forth and you either end up losing those notes or butchering them up. - There are some orgs (e.g. DoD, VA, Sequoia, etc) that have everyone follow the basic requirements but then add their own flavor on top. [3] - FHIR [4] is here, but I think everyone is already scrambling or haven't had the need to make the cut over to it until its government mandated. I have to say this has been the easiest spec. to grok, but it is still way too flexible for these companies to mess up. A cut over to FHIR for everyone should ideally be that you have to use the Hapi FHIR models [5]. Maybe have a way for Hapi to sign the models on their way out? Sorry, this turned out to be more of a rant, but I stare at this stuff everyday. There are a few other folks on the thread that know the industry as well that have some good info too. [1] https://media1.tenor.com/images/af0c71048d5a130cefc335423c597ce8/tenor.gif https://media1.tenor.com/images/af0c71048d5a130cefc335423c59... [2] http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 http://www.hl7.org/implement/standards/product_brief.cfm?pro... [3] https://xkcd.com/927/ https://xkcd.com/927/ [4] https://www.hl7.org/fhir/ https://www.hl7.org/fhir/ [5] http://hapifhir.io/ http://hapifhir.io/
telchar 8y ago
I do NLP with medical notes. What I have observed is that the redundancy between the note and information available elsewhere in the EHR in structured formats is pretty high, as is the amount of boilerplate (e.g. section headers and list templates that may not be filled in). This makes machine learning using the notes difficult since the content is so muddied up. It's far from impossible to do useful things with them but there is a lot of noise. Still, some things require us to look at the notes. For these things we would much rather have them than not. While it's preferred to have the information entered in a structured way, doctors find that more of a hassle than entering in the data free-text and it's also no good for retrospective analysis where we didn't know several years ago we would be interested in something and so no structured field existed.
- abrichr 8y ago
  Interesting insight! Where do you work?
  - telchar 8y ago
    I work for a hospital/health system.
bobowzki 8y ago
The medical journal is one of, if not the most, important inventions of modern medicine. I'm an MD and work with them every day. But yes, the current infrastructure is not good.
cabaalis 8y ago
I deal with various EHRs every day of my life, and 4-digits-worth of providers. The primary barrier is that practice managers are working to get data standardized, but get pushback from the providers who are busy doing their jobs being doctors and not data scientists. Some EHRs can streamline via templates and workflow. Others don't. I've literally had practice admins not implement new practices that would document properly and facilitate easy reporting because they would not be able to sell the change to the providers. I'm not blaming providers for the data issues. They have a job to do and they do it. It just doesn't always get documented in a reportable manner. There needs to be an easier way to document, or some kind of Middleware that documents for them. I see people a whole lot smarter than me trying to use ai to interpret notes. I personally think they are just facilitating the ongoing poor documentation problem. And things will slip through the natural language cracks, and it could be a potential health hazard.
- egillie 8y ago
  Agreed that 95% correct (or even 99%) AI probably isn’t the solution here, I’m surprised to see so many startups doing AI/NLP for doctors’ notes
tdeck 8y ago
Here's a fun thing about our system in the US. If you're taken to the emergency room, they'll ask your medical history. And not just once - they'll ask it in the ambulance, radio it ahead to the hospital, then make you wait while they ask you the same questions again and enter them into their system at the hospitsl. Then the next 3 doctors or nurses who come into your room do the same thing, asking you questions you've already answered. Doesn't seem to matter if it's obvious that speaking is painful for some reason (in a case I'm describing a family member had broken ribs).
- Spooky23 8y ago
  Then the ass in the insurance cart has to do their thing. My wife almost bled out on the table when one of these idiots was literally blocking the medical people. I physically removed him from the area and almost got arrested.
- arkades 8y ago
  We do this for a reason. Not only do different people ask specific questions that try to elicit different things, but patients stories evolve with each repetition. People don’t realize how much, but by the third time you’re getting that history, the picture is usually quite different from what the first history depicted. And since history is 90% of diagnosis, this isn’t some little quirk. It plays a huge role in helping patients. Huge.
  - cperciva 8y ago
    As a patient, I've been guilty of doing this deliberately. At ER triage, my priority is "get into a bed". Once I've been admitted, my priority is "get well". (And once I'm feeling better, my priority is "get out of here"...) As a type 1 diabetic, if I have high blood glucose and nausea, I'm going to say the letters "DKA" to the triage nurse. I'll never bring it up again -- because the first blood chemistry test answers that question one way or the other.
  - bookofjoe 8y ago
    Reminds me of what an attorney once said to me (I'm a retired neurosurgical anesthesiologist with 38 years experience; I occasionally served as an expert witness): "The client's story never sounds better than the first time you hear it."
brownkonas 8y ago
I refuse to believe (beyond a bad email notification , which is not acceptable for medical information) that being elaborate or non-concise is a problem. Why is 4x more medical density a bragging point , in other words?
NoblePublius 8y ago
I read number 1 —- “money” — as “doctors lie about what they are doing to get paid more by your insurance company”. Is that unfair?
xte 8y ago
Problem of medical notes have a name: bureaucracy. The hope is leaving it apart, and today it seems a bit utopia... Also in terms of "numeric/digital" vs "paper" the point is ignorance: how many people outside IT world (and even inside) do actually know enough a desktop to take their own personal notes in an ordered, usable and useful thing? IMVHO a so small percentage that we can probably know them all by name. Just take a look at a "common" mailbox: most of them are an utter pile of data, few with some incoherent taxonomies, few even with the sole inbox as an archival place. Than take a look a common "home directories": the very same mess. And if this is for personal and generic data do you think that those people are able to properly not only manage but share helpful information with digital systems?!
bill_from_tampa 8y ago
I worked at the VA for over 2 decades, including the transition from handwritten to electronic notes. Wow. When I retired, the nursing notes for a patient visit were usually 2-3X longer than the docs note. The nursing note was entirely populated by templated text created by a hierarchy of supervisory staff tasked with satisfying all regulatory requirements. The poor nurses would ask the patient a series of prompted questions, click on the appropriate box, and a page of templated text would emerge. Actually finding useful actionable info in the nursing notes was impossible, or close to impossible. The docs began to demand, reasonably, that actual patient problems identified by the nurse be put in a specific area of the note rather than randomly scattered throughout 4-8 pages of templated text (which without this demand could be randomly intercalated with such useful info as "pt c/o chest pain when walking, much worse", found on page 5 of 8. The docs notes were, in many ways, even worse. The notes required manual typing, and many docs are not trained skilled touch typists. So the two-fingered part of the note was often very brief and succinct. The templated portions were huge - impressive reviews of systems where you could not really tell if the specific items had actually really been asked or if the template just vomited forth a page full of text for administrative review. Make a doctor function as a data entry clerk and this is what happens.

