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What's In A Note?
by Simon M. Helfgott, MD
Americans love excess. When it comes to eating, driving, watching television, or sending text messages, we take (and eat) the cake. According to the Centers for Disease Control and Prevention, more than one-third of Americans are obese, an incidence that is 2.5 times the rate in France. Americans use text messaging four times as often as those in Great Britain. The average American television stays on for nearly 8 hours per day. What a life! No wonder there is so little time to exercise.
Our quest for excess extends into other domains as well. Consider the Standardized Aptitude Test, better known by its acronym, the SAT. In a fascinating study comparing the length of the SAT writing essay and the grade received, Les Perelman, PhD, the director of undergraduate writing at the Massachusetts Institute of Technology in Boston, observed a strong correlation between the two variables. The shortest essays, typically 100 words, received the lowest grade of one. The longest, about 400 words, usually were scored with the top grade of six. The correlation between length of essay and grade was also noted for essays with an intermediate number of words. In a New York Times article, he concluded: “I have never found a quantifiable predictor in 25 years of grading that was anywhere near as strong as this one. If you just graded them based on length without ever reading them, you’d be right over 90% of the time.” He was also struck by all the factual errors in even the top essays. Dr. Perelman contacted the College Board, the overseers of the SAT, and was surprised to learn that on this writing exam, students were not penalized for including incorrect facts. The official guide for scorers stated: “Writers may make errors in facts or information that do not affect the quality of their essays.” When asked how he would advise students to prepare for such an essay, Dr. Perelman responded: “I would advise writing as long as possible and include lots of facts, even if they’re made up.”
Are We Any Better?
I don’t mean to be cynical but the dictum, “to write as long as possible” has become the norm for some physicians, as well as for college applicants. The movement toward the use of electronic medical records (EMRs) has opened the floodgates for verbal excess. Nowadays, it is common to scroll through records that go on and on and on. Sometimes the content sounds eerily familiar. Wasn’t that history in the follow-up note the same as the history in the admission note from six months ago? A careful reading may identify some of these notes to be, in the frank words of Robert Hirschtick, MD, associate professor of medicine at Northwestern University in Chicago, “recombinant versions of previous notes.”
In the April issue of The Rheumatologist (p. 17), our ACR coding experts referred to this practice as “cloning,” which is defined as the cutting and pasting of the note from one visit to another. As described in the article, if a history of present illness (HPI) note is carried over from a previous visit, but the chief complaint and present illness do not match the review of systems (ROS) that the patient filled out, the note is not considered to be pertinent to the current visit, raising a red flag for our friends at the Office of the Inspector General (OIG) of Medicare. Can you spell “audit”?
Yet, cloning is not the only adverse behavior seen with the burgeoning use of electronic records. Composing redundant notes devoid of any clinical curiosity, critical thinking, or thoughtful review may be legal, but they are equally harmful to patient care. In a recent study, researchers from Columbia University in New York City actually attempted to quantify the redundancy of the clinical narrative in the EMR. They found that the signout and progress notes proved to be particularly redundant; the former contained an average of 78% and the latter 54% of information duplicated from previous documents. There was also significant information copying between document types (e.g., from an admission note to a progress note). The result is the creation of medical records that are bursting with kilobytes of irrelevant data and replete with copious notes that may inadvertently hide the clinical clues and critical observations that we are searching for.
Another development that has threatened the quality of the medical narrative has been the use of templates in the EMR. Though they allow for the concise and complete entry of important data that may otherwise be overlooked or forgotten, templates tend to crowd out space for the entry of free-form text and thoughtful observations. To many note writers, the use and abuse of templates appears to be a modern day issue, but the tension between using a formulaic approach to documentation versus a narrative one is not new. A wonderful review of the history of the medical record, written by Eugenia Siegler, MD, professor of clinical medicine at Weill Cornell Medical College in New York City, noted that concerns about the variable quality of physician documentation have been a recurrent theme in the medical literature for nearly a century. She describes the evolution of the medical record as it occurred over two centuries at the New York Hospital (NYH).
For example, to accommodate medical progress at the turn of the twentieth century, the medical records of the NYH were revised. They were now organized around graphs and a table, which left no room for any narrative—merely brief descriptions. House physicians no longer summarized the course of a patient’s hospitalization; they recorded their observations, but not their thinking. Physicians eventually broke free of these constraints. They began writing some interim notes across the columns and demarcating their notes from those of the nurses. Some physicians eventually moved beyond the tables altogether and composed occasional follow-up notes—the first progress notes—on the form that was originally used only for the initial physical examination. By 1922, either within or outside of columns, physicians were beginning to offer diagnostic speculations. The discharge summary evolved from words to sentences and was written first across the page, then on the back of the tables, and finally on a sheet of its own. Formal, typed discharge summaries would soon follow. Physicians had started to document their findings and opinions despite the forms.
