Here is my latest post on Physician's Weekly. 

"Do you have CoPaGA Syndrome?" Do you even know what it is?

You can read it here.

Can data in electronic medical records be trusted?

If the subject is respiratory rates, the answer is “No” according to a recent study. The authors reviewed the records of 28,500 patients over 220,000 hospital days and found recorded maximum respiratory rates “were not normally distributed but were right skewed with values clustered at 18 to 20 breaths per minute.”

The figure below shows maximum respiratory rates compared to heart rates which were normally distributed.

Reminder: Most sources say the normal respiratory rate of an adult ranges from 12 to 20 breaths per minute.

The problem of “copy and paste” in electronic records

As opposed to text that is copied and pasted or imported from another part of the electronic record, the average amount of manually entered information in a progress note is

a. 18%
b. 29%
c. 43%
d. 55%
e. 70 %

A study of 23,630 internal medicine progress notes written by 460 different hospitalists, residents, and medical students found that a mean of only 18% of the text was created by hand with 46% copied and pasted from previous note or somewhere else and 36% imported from another part of the record such as a medication list.

The analysis, done at the University of California San Francisco*, was possible because the Epic electronic medical record used there can provide the provenance of every character entered in a progress note.

Medical students had the highest percentage of manually entered text and wrote longest notes—averaging 7053 characters, but even the shortest notes, by hospitalists, averaged 5006 characters. For reference, this post contains 1189 characters.

Manual entry comprised 11.8% of resident notes with 51.4% of the remaining information copied and pasted and 36.8% imported.

Think about it. For all groups, less than one-fifth of every progress note they wrote was original material. For resident notes, it was closer to 10%.

The authors cautioned that their study was limited to a single service at a single institution, but I suspect the results would be fairly similar in many if not most hospitals.

*Location of the study corrected on 7/7/17.

Incidence of speech recognition errors in the emergency department

Speech recognition errors occurred in 71% of emergency department notes and 21.1% of notes with errors were judged as critical with potential implications for patient care says a recent study in the International Journal of Medical Informatics.

Investigators looked at a random sample of 100 dictated notes and found 128 errors or 1.3 errors per note.

More than half of the errors were ascribed to speaker mispronunciation. Although when I use speech recognition software, it sometimes does not accurately discern what I am clearly saying.

Other errors involved deleted and added words, nonsense, and homonyms.

An example of a nonsense error was "patient up been admitted for stable gait."

Some of the critical errors (with possible interpretations) were as follows:

Which is better—an electronic or a paper progress note?

It depends on whom you ask.

A new study says internal medicine house staff generally feel that the quality of progress notes is unchanged or better since the implementation of an electronic medical record, but the attendings feel that progress note quality is unchanged or worse.

Over 400 interns, residents, and attending internists at four university hospitals were surveyed. The paper appears online in the Journal of Hospital Medicine.

Specifically, 50% of residents felt that the quality of notes was unchanged and 39% thought the quality was better or much better. Conversely, 39% of the attendings felt the note quality was unchanged, and another 39% felt that it was worse or much worse.

From the paper: Half of interns and residents rated their own progress notes as “very good” or “excellent.” A total of 44% percent of interns and 24% of residents rated their peers’ notes as “very good” or “excellent,” whereas only 15% of attending physicians rated housestaff notes as “very good” or “excellent.”

When the 9-item Physician Documentation Quality Instrument was used to evaluate notes, attending perceptions of housestaff notes were significantly lower than housestaff perceptions of their own notes, p < 0.001. One of the PDQI items asked for a rating of how succinct resident notes were. That feature was rated lowest by attendings and residents alike. I can think of a lot of words to describe electronic progress notes, but "succinct" isn't one of them.

In all, 16% of interns, 22% of residents, and 55% of attendings reported that copy forward [copy and paste] had a “somewhat negative” or “very negative” impact on critical thinking, p < 0.001. Auto population of fields in notes was judged similarly.