252 points by mrestko 8y ago

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.

classichasclass 8y ago
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.
- Scoundreller 8y ago
  What is a “double” medrec? And what initial electronic order sets were implemented? Did the organization not just implement (as best as possible) the previously on-paper order sets? It’s not a perfect approach (you can do things with an online form that you can’t do on paper and vice-versa), but it seems like a good approach to avoid (more) mass confusion on Day1.
  - brokenmachine 8y ago
    > What is a “double” medrec? I think that's when you need a second doctor to approve orders for another.
Scoundreller 8y ago
I’ll shoot: what extra documentation has to be done on an EMR that isn’t necessary on paper? Has the “standard” been to document X, Y and Z, but providers felt (rightly or wrongly) that documenting those things is unnecessary, so they didn’t, but now they have to and it’s easily auditable? Is the problem the medium or the implementation?
peo939 8y ago
The fundamental problem in my opinion is that these EMRs were forced on providers and hospitals rather than emerging organically by choice. I fully support the use of EMRs as some ideal, but it should emerge as the best option not as something that was forced. The result was a lot of EMR systems that would have never been adopted if there wasn't added pressure from government regulations. I strongly believe that EMRs would look pretty different if they were adopted organically without regulation. It's really astounding to me that the elephant in the room of healthcare regulation isn't discussed more in public discussions of cost. As a result we end up with EMRs where the tail wags the dog, lack of transparency, lack of competition, lack of choice, etc. etc. etc. I keep hoping the weight of the edifice will cause the thing to implode as it becomes so obviously unsustainable, but it's as if more regulation just births more regulation.

