The Documentation Fallacy

"If it isn't documented it didn't happen!"

That is the documentation fallacy in a nutshell.  At first it seems like an obvious truth.  A silence falls on the crowd, everyone looks at the floor, and we move on.  Fallacy accepted.  I have seen the scene play out a thousand times, scripted by unimaginative attendings.  It is also scripted by administrators and attorneys who have a lot more invested in the process.  I can still recall a malpractice scenario in one of my throw away journals in residency.  A malpractice attorney walks in to depose an internist.  The patient in question is a diabetic who has lost his right leg to gangrene.  The attorney is questioning the doctor about wound care provided to the patient.

Attorney:  "Reading from your notes doctor what leg did you treat when you saw the patient."
MD:  "I treated the patient's left leg."
Attorney:  "Are you absolutely sure.  Did you document treatment of the left leg?"
MD:  "Yes I am sure - you can read it right here in the notes."

Case closed.  The attorney was hoping for no right or left designation in the original chart and an easy malpractice settlement.

This is a powerful vignette about why documentation needs to occur and how it can be protective in terms of risk management and avoiding malpractice litigation, but is it really that simple?  To take a look at the fallacious aspects of that statement requires an examination of what I call the period of excessive and useless documentation.  I will provide a couple of anchor points.

The first is my neurosurgery rotation in both my third and fourth years in medical school.  I was on a very busy neurosurgical service at Froedtert Memorial Hospital in the early 1980s. The hospital was brand new and there was a question of what services would be located there,  Neurosurgery and Neurology occupied an entire floor.  The team consisted of two senior neurosurgery residents, two general surgery interns, a general intern, and a medical student.  The residents spent a great deal of time in the operating room with the staff neurosurgeons and efficiency was critical to the entire operation.  We had to round on 20-30 intensive care unit (ICU) and general beds and discuss it with the residents by 10AM in a conference room.  All of the daily documentation had to be done by that time, because all day and night long there were calls to the emergency department (ED) and the ICU.  The ED consults involved a brief walk over to Milwaukee County Medical Center - the next building to the east (in those days) on the grounds.

A standard hand written progress note on a non-ICU patient on this service in those days was "Afebrile, VSS, wound looks good - no signs of infection."  We of course checked all of the wounds, labs, vital signs and did other focal exams as necessary.

Flash forward to just before 911.  I am sitting in a conference room with colleagues from my multispecialty group. We are listening to a presentation by a billing and coding specialist on all of the bullet points that are necessary to complete a note.  The examples shown are notes of about 300 to 500 words in length.  We are told that unless all of the bullet points are ticked off or commented on we could be prosecuted for billing fraud.  Not only that, but if a "fraudulent" bill goes out in the mail we could be prosecuted for mail fraud and possibly conspiracy under the anti-racketeering RICO statutes.  There had been several high profile prosecutions of health care organizations and individual practitioners with FBI involvement at the time.  We were told that our healthcare organization at the time now had an internal compliance bureau that would audit all of our notes to make sure the bullet points were checked of to avoid the large multimillion dollar fines and of course jail time.  A racketeering charge could result in federal prison time.  Clinical notes used by physicians had suddenly been usurped for an entirely different purpose - legal leverage by government agencies and businesses.  That leverage is used to deny payment, ration services, and generally exhaust physicians so that they don't have time to fight these tactics.

Flash forward a third time.  The year is 2009.  I am now sitting in a large multispecialty committee meeting on documentation and hospital oversight.  We are given several hospital progress notes that are 16-18 pages long.  That is a single progress note from one day that is 18 pages long.  We are told that several physicians are routinely compiling notes this long.  I say compiling because the electronic health record being used allows physicians to rapidly pull data in to the note from many places in the chart to rapidly build the note.  It also allows physicians to build their own custom templates and phrases to add to the note.  The note looks terrible because it is a mix of fonts and spacing - a great example of the primitive state of the electronic health record (EHR) that persists right through to today.  All of the notes are designed to meet billing criteria determined by the federal government rather than demonstrate contact with an intelligent life form.  EHRs - even fabulously expensive ones seldom produce a coherent, readable document and may even spread that incoherence over a ream of paper if you ask for the records.

That has been the progression of excessive and useless documentation as I have experienced it in my career.        