The authors felt that these differences could be explained because Attendings may expect notes to reflect synthesis and analysis, whereas trainees may be satisfied with the data gathering that an EHR facilitates. I agree.

Can all this be remedied?

Dr. Daniel Sexton, a Duke University internist, authored a three page guide [link is safe] on how to write effective progress notes. Here are just a few excerpts:

DO NOT TRANSCRIBE LAB DATA INTO THE PROGRESS NOTES UNLESS YOU INTEND TO COMMENT UPON IT. [All caps by Dr. Sexton]

It is often good and useful to explain your thinking in the chart.

Do not mindlessly repeat yourself in daily notes. [That goes for "copy and paste" too (my extension of this recommendation)]

LENGTH OF NOTES DOES NOT RELATE TO RELEVANCE OF NOTES. [All caps by Dr. Sexton]

I have written about the pitfalls of electronic medical records several times. In my blog's search field to your upper right, insert "electronic medical record" or "EMR" and click "Search This Blog" to see my other posts.

It's early in the academic year. Start writing better notes now. And please don't copy and paste.

How does a 16-year-old boy receive 38 times the normal dose of an antibiotic?

If you are a doctor, nurse, patient, or just someone interested in patient safety, you should read a five-part story called "The Overdose: Harm in a Wired Hospital" excerpted from a book "The Digital Doctor" by Dr. Robert Wachter.

Dr. Wachter and the hospital are to be commended for publicizing this incident so others may learn from it. The hospital staff, the patient, and his mother, also deserve credit for allowing their stories to be told.

A synopsis does not do justice to this well-written account of the boy's near-death experience in a top hospital in San Francisco. In short, he somehow received a massive overdose of the antibiotic Septra despite the presence of a sophisticated electronic medical record and multiple systems in place that were supposed to prevent such a thing from happening.

After the patient recovered from receiving 38½ pills when he should have been given only one, a root cause analysis found numerous faulty system issues such as an electronic ordering program that was overly complex, a nurse "floating" to an unfamiliar floor, a satellite pharmacy that was too busy and susceptible to distractions, "alert fatigue" among hospital staff, and a culture, like that of most hospitals, that may have discouraged questioning both authority and the almighty computer.

Medicine, like air travel, once was fun

A Wall Street Journal blog about a reunion of employees of American Airlines lamented the good old days of air travel. Here's an excerpt:

"They came together to celebrate the days when flight attendants in white gloves hustled to serve you, gate agents doled out upgrades and arranged seating so families could be together, and managers worked flights with the single mission of ensuring excellent customer service."

The employees told tales of the fun they had and the camaraderie they shared. The passengers had fun too.

One retiree said of today's airline employees, "They don't look like they are having any fun at all."

Certainly the same can be said of today's passengers.

I'm usually not a fan of the airline-medicine analogy, but I'm going to make an exception here.

Back in the day, those of us in medicine had fun too. Don't get me wrong. It wasn't at the expense of the patients.

We always approached our patients with a proper attitude of respect. But it was OK to enjoy those encounters and also the fellowship of colleagues. We helped each other out, and we did it with spirit and camaraderie.

Not anymore.

All we read about now is how doctors are burned out, stressed, depressed. We battle with electronic records, hospital administrators, clipboard carriers, third-party payers, the government and just about everyone else.

What happened to the fun? It's all about the money.

David Shaywitz in Forbes: "The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective."

He added: "Many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience."

I believe what Shaywitz said is true. Can anything be done or is it hopeless?

Follow-up: Meaningful Use Stage 3 is coming

Yesterday, I posted "Meaningful Use Stage 3 Is Coming: Should Be Fun" which discussed some onerous new rules that Stage 3 will impose including this one:

More than 25% of patients seen by an eligible professional (EP) or discharged from a hospital or emergency department (ED) must "actively engage" with their electronic health records (EHRs).

I said that in my experience most of the patients I took care of would have been unlikely to engage their EHRs and expressed concern that physicians would be penalized for their patients not reaching the 25% threshold.