arielweisberg 8y ago

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.

limeblack 8y ago
Yes at least with paper they were typically tied to one hospital. Now with Epic they are basically automatically pulled over.
- cordite 8y ago
  The product for this is called Care Everywhere for epic to epic transfers. An example handout from Yale New Haven Hospital about it: https://projectepic.ynhh.org/Epic%20Newsletters%20and%20Fact%20Sheets/FAQ%20Care%20Everywhere.pdf https://projectepic.ynhh.org/Epic%20Newsletters%20and%20Fact... You can also find out more about cross-vendor interchange at https://carequality.org/ https://carequality.org/
rhcom2 8y ago
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".
- isaacdl 8y ago
  This is interesting, and I didn't know it! Does it include everything (doctor's notes, etc.), or just whatever your doctor/organization wants to include in your "official" medical record? I'd like to do this myself, but I want to understand what I'm actually entitled to so I can be prepared if they push back.
- limeblack 8y ago
  Same experience. Try requesting through a Psychologist or case worker I have had success with that.

goldcd 8y ago

In (the UK at least) your medical notes follow you as you sign on with a new GP (General Practitioner - first point of medical contact for anything non-urgent). Now knew this theoretically happened, but was quite bemused to see it happen in practice. I rescued a rat from the silken-jaws of my pseudo-homicidal cat, and the ungrateful rodent bit through half of my finger - I thought it would be sensible to have a checkup/shot. I've only got a hazy recollection of what shots I've had when, so my notes were consulted. Seemingly, according to my paper notes produced from the cabinet, 40 years ago "I was an adorable wee thing" (aged 2).

jermaustin1 8y ago
That's amazing. I guess, in the US, we only started tracking patients recently. I had to call and have my old records faxed from my old GP in Texas to one in New Jersey, and then again from that GP to my NEWER one in New York. Earliest record was from when I was 7, since neither my mother or I remember who my pediatrician was before then.
- limeblack 8y ago
  I disagree on this stance. If you were diagnosed with depression when 13 but no longer depressed its nobody not the doctor, the nurse, the IT staff jobs to know this unless you choose. You have everything from Psychology/Psychiatry notes to overdose records that many health staff can pull up from almost any computer. EDIT: Remember many jobs disqualify you from the job if you have any past psychiatric treatment. Even if you are in your 40s Psych drugs at 13 are a disqualifier. "Paying cash" is what some doctors have resorted to. http://www.idealmedicalcare.org/75-med-students-antidepressants-stimulants/ http://www.idealmedicalcare.org/75-med-students-antidepressa...
  - jermaustin1 8y ago
    I could be wrong, that's why I said I guess. It was just based on my personal experience in switching doctors a couple times when I moved away from my home town.
  - 8y ago

DanielBMarkham 8y ago

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 -- and there's this struggle for his attention that I watch play out. It usually involves a lot of verbal grunts. "So we've got this .... er.. .. and it looks .. hmmmm. .... So this is...." This could go on for a bit. Eventually we get to either a statement or a question. Frankly I'd think the guy was having some sort of mental issues if it weren't for the facts that 1) he used to be fine before they all started carrying around pads, and 2) he's fine outside the clinic. I really hope that the tech community has helped make healthcare better. It's certainly had an impact.

Spooky23 8y ago
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.
nradov 8y ago
Some provider organizations hire medical scribes to sit in the exam room and do real time EHR data entry so that the doctor can focus on the patient.
mikekchar 8y ago
Maybe not relevant for you, but one thing that has helped me with my doctor is that the first thing I do when I go in is sum up what happened in our previous couple of visits. My doctor doesn't have enough time to prep for my visit. I mean, he should, but he doesn't (been there, done that). So I give him the executive summary to speed things up. I visit my doctor a lot, so he now trusts me to give him accurate and useful information.

SL61 8y ago

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-hate-their-computers 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.

