The widespread implementation of electronic medical records (EMRs) and electronic health records (EHRs) has significantly changed the quality and quantity of healthcare for both the better and the worse. The digitalization of medical records provides comprehensive documentation of all events and actions associated with an individual’s medical care. Likewise, legibility, accountability and credibility are greatly improved by access to all information pertinent to a patient’s healthcare.
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Explore This IssueJanuary 2017
Under the current fee-for-service reimbursement system (which is soon to be replaced by a fee-for-value reimbursement system), the EMR also acts like a giant cash register that tracks the quality and quantity of medical services provided that are documented to be medically necessary in order to reduce waste, fraud and abuse and maximize provider accountability and reimbursement for medical services.
So what’s not to love? Plenty!
The Bad & the Ugly
The sheer volume of documentation that is displayed all at one time may overwhelm the healthcare provider, who can get distracted in locating the information he needs in a sea of medical documentation that the provider must somehow confirm has been reviewed. Ultimately, the healthcare provider is taking care of the EHR demands as much as the patient, if not more.
Thoughtful consideration of a patient’s concerns and complaints, along with formulation of a diagnosis and treatment plan (not to mention examination), is undermined by the inflexible demands of the EHR program, which will not progress to the next task until all tasks required are completed. What used to be a one- or two-page succinct document describing an office visit has morphed into a 6–10-page regurgitation of previous medical records that may or may not be relevant to current healthcare needs (also known as note bloat).
Pressure to Diagnose
In order to facilitate care, the healthcare provider is required to provide a diagnosis to proceed with permission for further diagnostic and therapeutic efforts, regardless of certainty that the diagnostic label is accurate and correct. The key to the kingdom of both therapy and payment is the diagnostic label, which, hopefully, is accurate and reflects the correct diagnosis.
A medical diagnosis involves the identification of the nature and cause of illness symptoms and the determination of the cause of an associated disease process. Sometimes, symptoms of illness are not associated with a defined disease process, and sometimes, a disease process is silent and not associated with illness symptoms.
Illness is how a patient feels (subjectively reported), and disease is the identification of abnormal body tissue and/or function that can be measured directly by examination or indirectly by diagnostic studies.
The problem or diagnosis listed opens doors for treatment and payment, but is often an approximation of the patient’s clinical problem rather than a definite diagnosis supported by the medical evidence. Just as a map is not the territory, but a representation of the territory, an EHR diagnosis is a representation of a patient’s health status that allows the healthcare delivery system to pigeonhole a patient for purposes of medical evaluation, management and reimbursement.
Ever-increasing non-medical demands, including data entry into the EHR, often result in uncritical acceptance of a listed diagnosis or problem at face value. Very little energy is left for critical thinking and intellectual honesty given the pressures on the healthcare provider to please the customer and be productive. Yes, healthcare is now a business transaction between a provider and client, a transaction that has to be validated and approved by the entities that ultimately pay for the healthcare services. Whatever “diagnosis” gets the job done is the basis for future healthcare services (even when the diagnosis is not really certain). In an effort to prevent having a dissatisfied customer, which can adversely affect the healthcare provider’s performance evaluation and value, no attempt is made to address the patient’s self-defeating thoughts and behaviors even if time allows.
Forces of fashion, politics and economics drive diagnostic labeling from being a thoughtful intellectual construct to a diagnostic hunch based on inductive reasoning with assumed pathophysiology, even though examination and diagnostic testing cannot establish diagnostic certainty.
A diagnostic hunch is not the same as a diagnostic fact, even though the patient and healthcare delivery system may be satisfied. The ever-growing list of diagnostic labels used to justify healthcare services is not to be taken at face value so the service transaction can be completed and allow the provider to go on to the next patient while looking good on paper.
Often, marginal or non-specific diagnostic laboratory findings are the basis for a diagnostic label that appears to be definitive and not just descriptive. These diagnostic labels, often from multiple providers, need to be critically reevaluated over time and not accepted just because they are on the record. These diagnostic labels soon are treated as established and accepted diagnoses that serve as the basis for evaluation and therapy.
Often, valid but unproved medical theories and findings are reverse engineered to explain unexplained symptoms that are resistant to diagnosis and treatment. Many of the symptoms are the body’s response to stress and abuse, which only the patient can address and are not amenable to surgical or medical therapies. The diagnostic labels serve to justify ineffective therapeutic and diagnostic efforts. The more physical complaints and symptoms, the more diagnostic labels—both correct and incorrect—accumulate over time.
Unfortunately, the “note bloat” discussed above not only overwhelms the senses of a provider trying to locate clinically meaningful information from the past, the multiple episodes of healthcare contact make drilling down into the electronic records extremely laborious and time consuming. Often, hundreds of individual notations for dates-of-service document communications with the patient by multiple providers and staff members over time. Sorting out the clinically significant ones from the less meaningful diagnostic labels can be an overwhelming task with regard to the time and effort required.
After all is said and done, the conscientious practitioner should remember the old saying, “Don’t believe everything you read!” Rather than being lured to the path of least resistance to facilitate meeting patient expectations, as well as administrative demands, with regard to development of a diagnosis with a treatment plan, critical thinking and intellectual honesty must prevail—even if not appreciated by the patient or the various insurance and administrative requirements needed to allow testing, treatment and payment for services provided.
Many physicians have learned how to game the system by telling white lies that allow the healthcare provider to manipulate the system to get things done, as well as look good on paper.
Thoughtful consideration of a patient’s concerns & complaints, along with formulation of a diagnosis & treatment plan (not to mention examination), is undermined by the inflexible demands of the EHR program, which will not progress to the next task until all tasks required are completed.
Where We Are
In summary, the EMR promotes diagnostic labeling, which justifies the medical treatment provided rather than valid diagnoses. This flawed model of healthcare allows reasonable but unproven concepts regarding disease processes to be accepted over time as fact with resulting bad results purchased at a high cost both financially for society and personally for the patient.
The diagnostic label has become the modern equivalent of the deus ex machina (a god introduced by means of a crane in ancient Greek and Roman drama to decide a final outcome). If a healthcare provider needs an explanation or justification for services provided or requested, just come up with the needed “diagnosis.”
Also, this author believes that having a non-medical scribe in the room doesn’t help the doctor–patient relationship, although the physician is relieved of some of the documentation burden.
EMR documentation requirements are changing the diagnostic paradigm for all physicians, who have to fulfill burdensome documentation demands, as well as provide thoughtful, compassionate and competent patient care.
David Knapp is a semi-retired rheumatologist with 38 years of practice experience. He keeps his hand in the professional world by providing locum tenens work and says he has gotten an eyeful of how the EMR is being used at the different institutions where he has worked.