But here's the reality.  If I spend 60 minutes with a patient and don't tick off some bullet points that don't really apply to what I am doing - don't think for a minute that "if it isn't documented it didn't happen."  Try that experiment yourself.  Sit down and have a one hour conversation with a friend and then decide how you are going to document what happened.  I have been a student of Communication Theory since I read the first paper by Shannon And Weaver and and have never seen an adequate discussion of optimal information transfer between two people or how it should be recorded.  The only way to get to the content would be a verbatim recording or transcript and that would contain a lot more information than is typically contained in one of my notes.  I could try to approximate that by writing an 18 page note but let's also assume that like most doctors you have 5 - 10 minutes to document something.  It is obvious the vast majority of communication that happens will not be documented.  In psychiatry there is the added issue of people who say: "I want to talk about this but I don't want you to put it in the medical record."  That information is generally very sensitive and in some cases is considered privileged psychotherapy information separate from the medical record and unavailable to other providers.  It is still a question of what gets documented, but what is documented is still information depleted relative to the original conversation.

Now - let's consider what the US government and by default most insurance companies want physicians to do.  For a standard outpatient assessment of varying intensities there are a number of  "bullet points" required to meet billing criteria.  That means that a certain number of them need to be checked off.  If they are - the bill can be submitted.  There are huge quality problems with that approach.  I previously posted the questions that I ask about sleep to practically all of the patients I see for evaluation whether they have a primary sleep compliant or not.  On a lot of outpatient forms a sleep complaint is a single check box.  On the most widely used screening tool by managed care organizations for their collaborative care approach - the single question is:  3. Trouble falling or staying asleep, or sleeping too much.  The choices are "not at all", "several days", "more than half of the days", and "nearly every day".

Think about that sleep screening question for a moment.  It is important because a lot of managed care clinics have it right in their electronic health record.  The patient may check it off on a tablet and it is imported into their record  on an ongoing basis.  After all of that whiz bang technology what do we know?  We know that the patient has one of three sleep problems (even a physician with a paper form could circle one and immediately upgrade the quality of information).  And we know approximately how many days per week the problem exists.  Go back to my sleep questions and compare the information content.  And yet these managed care settings are highly likely to have somebody sitting in a meeting, looking slightly annoyed and endlessly voicing the Documentation Fallacy and the importance of these checklists.  In the case of the questionnaire and many if not all template approaches - it was documented and you don't really know what happened.

In addition to poor quality, low information content, reduced direct patient contact time, and excessive time taken to generate - notes that are designed for billing and administrative purposes are also a drain on the environment. On current hospital medical records systems  they take up disc space.  Not as much as imaging data, but when you look at the graphic at the top of this page - all of these low quality, information poor notes are piling up by the tens of thousands every day.  Contrary to the traditional use - for relevant historical data and to learn what previous physicians were thinking - we currently have exabytes of data that is so information poor it is generally never seen again.  It was viewed once by a billing and coding specialist and once by an insurance company and then it is banished to one of the storage arrays that are running 24/7 - never to be read again.  More importantly - never to be read by a doctor again.  Thirty years of stakeholder meetings got us here in the first place.  If physicians cannot finally assert themselves - the profession will continue to do this scutwork till the end of time.

So when you hear the Documentation Fallacy uttered - feel free  to gasp and roll your eyes.    



George Dawson, MD, DFAPA



Supplementary 1:

The American College of Physicians is the only physician professional organization to take a stand on the unnecessary administrative burden placed on physician in the United States.  That is a very recent position and a departure from the usual positions taken by professional organizations that physicians should be prepared to fall into lock step and do whatever documentation that governments or insurance companies or electronic health record manufacturers want them to do.  You can read Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians at this link.  It is obviously a politically correct approach that is basically a call to stakeholders.  Stakeholders with a conflict of interest like looking for any excuse to not pay or pay less will not be motivated to change 30 years of what amounts to physician exploitation.

A quote from that position paper:

"Related work by Sinsky and colleagues (46), also discussed earlier, focused on how physician time is allocated in ambulatory care and found that physicians spent 49.2% of their time on EHR and desk work, versus 33.1% on direct clinical face time with patients and staff."


Supplementary 2:

I posted this a while ago on some additional documentation that psychiatrists were supposed to do about quality to avoid payment penalties.  If you follow the link Physician Quality Reporting System you will be taken to the APA web site.  Note in the right column a heading called  View the list of 2017 MIPS Individual Quality Measures.  A click on that link leads to a long list of various "quality measures" and how to report them.

Supplementary 3:  

I have not had time to go through all of the documents on the APA web site but a number of them are written by the NCQA and NQF.  Neither of these organizations would be considered as quality initiatives by physicians.  In my opinion, the NCQA started as a managed care heavy organization and I am sure any objective analysis of the outcome measures would illustrate that.  The NQF started by political mandate and I am sure carries forward the usual political biases of all of the self declared health care experts sitting in Congress.  So how do they end up as further reasons for more documentation by physicians who are cranking out so much paperwork that they have no time to see patients?  And how do they end up on the web page of a physician professional organization?