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User23 8y ago

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.

petermcneeley 8y ago

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.

jlamberts 8y ago
In my experience, it's a combination of a couple of things. First off, the field is heavily regulated (in the US anyway) and the penalties for violating regulations like HIPAA are incredibly high. Second, the field is currently dominated by major players such as Epic, so its pretty important to be compatible with them, but they don't really have an incentive to open up their ecosystem since they have such a stranglehold on the market. Finally, a lot of medical folks have been burned by technology in the past, and, in my experience, often view a lot of the tech they have to use as an insurance and government mandated evil, rather than a way to make their lives better. Not to say things can't be improved, but there are a lot of factors that make it more difficult than a traditional B2B or B2C product.
- deleted 8y ago
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- nradov 8y ago
  The Epic ecosystem is actually pretty open now. They have multiple web service APIs with full documentation, and even provide a developer sandbox you can use to test client applications. https://open.epic.com/ https://open.epic.com/ Epic also has an app store. You can write your own SMART on FHIR apps, then deploy them inside the EHR with full access to patient data. https://apporchard.epic.com/ https://apporchard.epic.com/
  - arkh 8y ago
    The full FHIR standard can be a lot at first sight https://www.hl7.org/fhir/ https://www.hl7.org/fhir/ but I'd recommend anyone having to store names, addresses or contact information to check how they do it. The last example for names is always fun: https://www.hl7.org/fhir/datatypes-examples.html#HumanName https://www.hl7.org/fhir/datatypes-examples.html#HumanName

Thriptic 8y ago

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.

roywiggins 8y ago
Epic provides progress note templates: http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG http://ist.jefferson.edu/content/dam/ist/epic/SmartList.PNG http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABDU/-k-vLlIHj5M/s1600/epic+screen+shot.gif http://3.bp.blogspot.com/-13TVMTrcPkA/UPWKAB_rTGI/AAAAAAAABD...
nradov 8y ago
All large hospitals and clinics already have standardized note formats. For care transitions the HL7 C-CDA 2.1 Continuity of Care Document (CCD) format works pretty well. Modern EHRs can export a summary of a patient's chart in that format. Some data may be lost in translation but usually it works fine. But there are often still technical obstacles to transporting a CCD from one provider to another. There are existing formal code systems for notes: CPT, ICD-10-CM, RxNorm, CVX, SNOMED-CT, etc. Those are helpful for billing and analysis purposes, but they can't replace free form narrative text for most clinical use cases.
sxg 8y ago
Many departments do standardize their note formats. The problem is that the note is directly connected to billing, and the billing requirements are absurd. I'm a medical student, and I recently visited my PCP for a medication refill. I have no significant medical history whatsoever, and the visit took no more than 15 minutes as expected. A month later, I was given a bill for $330 stating my hospital visit was level 4 acuity (there are 5 levels, with level 5 being ICU-like care). I looked into how the billing level is determined, and I found this article explaining how components of the notes are tied to billing levels [1]. Basically, by including 6 elements to the physical exam rather than 5, you can bill at a higher tier. There are several other areas that are tied to billing like this, including the family history, social history, etc. My PCP had completely filled out her standardized note to include every little detail I had mentioned—many of which were totally irrelevant to my current issue. I talked to some other physicians about this, and I learned that hospital departments use their standardized notes to include as much detail (i.e. bloat) as possible so that physicians can bill at higher tiers since billing is tied to the number of details included in the note. [1] https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-bt4 https://www.aafp.org/fpm/2003/0100/p29.html#fpm20030100p29-b...

qrbLPHiKpiux 8y ago

Doc here - spot on. 25% of my day is typing, reading, deciphering, referencing. I waste so much time not providing care.

