System Archives - Page 48 of 51

EMR – Bigger Is Not Better

Docs spend more time with electronic health records than with patients. Many blame electronics. True, bad systems eat hours of nurse and physician time, but the biggest waste is fat charts.

If bigger is better for patient charts, then medical students make the best charts; staff physicians the worst.

Every year, trainees get better at sharpening details. Expertise leads to focus on critical information: everything that does not add value gets left out. Charts get shorter…until providers start padding charts for other reasons.

Modern patient charts aren’t just about patients.

Charts get longer to:

1. Protect against Lawsuit:

A long chart makes it tough to prove providers weren’t thorough. You can prove you thought about all sorts of things by listing all the negative responses you found even though the negatives don’t help the patient.

2. Protect against audit from your regulatory college:

The overseers/authorities/police believe they know what makes a great chart. They support #1 above and enforce it, and they (groups of lawyers and lay-people mostly) define ‘best practice’.

3. Protect against billing audit:

Long charts look like lots of work was done.

Value Added?

Would an informed patient willingly pay for long notes that were created to protect providers?

Do long lists of ‘pertinent negatives’ add anything for patients? Sure, they ‘prove’ providers considered a differential diagnosis, but considering a differential diagnosis is core medical practice; why should they prove they did it?

The whole medical decision-making heuristic rests on a differential diagnosis approach; why prove it over and over on every single chart?

As a provider, if you just wrote the diagnosis, does that mean you suddenly became anti-differential diagnosis? Even if you recorded pages of negative findings and came up with the wrong diagnosis, does that help the patient any more than just writing the wrong diagnosis in the first place? All it proves is that you were thoughtfully wrong.

Two types of Complaints

A. You know what’s going on:

This chart needs positive historical points and physical findings, diagnosis, and treatment. That’s it. Nothing else adds value for the patient.

B. You have no clue what’s going on:

This chart needs more. You should write a book: everything you thought about and why it doesn’t fit. In fact, long charts define clinical uncertainty, not clinical excellence.

If patient charts should be about patients, we need to:

1. Change expectations:

Focus only on what adds value for patients.

2. Change charts:

The whole process could be done with macros and tick-boxes. Only critical findings (positives, diagnosis, treatment plan) need manual entry.

When physicians and nurses go back to review a chart, they NEVER need all the information in it. NO ONE DOES, except non-providers! Clinicians look at old charts to find 1-2 critical pieces of information that have meaning for their patient.

How short would your chart be if you weren’t worried about lawsuits and audits? What needs to be in the chart if only patient benefit mattered?

Number of specialized doctors who are unemployed growing, study finds | Toronto Star

http://www.careerealism.com/ — www.careerealism.com/

Number of specialized doctors who are unemployed growing, study finds | Toronto Star.

Patients wait over a year to see consultants, especially in rural areas. Patients and physicians are frustrated. This article adds gasoline to the fire.

My Uncle, a rural physician, suggests a central registry of consultants listing their wait times and ability to see referrals.

Lack of operating room time keeps many surgeons unemployed. Patients wait; surgeons work part-time; the system ‘saves’ money.

Intolerable.

Death, Dying, Euthanasia and Physicians

Dying people show up each day in my emergency department. Young and old take their lives, or have life taken from them.

Death is everywhere, if we look.

Recently, death and dying holds media attention: legislation in Quebec, Dr. Low’s passing, and even Sue Rodriguez.

Aside from places like the Netherlands, physicians have almost no experience with euthanasia or assisted suicide.

Doctors know end of life care, not euthanasia; palliative care, not physician assisted suicide.

Dr. Wooder, president of the OMA, was wise to focus on what physicians know best, when he decided to focus on end of life care this year.

Emotional stories and tragic personal experiences fill most discussions about death. We wade over our heads into content and debate unfamiliar beyond anecdotes.

When we don’t know, we tell stories.

We need to start with definitions. As President Clinton said, “It depends on what the meaning of the word ‘is’ is…”

Six terms you need to know:

Euthanasia: few agree on a definition, but most say that “euthanasia involves doctors making decisions which have the effect of shortening a patient’s life and that these decisions are based on the belief that the patient would be better off dead” (Keown, 2005).

Active, physician-assisted suicide (PAS): you end your life. You push the button, take the drug, or start the infusion. Your doctor gets you started with supplies and instructions, but you end it. If PAS doesn’t go far enough, your doctor might have to perform voluntary, active euthanasia.

Voluntary, active euthanasia (VAE): you let your doctor end your life. You give consent; your doctor pushes the button…

Non-voluntary, active euthanasia (NVAE): your doctor ends your life when you are not competent to give consent due to severe disease, dementia, etc.

Involuntary, active euthanasia (IVAE): your doctor ends your life against your wishes.

Passive euthanasia (PE): PE involves withholding or withdrawing of medical treatment by a doctor with intent to kill. Defining what includes “medical treatment” is tough and needs its own blog post. Are tube feeds medical?

Finally, we need to grapple with: Intent – aiming to have something occur, and Foresight – being aware that something might occur.

Most of this post came from two great books:

Euthanasia, Ethics and Public Policy: An Argument Against Legislation by John Keown

Rethinking Life and Death: The Collapse of Our Traditional Ethics by Peter Singer

These books look from opposite ends of life. Keown writes clear, careful prose and offers an in-depth review of the Danish experience of euthanasia. Singers writes engaging, thoughtful philosophy about difficult cases in support of unpopular ideas like involuntary euthanasia. On the back of Singer’s book, the Washington Post blurb says:

Far from pointing a way out of today’s moral dilemmas, Singer’s book is a road map for driving down the darkest of moral blind alleys…Read it to remind yourself of the enormities of which putatively civilized being are capable.

Keown reminds us that, “Hard cases make bad law“. So far, most of the news serves up ‘hard cases’. We need to move past these and start discussing how most people die and what we are doing to improve that process.

What do you think? Can we have an adult discussion about death? Should we let everyone do whatever they want with their lives and how they end?