A telling statistic from the NQF web site: "30% of NQF endorsed measures are developed my medical specialty societies."  Where do the rest come from?

Attribution:

Graphic at the top is from Shutterstock per their standard licensing agreement.  Credit is
"Stack of the old paper documents in the archive." by Loginova Elena.

At The Edge Of My Notes........

For all of my professional life I have done my original notes the same way.  There is usually some kind of form anywhere from 4 to 8 pages long.  I list a few things on it, but for the majority of the interview I flip it over to the blank side and write free hand.  I have to write fast and my handwriting is bad - no cursive, just a crude combination of capitals, lowercase, and symbols that only I know the meaning of.  At some point back in the 1990s when I was studying medical decision making and reading how experts move between chunks of data - I started to draw out chunks of data on the paper.  Circles, squares, timelines, triangles with various connectors to show relationships.  There is a rhythm to it depending on how fast the person I am interviewing is talking and how much information is being discussed.  I have as much time if the person is mostly silent as I do if the person is rambling and including far too many details.  When you write that much, the feel of the pen in your hand and how it moves over the paper can be extremely important.  I only use Pilot G-2 pens.  I alternate between the 1.0 and 0.7 mm tips in black, red, and blue.  The red and blue are only for highlighting and editing.  Gel ink has a perfect feel as your hand is gliding across the page but it is messy.  At the end of a busy day my hands are smeared with ink.  After writing it all down the next step is dictation.  I have to translate all of my non-linear scratchings into a very linear and coherent report with a formulation, various diagnoses, and recommendations for a treatment plan.

The diagram at the top of this post is an example of one collection of words and symbols that are in the corner of one page of my notes.  It took me about 38 seconds to draw it, in pieces as I heard the various elements being described.  The HR in the middle of the circle here is heart rate.  Arrows in the up direction mean increasing and the down direction is decreasing.  I don't like to see elevated heart rates.  I have seen too many middle aged stimulant users with cardiomyopathy and had too many conversations with Cardiologists about whether or not sinus tachycardia is a benign finding or not.  I have obsessed far too long about who I can treat with medications based on their heart rate being greater than 100 beats per minute (bpm).  I am not reassured by the latest review in UpToDate on idiopathic sinus tachycardia and benign outcomes (1).  I doubt that the people in those studies are the same people I am seeing on stimulants, antidepressants, antipsychotics, street drugs, alcohol, caffeine and plenty of tobacco.  In the middle of trying to construct an impossible timeline of insomnia, anxiety, depression, childhood adversity, adult psychological trauma and multiple medical problems I am drawn temporarily to the little heart rate circle and I am trying to figure it out.  It all starts with THC and proceeds clockwise.

I have been impressed by the number of daily cannabis smokers who at some point notice that they are getting anxious and panicky from it.  Despite all of the hype by the pro-marijuana contingent, most people can relate to augmented heart rate and increased intensity of heart beats when smoking marijuana.  It happens when THC drops the blood pressure and your heart acts reflexively.  That is typically ignored by young smokers, unless they have had a panic attack.  In that case, it feels like they are starting to have a panic attack and they start to feel very uneasy.  In many cases they start to develop panic attacks every time they smoke.  That often leads to them discontinuing the use of cannabis, since panic attacks are very unpleasant experiences.  So THC can lead to increased heart rate.

Caffeine is ubiquitous in American society.  It affects too many dimensions in psychiatry to not be asked about.  The answers are often shocking.  With the availability of espresso in most places, I often get an estimate in shots of espresso per day.  For filtered coffee fans, I learned to ask the question: "If you are home alone - do you ever drink the whole pot of coffee by yourself?"  And then there are the additional estimates of mg caffeine in terms of black tea, green tea, and every form of esoteric energy drink.  I can usually track down the mg caffeine using some online resource.  The DSM-5 suggests that caffeine consumption "...well in excess of 250 mg" can be a problem.  I find myself routinely advising people on how to get their caffeine consumption down to less than 1,000 mg/day and use it in the mornings - as a starting point.  In some cases, I am told that people are drinking beverages that combine alcohol, caffeine, and some other questionable compounds.  The pharmacokinetics of caffeine are important.  Most people know what happens if they get wired or precipitate a panic attack with a triple shot of espresso, but they don't know what can happen to sleep with steady state levels of caffeine.