notabee 8y ago
I just want to say that I'm happy to see one of y'all on here. If doctors and engineers were to collaborate together directly to fill in each others' domain knowledge gaps instead of buying crap software from companies with poor incentives, some truly amazing things could happen.
- JshWright 8y ago
  It's not as uncommon as you think. I'm both a paramedic and a developer for an EHR, and we have a number of other medical professionals (including a physician) in various product related roles.
  - notabee 8y ago
    I know that EHR companies surely employ both engineers and medical professionals, but are they able to freely innovate and explore, or are they bound to top-down bureaucracy with, as another responder mentioned, misaligned incentives? The kind of thing that I imagine would be a fully open source, open standards implementation that could allow easy portability of records between all providers.
- TheCoelacanth 8y ago
  I have a feeling it's more a case of misaligned incentives than just that people with the right knowledge are not involved. Medical professionals are certainly one set of stakeholders that EHR developers consider, but I'm almost certainly they aren't the ones given the highest priority. I would bet that billing, legal compliance and protection from accusations of malpractice are all given a higher priority than actually being able to effectively treat patients.
robmiller 8y ago

yumraj 8y ago

My kids' pediatrician was part of a small office, which merged with a larger office that is affiliated with a large hospital and hence uses EPIC. She used to take hand notes on paper and was quiet efficient when she was with the smaller office. After the move I have seen her struggle with EPIC, and then recently hire a medical transcription service and be followed by a person taking notes so that she can focus on the medical stuff. And, of course I have no idea if the quality of her notes has suffered.

organsnyder 8y ago
Believe it or not, Epic is one of the more provider-friendly solutions out there, according to many providers I've talked with (I work in the healthcare software industry).
- JshWright 8y ago
  Epic _can_ be not as awful as some (it's still a far sight from "friendly" in my opinion). The problem is that it's highly customized in each installation, and the vast, vast majority of them "customize" it in very provider-unfriendly ways (tons of irrelevant required fields for billing, etc). Even in the best case scenario though, it's a lot of clicking around to find clinical information that may be relevant to a patient (which means it can often go unnoticed).

samsolomon 8y ago

I've done a good bit of thinking about medical note taking. To me it's a little odd that hospitals are the ones who keep this information. I'd think that the records should belong to patients—it's about them after all. And that the patients would provide access to doctors or hospitals. Right now I've got a personal medical journal that has things like: * Sickness - Date Range and Notes * Flu Shots - Date * Injuries - Date and Notes * Observations - Date and Notes * Blood tests - Date and Photos of Tests Before my yearly checkup (or if I have to visit a clinic) I review the last entries and open them on my phone incase my doctor wants to see any of them. It works well enough for me, but seems like there could be a ton of opportunity for improvement. I'd love to have a system where my doctor could be notified and comment on new notes or events. Also the ability to bring in my scale, run tracker and other fitness data.

mikekchar 8y ago
One thing I like about Japan, where I live now, is that every time I get a test done (and unfortunately I've had a lot of them recently), they send a copy of the results to me. I have everything my doctor has. He also writes personal notes for himself, but usually they are descriptions of symptoms when I complain about stuff. I could write them down too (and maybe I should), but those are his personal notes just to remind him what was going one when I visited him. I don't need access to that, as far as I'm concerned (although he shows me what he's writing and sometimes I even ask him to show me what he's written on a previous page).
davycro 8y ago
Notes intended for patients would have a different form than notes intended for doctors. Unfortunately medical records achieve neither. My notes are bloated with information needed to bill the maximum amount from the center of Medicare services, which ultimately hurts all parties. The bloat obscures critical information from other doctors. Patients are unable to read a meaningful account of their care, and are charged more for worse services.
mikecsh 8y ago
The problem with this is that a very small minority of patients are that diligent or reliable, for various reasons (dementia, forgetfulness, disinterest, mental illness, low IQ, substance abuse, not realising the information is required, brought in by ambulance unconscious and peri-arrest, etc.). Here in the UK patients do have responsibility for some records - notably anticoagulation records and maternity / child health records. I have seen literally one patient present with their anticoagulation record. I have lost count of the number of patients who come to appointments without their maternity notes or child health notes. Even trying to get an accurate medication history from a patient is near impossible and we end up having to look at past hospital discharge letters, call their GP, or look on shared record systems to try and piece together what they are taking. I'm all for patients "owning" their records but they must be held in a way that is accessible when needed regardless of human variabilities.

nathan_long 8y ago

One "solution" is sometimes to use speech-to-text. The mangled results would be hilarious if they weren't frightening.