A reader commented that the VA has had a patient portal called the Blue Button since 2010. He pointed out that in May of 2012, more than 500,000 unique patients had accessed their EMR. He meant this as a rebuttal to my opinion about the potential level of engagement.

However, it turns out that in 2012 over 6.3 million patients were treated by the VA system.  [See page 4 of this link.] If you divide 1 million by 6.3 million, you get 15.9%.

It seems like they have quite a way to go to get to 25%

I rest my case.

Are we on our way to third-world medicine?

In a post last week, I discussed why elderly patients don't get out of bed and walk when hospitalized. I wrote that a major reason that staff does not have time to walk patients is that they are too busy documenting useless checkboxes on the electronic medical record.

The New York Times article about the negative effects of bed rest on the elderly which led me to comment stated that "hospital nurses seemed grateful" when the author offered to walk her father. She also mentioned that she had to supply a walker, robe and slippers.

My next question is "Could this be the first step toward third-world medicine?" [Pun intended.]

We've all heard stories about how in certain countries, families must provide hospitalized patients with bedding, food and basic hygiene.

A recent article about a family's experiences with a relative who had surgery in Cuba illustrates the point.

The author wrote, "Prior to the trip [to Cuba], my wife wisely purchased towels and two sets of sheets and pillowcases for her mother’s use during her hospital stay. In addition, we packed several aerosol cans of spray disinfectant, special soap used for sponge baths and a room air-freshener that plugs into to an electrical outlet.

Regarding the postoperative stay, he says, "The next two days for me was [sic] spent shuttling food and juice to the hospital for my wife and her mother."

"At the end of the third day, my mother-in-law had arranged to trade her used sheets and towels for a week’s supply of Vicodin and Percocet with another MD on staff."

Is this where we are headed?

First, families start walking the patients because the nurses are "too busy" to do it.

Next will we have to bring linens and food and barter for medications?

Maybe it won't be that difficult. The way it is now, a family member should be present at the bedside of any relative who might be sedated or confused to help prevent some of the thousands of medical errors that occur each day.

If someone is going to be sitting there on watch anyway, he might as well bring food and sheets and get the patient out of bed. Maybe we could enlist the relative to do some of the charting in the electronic medical record too.

Of course, there are always loose ends.

What happens if the patient has no relatives who are free to spend days in the hospital caring for the him or has no family at all?

Where is all that money that hospitals are making by overcharging everyone going?

Hospitalized elderly patients spend too much time in bed. Why?

43 minutes—that’s the median length of time a hospitalized elderly patient spends standing or walking daily, reports a New York Times story. Not only that, the study from which the 43 minutes number came also noted that elderly spend 83% of their hospitalizations lying in bed.

The paper was a study of the activity of elderly patients who spent about 6 hours per day on their feet before they were admitted. Failure to walk around in the hospital had significant negative effects on the activity levels of patients for as long as two years after discharge from the hospital.

That brings up the question, why didn't they walk more?

According to the Times, "Even when physicians recognize the hazards of immobility and write orders that include ambulation, overworked staff can’t always find the time."

Ah, the real question is, why can't they find the time?

I'll tell you why. They are too busy documenting unnecessary garbage in the electronic medical record (EMR).

Here's an example of what I am referring too. This was tweeted on June 2, 2013:

"@Apathetic_Cynic: Check da box @docgrumpy: Intubated, GCS of 3 x 2 weeks. Today someone documented counseling pt to quit smoking" 

If you don't speak Twitter, here's the translation:

A doctor who calls himself Apathetic Cynic retweeted what a another doctor (docgrumpy) wrote which said that a comatose patient who was completely unresponsive for two weeks in an ICU was documented to have received smoking cessation counseling.

Of course, the patient could not possibly have understood such counseling. It likely never happened. But the box in the EMR was properly checked, and all is right with the bean counters.