The Early Years of the EMR
For most of my years in practice, I have used an electronic record. Our hospital first proposed that we begin using an EMR in 1989 as a way to document our division’s expertise in patient care. This served us well whenever the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) arrived for their periodic reviews.
I recall the communal hand wringing when we realized that the paper charts containing the rest of our patients’ records would not be traveling with them to their clinic visits. This created some interesting challenges when trying to assimilate outside lab results and consult visits into the record, since scanning technology had not yet become commercially available. Somehow, we managed to deal with this issue.
More daunting was the high cost of medical transcription. A two-page typed consultation cost about $8.00, while a follow-up note charge might be around $3.50. Multiply those numbers by 25,000 visits per year and the results were eye popping. Some members of our division decided to work with an upstart dictation service company. They promised great results at half the cost. What we got were half the results at the same cost but with some laughs thrown in. Most of their typographical errors were minor irritants, an errant “s” here or there. There were countless in-note sex changes and there was a generous use of phonetic spelling. My dear 90-year-old patient became an adolescent 19-year-old girl with “Polly-myalgia room attica”. Then there was my patient with a pigmented villonodular synovitis of the knee that was transcribed as “pelvic inflammatory sinusitis.” Now talk about a fascinating juxtaposition of human anatomy! In his book, America, the comedian Jon Stewart quips that the Massachusetts legislature ratified everything in John Adams’ 1780 Massachusetts Constitution, “except the letter ‘R’.” This may explain how that rare mimic of central nervous system vasculitis became typed as “moyer-moyer” in someone’s record. One of the many hazards of living in Boston!
Some Novel Future Uses of the EMR
Despite these quirks, I would never trade the EMR for pen and paper. Yes, there was a time when some medical notes were elegant missives full of flowing prose that described lengthy hospitalizations. The penmanship was superb, cursive letters carefully constructed using a fountain pen. After all, the writers had plenty of time. They were not likely to be interrupted by the hospital paging system, beepers, or text messages. The Current Procedural Terminology (CPT) codes, which dictate the requirements for the content of notes, had not yet been created.
Without a doubt, the EMR makes our lives easier. Notes are legible and in chronological order. They can be sent electronically to other providers. Most systems can link notes to imaging and laboratory results. There is another major advantage for using electronic records: the opportunity to harness the data for research. Take, for example, the use of patient data mining using search-engine technology. Work done in this field by Kenneth Mandl, MD, MPH, associate professor of pediatrics, and Isaac Kohane, MD, PhD, professor of pediatrics, at Harvard Medical School in Boston, has demonstrated the utility of this technology. They studied whether data mining could identify adverse medical events occurring in large populations by searching the electronic medical records of patients seen during the previous ten years at Brigham and Women’s and Massachusetts General Hospitals, both in Boston. After searching the full database, they then focused on patients with coronary heart disease. Analyzing demographic information, billing codes, visit dates, medication histories, and diagnostic data, and using natural language processing and other search tools, they identified those patients who had taken rofecoxib and whether they had suffered myocardial infarctions (MIs). They observed a nearly 20% jump in the number of MIs just eight months after the release of rofecoxib, an effect that vanished within a month of the drug’s withdrawal from the market.
Data mining as a tool in rheumatology research is moving forward, too. Some of my rheumatology colleagues at Brigham and Women’s—Katherine P. Liao, MD, Robert Plenge, MD, PhD, Elizabeth Karlson, MD, and Soumya Raychaudhuri, MD, PhD—have developed computer algorithms that can accurately identify patients with rheumatoid arthritis (RA) in very large databases, even across different EMR systems. When such information is linked to biospecimen repositories, the opportunities for research are endless. Some of their current studies in RA patients include the identification of genetic predictors of the response to anti–tumor necrosis factor (TNF) therapies and the genetic predictors of lipid levels. By combining billing data with clinical data from the EMR, Sonali Desai, MD, has led a study within our division that can assess the pneumococcal vaccination rates of immunosuppressed patients. Using this data she created a quality-improvement intervention that has increased vaccination rates from 50% in 2008 to more than 80% in 2012.
Back To the Future
The tension between the need to document the patient’s medical condition versus the constraints of the medical record persists. Dr. Siegler described how changes in medical record structure—in particular, the compromises required to manage data and improve efficiency—dramatically altered what physicians wrote more than a century ago. Faced with a rigid system, the physicians who created these records responded by conforming generally to the structural constraints but, when necessary, they found ways to break free of these constraints. As Dr. Siegler stresses, the transformation of these records mirrors the challenge that we face today when using the EMR—managing information in a way that does not discourage expression and thoughtful analysis while fulfilling the more mundane aspects of data collection and record documentation. We need to become the custodians of the medical record who will be remembered for keeping the art of medicine alive in every chart.
Dr. Helfgott is physician editor of The Rheumatologist and associate professor of medicine in the division of rheumatology, immunology, and allergy at Harvard Medical School in Boston.