egillie 8y ago
I know some places have scribes (often students), and I wonder why they aren’t more common given how valuable doctors’ time must be

VikingCoder 8y ago

1. Money 2. Legal liability (CYA) 3. We don't use outcome-based medicine

skwb 8y ago
1. There's an old saying in healthcare that patient care is always first, but money is a close second. 2. Sort of yes, but I've heard it more time from managers who use it more of an excuse for not wanting change rather than it being a legitimate argument (i.e. from people with little to no legal training). 3. This is changing slowly. The Affordable Care Act and it's little known cousin MACRA have started to shift the entire system (albeit slowly) towards more outcome based measures, primarily through Medicare. Major payers are following in their steps. Not happening overnight, but any major healthcare executive sees the writing on the wall and is taking these considerations into account for their investments. [0]. https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/ https://www.healthaffairs.org/do/10.1377/hblog20180810.48196... [1]. https://www.healthaffairs.org/do/10.1377/hblog20180810.481968/full/ https://www.healthaffairs.org/do/10.1377/hblog20180810.48196...
- VikingCoder 8y ago
  3. No, it's not. If you go in for a wonky heart, and you get some kind of imaging done on your chest, and then spot something in your lungs, they SHOULD ignore it. Outcome-Based Medicine says that's what they should do. They CAN'T ignore it. Cardiologists actively want the lungs REMOVED from the images they order, because they don't want to accidentally notice any lung nodules. That's crazy! And that's just one example. We don't know how to properly ignore the things we should. And if something IS there, and there COULD HAVE been action taken on it, then the people who looked at the images are potentially liable in court. Or at least in settlement. The whole thing sucks.
  - skwb 8y ago
    Yes, it is. You appear to be conflating my point of how healthcare is changing with regard to payment structures with clinical guidelines which tend to have potentially more subtleties. There are some areas of healthcare where it is very cut and dry what defines good healthcare management. These are where we've developed good reporting outcomes that tie closely to clinical and resource utilization outcomes from the published literature. Think of your high volume routines cases such as diabetes (monitoring of A1C)[0] and knee replacements [1] that make of a large portion of health care cases. These are certainly not covering all healthcare episodes, but represent areas where significant fat can be trimmed. With regard to your above clinical case, there are specific approaches for (what I assume is an incidental finding from a coronary CTA) reporting lung nodules and requesting follow up studies [2]. However, this represents an area where there is significant good faith professional disagreement of reporting. I will agree that high-evidence clinical guidelines are not always followed, and payment reform has not been influenced all medical professions equally. The way healthcare is delivered is changing, and is being highly influenced by national policy level decisions. [0]: https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/full/ https://www.healthaffairs.org/do/10.1377/hpb20121011.90233/f... [1]: http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-Payments http://files.kff.org/attachment/Evidence-Link-FAQs-Bundled-P... [2]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5903561/

Scoundreller 8y ago

My favourite citation from the link: “In fact, across this same EHR, clinical notes in the United States are nearly 4 times longer on average than those in other countries” It seems that the EHR isn’t the root cause of the problem.

jcowdy 8y ago
I was one of the people that gathered and analyzed the data that the cited study used and can't agree with your conclusion more. Sure, the EHR makes "note bloat" easier than paper but the difference in length across different countries (using the same software) shows that note length is more a result of the environment than the tool. I think there is also a general misunderstanding of "the note" in an EHR context. The progress note is really just one aspect of a provider's documentation of a visit. Things like medications and allergies are generally indicated as "reviewed" elsewhere in the chart and yet all of this information is many times also entered into the progress note unnecessarily adding to note bloat. In the days of the paper chart the progress note ended up being the only summary of the visit and even though it's now just one piece of the visit documentation, it's still written as though it will be the only source of truth.
- Scoundreller 8y ago
  It’s a sad situation. Unhappy users are much louder than happy or neutral users. As a result, when a non-US health provider wants to do some informal research on implementing EHRs, they mostly read a lot of angry complaints.