A paper from the Journal of General Internal Medicine found that interns spent 12% of their time with pts. That's 8 minutes per hour. "Computer use occupied 40% of interns' time," much of it spent documenting.

Ask any nurse, and he will tell you that the EMR demands ever-increasing amounts of documentation such that the documentation itself is now the endpoint. On hospital I am familiar with has a 7-page nursing assessment section that must be completed for any admitted patient.

Here are the sections that need to be filled out.

Cognition, verbalization, hearing, vision, educational barriers, pain assessment, restraint information, health history, advance directive, alcohol and drug use history, smoking history, diabetes mellitus, discharge planning (self-management of health, latex allergy screening, nutrition assessment, room service appropriate, urinary elimination habits , bowel elimination habits, activities of daily living/mobility, fall risk assessment, legal contact information, living situation and primary care giver, abuse, opt out/visitor restriction, suicide assessment, psycho-social concerns, spiritual needs, allergies, vital signs, height/weight, respiratory, cardiovascular, peripheral vascular, venous access, tubes and drains, neuromuscular, skin-Braden scale, skin assessment, skin co-morbidities, HEENT, gastrointestinal.

How long do you suppose that takes? There is a fair amount of redundancy too. For example, nutritional assessment will be done by the nutritionist. A complete history and physical should be done by the physician (or maybe not, because she has a lot of documenting to do too). Discharge planning is done by case managers and social workers. Contact information is obtained by the admitting office.

And guess what? A number of these nursing assessments must be documented every shift.

Now do you wonder why the staff doesn't have time to get  the patients up and walking?

Electronic charting, tracking and malpractice lawsuits

A recent article on amednews.com called "Medical charting errors can drive patient liability suits" led with a case involving a bad outcome after coronary artery bypass surgery. The plaintiff's attorney alleged that the doctors did not review the patient's lab results or x-rays because they did not specifically say so in the medical record.

The article quoted a defense attorney who said, "By the time [the doctors] are deposed, it's three years later and they say, 'I'm sure I looked at that,' but there's no charting to back it up.” 

Unless there is something very unusual about the electronic medical record (EMR) used by the doctors in that case, there should be a very easy way to determine if they viewed the results in question.

A feature of every EMR that I am aware of is that each time a chart is accessed, the EMR records who accessed the record, where they accessed the record from, what they looked at and for how long they stayed on a page down to the second. It is like an electronic fingerprint with time included.

When I was a surgical department chairman, I had many opportunities to see how this worked. 

For example, I was asked to review a situation in which a resident failed to call for help with a patient who was crashing in the ICU. An arterial blood gas showing severe metabolic acidosis was not acted upon on a timely way. The resident said that the nurse did not report the critical blood gas result to him after the lab phoned it to her. This could not be verified, but the EMR showed that he had seen the result some 30 minutes before calling his senior resident.

Another case centered on an allegation by a gynecologist that a consultant surgeon failed to respond promptly to a call to assist with a bleeding patient in the operating room. The EMR revealed that four days after the case, the gynecologist had altered her operative dictation to make it appear that she had called for the consultation much earlier in the course of the surgery than what actually had occurred.

A surgical resident looked at a chart of a patient who did not have a surgical problem and was not on his service. She denied having accessed the record. When it was reviewed, the EMR showed that she had looked at 9 separate sections of the chart and had spent more than 10 minutes doing so.

As is true of many reports about malpractice trials, important details about the heart surgery patient's case are lacking. But surely the defense attorneys must have known that the EMR could be searched to see if and when the doctors in question looked at certain portions of the chart.

If all medical, nursing and ancillary staff members are not aware of the tracking features of EMRs, they should be. This is the same type of tracking that catches unauthorized personnel who peek at the chart of a celebrity or other prominent patient in the hospital. 

Note the example of the recent Boston Marathon bomber who was hospitalized. Staff who were not involved in treating him were repeatedly warned not access his EMR. 

Consider yourselves informed. Big brother is watching.

