Cut and Paste Medicine

October 29, 2011

I saw it begin to happen in the ’90′s.  Residents came to rounds with their daily notes produced on a word processor.  The notes were impressive.  Legible, lengthy and meticulously detailed at first glance.

Then I started to notice a pattern.  The impressive notes began to look very much alike.  The thorough exam varied little from patient to patient.   And problems that occurred on previous days seemed to persist in the medical record, even when it had resolved.  In some cases the previous day’s note was printed only to have one or two additional elements added by hand.  It was never really clear what was worse: the lack of effort or the illegible writing.

Our electronic health records (EHR) offer similar options.  We can smart text our way to clinical efficiency.  Some doctors have entire impressions and elements of the history pre-generated for common conditions.  These are advertised features of the most common EHRs.  Technology can make us look more thorough than we really are.

The adoption of automated documentation carries the risk that we make all patients look alike.  The drive for thorough documentation comes with the failure to convey what’s happening with a patient.  In some cases this is a consequence of laziness.  Other times it’s a technique for survival in a regulated world that asks more and more of a doctor’s bandwidth.

Medical documentation should reflect the unique characteristics of every patient’s story.  As physicians it’s important to avoid the empty clinical narrative that technology makes easy.  As educators it’s our responsibility to medical students and residents to see to it that this transition to EHR brings with it the clear thinking and individualized documentation that was necessary with pen and ink.

For another interesting post on the subject read Jaan Sidorov over at KevinMD.


{ 15 comments }

peter elias October 29, 2011 at 4:36 pm

McLuhan’s comment that the medium is the message applies here. I agree with your nicely articulated plaint. For me, stories lie at the heart of clinical practice. Each patient and each care adventure transcends the science involved only if the story is allowed to be told, processed, and leveraged.

I love snowstorms, because the cancellations provide or long appointments and quality conversation.

It’s not just medicine, of course. Almost all media have seen the trend toward shorter, quicker, slicker and sadly shallower content. The 10 page letters I wrote over the course of a week and exchanged with my parents in the 60s while studying abroad are now replaced with one line tweets. They saved my letters. I doubt many recipients save tweets.

Thanks for the nice column. I’ll mention it on my blog: http:petereliasmd.com

Peter

DrV October 29, 2011 at 8:19 pm

Beautiful. Hard to top that. Thank you.

And social media needs a McLuhan.

peter elias October 29, 2011 at 4:37 pm
Linda Pourmassina, MD October 29, 2011 at 5:08 pm

Cut-and-paste medicine, especially the type that auto-populates the history portion of notes, gets in the way of really understanding of our patients. The patient’s story is so important. It should be honored and reflected in our notes. Subtle, unique details can not only expand or hone our differential, but they also enable us to efficiently reference or recall a patient. To date, I have refused to cut and paste histories, though I am sure it would be easier. I worry that this practice neglects another important trait of doctoring – treating each patient as an individual.

Cutting and pasting the assessment portion of a note seems to bypass a certain thought process that used to occur when the brain connected to the hand which was connected to the pen which was connected to the paper. Technology can help us cut corners, be more efficient, and provide some safeguards (programs that assess for medication interactions, for example). But, as much of our work is still cognitive and EHRs cannot do the thinking for us (yet), we need to continue to think safely and be more diligent than ever.

Thanks for this post, Brian.

DrV October 29, 2011 at 8:24 pm

I’m particularly bothered by the lack of synthesis that happens under the impression. This is where we should understand the thinking of the treating physician. This needs close attention in training although I’m not sure that those who conduct training are necessarily up to the job.

The impression and clinical thinking is a post for another day.

Dr. Wes October 29, 2011 at 6:01 pm

Bryan-

For clinically busy physicians, cut and paste is a boon to “efficient” use of the EMR to assure proper E&M coding and collections. Sadly, it has very little to do with providing sound care to patients. In fact, finding the tidbit of new information in each new note is getting harder and harder as everyone puts the same “requirements” in each note. Yet they must, lest they not get paid.

So when CMS removes their ridiculous documentation requirements, then maybe we’ll see less of this practice and more of the Utopian notes you desire. ‘Til then, better get used to it.

DrV October 29, 2011 at 8:31 pm

Welcome to my fantasy world, Wes. Let me get you some Kool-Aid.

And agree on all counts. Much of this is driven by mandated documentation which seems to snowball.

Nick November 1, 2011 at 1:55 pm

Agreed. I think we’ve got to make peace with the realities of documentation and reimbursement requirements, and just develop better filters to hide the cruft when we search patients’ charts. More thoughts at: http://blogborygmi.blogspot.com/2011/11/ehr-cutting-pasting-in-perspective.html

WarmSocks October 29, 2011 at 6:06 pm

Erroneous cut-and-paste will stop when patients start requesting copies of chart notes and see all the inaccurate things that were pasted into their medical record. If doctors (or their support staff) have to take extra time to fix the errors in the record, or insurance declares fraud when things are billed but not done, cut-and-paste will no longer be deemed a time-saver.

Chris Johnson October 29, 2011 at 9:27 pm

This is why I never use smart text. I found it mind-numbing. So now, although I do use a progress note template (or H&P or consult) to type my notes into the EMR, I type the words each day, including the lab values. I found that if I didn’t, I didn’t see things staring me right in the face. If you type out that sodium of 122 you’re reading on the screen, it tends to reach out and grab you.

Sam Blackman October 30, 2011 at 7:16 pm

There was a great piece on this in JAMA a number of years back called “Copy-and-Paste”: http://jama.ama-assn.org/content/295/20/2335.extract

It was very funny, in a subtle way.

DrV November 1, 2011 at 8:37 am

Thanks, Sam. I’ve seen this since writing it. Missed it somehow.

Dr Aniruddha Malpani, MD October 31, 2011 at 7:48 am

Doctors are at least as smart as healthcare administrators. They learn to game the system very quickly !

Mark Morgan, MD November 6, 2011 at 1:44 am

I think physicians using these tools manage to wrangle boilerplate into a truthful representation of the visit. Legally and realistically, that’s the assumption we all have to make.

I’m happy we’ve begun to move beyond an era when one Art of Medicine was penmanship, lots and lots of penmanship. Ughh! Lots and lots of poor, hard-to-read penmanship that was and will continue to be ignored for all time (even if it was saved electronically).

Art of Medicine that is valuable hides in the differences between cases and what lies outside the boilerplate. If we can achieve veracity in the redundant information (the comprehensive ROS or whatever history or examination element that was a rote exercise for the episode) then we are taking ourselves to the Art faster and we will have more time for the Art.

Dawn Ebach November 8, 2011 at 6:26 pm

Cut and paste has really frustrated me for awhile when it comes to residents notes. For example d3/10 of antibiotic for 3 days in a row. However, I find the use of EMRs where the note is a bunch of check marks even more irksome. A bunch of yes and nos hardly tell a story and only reminds me of surly teenagers who can’t seem to say anything more!

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