deckar01 8y ago

I recently built my mom a basic web app to automate building patient evaluations. She has been using paper forms with checkboxes for decades and they started requiring the info in digital format over the last few years. She had been copy and pasting from the digital version of the blank form into MS Word. It was time consuming, but still faster than typing it by hand. To be clear, a paragraph containing sentences is the format medical professionals are required to present this information in. Automating the boilerplate stuff actually gives my mom more time to type in the information that the paper forms don't anticipate and provide actual care to patients. The problem is not automation. The problem is unscrupulous executives who maximization profits at the expense of quality of service. The examples provided in this article are unethical and anyone who is caught dumping irrelevant data into important medical records should be held responsible.

leovander 8y ago

Spec. Off's [1] - Doctor enters your visit (encounter), cross your fingers that his system has the most up-to-date medical codes (e.g. snomed, cpt, icd, etc) - Doctors notes for that encounter are potentially entered as a text area in one system (u/petermcneeley). Can be notes at the encounter level or for a specific diagnosis/lab result/etc. - The codes vs free text, is what we refer to as discreet and narrative/free text. - The current IHE spec. [2] (last updated in 2015?), allows for codes to be interpreted from narrative text if a valid code is not provided. I think there are a few startups that have popped up here that are trying to make sense of the narrative text. - That same spec would be great if everyone followed it but they have to get their system to bend a little bit or throw an integration engine in front of the problem to play nicely with others. (u/nradov) - Start sending those back and forth and you either end up losing those notes or butchering them up. - There are some orgs (e.g. DoD, VA, Sequoia, etc) that have everyone follow the basic requirements but then add their own flavor on top. [3] - FHIR [4] is here, but I think everyone is already scrambling or haven't had the need to make the cut over to it until its government mandated. I have to say this has been the easiest spec. to grok, but it is still way too flexible for these companies to mess up. A cut over to FHIR for everyone should ideally be that you have to use the Hapi FHIR models [5]. Maybe have a way for Hapi to sign the models on their way out? Sorry, this turned out to be more of a rant, but I stare at this stuff everyday. There are a few other folks on the thread that know the industry as well that have some good info too. [1] https://media1.tenor.com/images/af0c71048d5a130cefc335423c597ce8/tenor.gif https://media1.tenor.com/images/af0c71048d5a130cefc335423c59... [2] http://www.hl7.org/implement/standards/product_brief.cfm?product_id=258 http://www.hl7.org/implement/standards/product_brief.cfm?pro... [3] https://xkcd.com/927/ https://xkcd.com/927/ [4] https://www.hl7.org/fhir/ https://www.hl7.org/fhir/ [5] http://hapifhir.io/ http://hapifhir.io/

telchar 8y ago

I do NLP with medical notes. What I have observed is that the redundancy between the note and information available elsewhere in the EHR in structured formats is pretty high, as is the amount of boilerplate (e.g. section headers and list templates that may not be filled in). This makes machine learning using the notes difficult since the content is so muddied up. It's far from impossible to do useful things with them but there is a lot of noise. Still, some things require us to look at the notes. For these things we would much rather have them than not. While it's preferred to have the information entered in a structured way, doctors find that more of a hassle than entering in the data free-text and it's also no good for retrospective analysis where we didn't know several years ago we would be interested in something and so no structured field existed.

abrichr 8y ago
Interesting insight! Where do you work?
- telchar 8y ago
  I work for a hospital/health system.

bobowzki 8y ago

The medical journal is one of, if not the most, important inventions of modern medicine. I'm an MD and work with them every day. But yes, the current infrastructure is not good.

cabaalis 8y ago

I deal with various EHRs every day of my life, and 4-digits-worth of providers. The primary barrier is that practice managers are working to get data standardized, but get pushback from the providers who are busy doing their jobs being doctors and not data scientists. Some EHRs can streamline via templates and workflow. Others don't. I've literally had practice admins not implement new practices that would document properly and facilitate easy reporting because they would not be able to sell the change to the providers. I'm not blaming providers for the data issues. They have a job to do and they do it. It just doesn't always get documented in a reportable manner. There needs to be an easier way to document, or some kind of Middleware that documents for them. I see people a whole lot smarter than me trying to use ai to interpret notes. I personally think they are just facilitating the ongoing poor documentation problem. And things will slip through the natural language cracks, and it could be a potential health hazard.