Dictations can be tricky

I was a surgical residency program director for many years. Not long before I left medical education, I had to stop allowing residents to dictate cases they did. It began to take me longer to proofread and correct their dictation than the time it would have taken for me to dictate them myself.

Here are two examples. The first is from the dictation of an open cholecystectomy.

The next one is the actual dictation of a tracheostomy in its entirety. Parts that are inaccurate and/or incomprehensible are underlined in red. 

I think I was correct in my decision to take over the dictating duties, don't you?

EMR Follies, Part 2

The other day I posted a story about one of the pitfalls of the Electronic Medical Record (EMR). Here are a few more.

1. In some versions of the EMR it is very easy to copy and paste. This leads to the creation of duplicate progress notes such as the following passages which were buried in a pair of nearly identical 500+ word notes:

03/09/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”
03/10/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”

2. The ability to copy and paste coupled with the ease of dictation results in voluminous notes. As you may know, coding (directly linked to reimbursement) for visits is based on the extent of the care given. “If it’s not documented, it didn’t happen,” goes the saying. But now we have the inverse. It is so easy to document that notes are easily puffed up to “document” extensive encounters with every patient.

3. Because they are so long, they are difficult to read and the black-on-white appearance of the words on so many screens causes the reader to skim over most of the note and go straight to the plan or recommendations.

4. For privacy reasons, most of these programs shut down if one does not touch the keyboard or mouse within a minute or two. This means if one gets a phone call or other distraction, one often has to log in again. Again for privacy reasons, passwords must be changed frequently. I am unaware of massive attempts by hackers to access medical records. Most of the time they really aren’t that interesting.

5. Nurses’ notes have become very easy to write thanks to pop-up windows. In addition, regulatory agencies have mandated “documentation” of multiple nursing interventions and screens (likelihood of falling, skin condition, pain assessment, nutrition, etc, etc). Not only is the nursing record unreadable due to its size, the zeal to document has taken the nurse away from the bedside. They are so busy documenting that they have no time for patient care.

6. This is analogous to the lament from patients that their doctor no longer talks to them but rather sits facing the computer monitor so he can document his comprehensive visit.

7. Reviewing a record for assessment of quality of care is almost impossible as it is no longer possible to “leaf through” a medical record. And if the record is printed, one gets a two-foot high pile of paper with every iota of information about the patient’s admission. And it’s all black text on white paper so important items cannot be distinguished from garbage.

Yes, I know I have omitted references to the good features of the EMR, (instant access—while sometimes cumbersome—to old records, legibility, etc). But it is my blog after all.

EMR Follies

Soon I will write a more definitive blog on the shortcomings (and there are many) of the electronic medical record (EMR). I am working at my clinical job this weekend. I couldn’t resist sharing this with you. At my hospital, the dictation system is great. Dictations of the history and physical (H&P) examination usually appear in the EMR within an hour or so of their dictation. When the physician logs in, he sees a list of documents to be verified with his electronic signature.

I was asked to consult on a patient on the internal medicine service today. Below is a screen capture of the list of her medications in the dictated H&P. The H&P had been verified by the doctor who dictated it. If you can overlook the fact that the patient was on 22 different meds (not a record for patient on the medicine service, by the way), check out #13 on the list.


Yes, it is the wonder drug _ _ _ _ _. So what happened? For whatever reason, the doctor obviously did not read his lengthy H&P. (Remember, it was a medical patient.) He signed off on it without a glance. Should I ignore this and go ahead with surgery on the patient? What if the drug was Coumadin, an anticoagulant, which is often given in a dose of 5 mg?

What's that you say? Ask the patient? Well, like many patients, she has no idea what medications she is taking. The list was brought in by a relative and is nowhere to be found. Ask the doctor who did the H&P? No, sorry. It's a hospitalist service and she was admitted two days ago. The doctor is off this weekend. Via a blood test, I was able to determine that it was not Coumadin.

Stay tuned for more examples of EMR follies.