egillie 8y ago
Agreed that 95% correct (or even 99%) AI probably isn’t the solution here, I’m surprised to see so many startups doing AI/NLP for doctors’ notes

tdeck 8y ago

Here's a fun thing about our system in the US. If you're taken to the emergency room, they'll ask your medical history. And not just once - they'll ask it in the ambulance, radio it ahead to the hospital, then make you wait while they ask you the same questions again and enter them into their system at the hospitsl. Then the next 3 doctors or nurses who come into your room do the same thing, asking you questions you've already answered. Doesn't seem to matter if it's obvious that speaking is painful for some reason (in a case I'm describing a family member had broken ribs).

Spooky23 8y ago
Then the ass in the insurance cart has to do their thing. My wife almost bled out on the table when one of these idiots was literally blocking the medical people. I physically removed him from the area and almost got arrested.
arkades 8y ago
We do this for a reason. Not only do different people ask specific questions that try to elicit different things, but patients stories evolve with each repetition. People don’t realize how much, but by the third time you’re getting that history, the picture is usually quite different from what the first history depicted. And since history is 90% of diagnosis, this isn’t some little quirk. It plays a huge role in helping patients. Huge.
- cperciva 8y ago
  As a patient, I've been guilty of doing this deliberately. At ER triage, my priority is "get into a bed". Once I've been admitted, my priority is "get well". (And once I'm feeling better, my priority is "get out of here"...) As a type 1 diabetic, if I have high blood glucose and nausea, I'm going to say the letters "DKA" to the triage nurse. I'll never bring it up again -- because the first blood chemistry test answers that question one way or the other.
- bookofjoe 8y ago
  Reminds me of what an attorney once said to me (I'm a retired neurosurgical anesthesiologist with 38 years experience; I occasionally served as an expert witness): "The client's story never sounds better than the first time you hear it."

brownkonas 8y ago

I refuse to believe (beyond a bad email notification , which is not acceptable for medical information) that being elaborate or non-concise is a problem. Why is 4x more medical density a bragging point , in other words?

NoblePublius 8y ago

I read number 1 —- “money” — as “doctors lie about what they are doing to get paid more by your insurance company”. Is that unfair?

xte 8y ago

Problem of medical notes have a name: bureaucracy. The hope is leaving it apart, and today it seems a bit utopia... Also in terms of "numeric/digital" vs "paper" the point is ignorance: how many people outside IT world (and even inside) do actually know enough a desktop to take their own personal notes in an ordered, usable and useful thing? IMVHO a so small percentage that we can probably know them all by name. Just take a look at a "common" mailbox: most of them are an utter pile of data, few with some incoherent taxonomies, few even with the sole inbox as an archival place. Than take a look a common "home directories": the very same mess. And if this is for personal and generic data do you think that those people are able to properly not only manage but share helpful information with digital systems?!

bill_from_tampa 8y ago

I worked at the VA for over 2 decades, including the transition from handwritten to electronic notes. Wow. When I retired, the nursing notes for a patient visit were usually 2-3X longer than the docs note. The nursing note was entirely populated by templated text created by a hierarchy of supervisory staff tasked with satisfying all regulatory requirements. The poor nurses would ask the patient a series of prompted questions, click on the appropriate box, and a page of templated text would emerge. Actually finding useful actionable info in the nursing notes was impossible, or close to impossible. The docs began to demand, reasonably, that actual patient problems identified by the nurse be put in a specific area of the note rather than randomly scattered throughout 4-8 pages of templated text (which without this demand could be randomly intercalated with such useful info as "pt c/o chest pain when walking, much worse", found on page 5 of 8. The docs notes were, in many ways, even worse. The notes required manual typing, and many docs are not trained skilled touch typists. So the two-fingered part of the note was often very brief and succinct. The templated portions were huge - impressive reviews of systems where you could not really tell if the specific items had actually really been asked or if the template just vomited forth a page full of text for administrative review. Make a doctor function as a data entry clerk and this is what happens.