Exercise can be an important source of accelerated heart rate.  In most cases it is just rushing to get the vital signs done, but there are  other important causes.  There are the deconditioned folks who decide that they are going to turn over a completely new leaf by starting to exercise vigorously.  I may be seeing them a day after and exercise session and they still have an elevated heart rate.  There are the conditioned folks who still overdo it.  That has led me to ask people if they are wearing a heart rate monitor and what their goals are.  Some of the responses are shocking.  I have had many people tell me that they are running their heart rate well beyond their age-determined maximal heart rate for a long time.  I have never had a person tell me why that might not be a good idea.  It is an opportunity to educate people on how to not overdo it and either maintain conditioning or start some basic conditioning.  It also leads me to consider some people who may have undiagnosed intrinsic heart disease and what further evaluations need to be done.

Medications can be an important direct or indirect cause of tachycardia.  As a group, older medications like tricyclic antidepressants and anticholinergics were more reliable causes.  Of current day medications stimulants are probably the most important cause of increased heart rate.  In general stimulants increase heart rate 3 - 10 beats per minute (bpm) and increase blood pressure by 1.5-14 points.  More recent generation medications are rarer causes, but it is always important to look for that one person in a hundred or a thousand.  Is that really an idiosyncratic reaction or is it a sign of something worse like neuroleptic malignant syndrome or serotonin syndrome?  In my current line of work withdrawal from medications is a more important cause of tachycardia than a direct effect of the medication itself.  Coming off of benzodiazepines, barbiturates, and clonidine are important causes. Tachycardia and various rare cardiovascular effects are still listed in most package inserts and that is an important reason for monitoring vital signs and electrocardiograms.

A lot of people seem to think that anxiety is a potent cause of tachycardia.  That may be true for panic attacks but on an ongoing basis I have found that anger is much more likely to elevate pulse and blood pressure.  I have seen persistent tachycardia in the 120-130 bpm range due to anger.  I have seen patients started on antihypertensives because of this and I think it is a good idea as long as there is a plan to decrease and stop the medication when the anger resolves.  I always tell my patients that an explanation (a white coat, life stressors, too much caffeine, etc) only gets you so far.  If you are still running a high pulse and blood pressure at home it should probably be treated and closely followed.  I personally don't like to see people running systolic blood pressures in excess of 150, diastolics greater than 95, or pulses greater than 100 while they wait for "lifestyle changes" to take effect, but I know for a fact that there are primary care physicians out there who disagree with me.

Anxiety especially the persistently panicky person can have elevated pulses.  Many of these folks look thin and hypermetabolic.  They are routinely checked for hyperthyroidism and they are always negative.  I listened to a NASA physician lecture about a subgroup of patients with this body habitus many years ago.  He said that thin people with arachnodactyly can be bothered by anxiety and panic and the best treatment was moderate levels of exercise like walking rather than medication.  He defined the condition as anyone who can grasp their wrist with their thumb and middle finger and notice that they overlap at least to the most distal joint of the middle finger.

Epidemiological studies show that people who are sleep deprived or have their circadian rhythm disrupted have poorer cardiovascular health.  There are many people who develop tachycardia in this setting.  Sleep disordered breathing disorders can also be an important cause of tachycardia in the daytime.  These folks often have an associated problem like undiagnosed atrial fibrillation.  Many of the commercial automatic blood pressure machines do not detect irregular pulses, so it is important to check pulses and pulse deficits in the office.  All psychiatrists should have access to lab facilities where electrocardiograms can be run and referral facilities to do the necessary testing and management of the identified conditions.

All of that and more flows from a little 2 x 2 inch drawing on one of my intake notes.  I would have thought by now that some enterprising software developer would have come up with a system of icons that I could just point to and grow on a computer tablet, but so far it seems that electronic health record developers really are not designing software with physicians in mind.  They would rather have us enter full text or more commonly very choppy phrase based notes than using icon based full information approaches.  My little HR circle contains a lot of information and the only way I have seen the information content estimated is by constructing all of the possible text based narratives and then measuring the amount of text.

That method has its limitations because when I (or any other physician) makes a drawing it is connected to our own unique conscious state.  There is certainly overlap with all physicians to some extent or at least the ones with an HR icon in their notes.  The overlap gets closer among those of us who are looking for arachnodactyly.      


George Dawson, MD, DLFAPA


References:

1:  Homoud MK .  Sinus tachycardia: evaluation and management.  In: UpToDate, Cheng A, Downey BC (Eds), UpToDate, Waltham, MA. accessed on March 5, 2016.

Information versus Wisdom

I saw this post on another blog today and thought it was a good title.  I end up pondering this idea almost every day.  In medicine these days we are inundated by data scientists on the one hand and administrators on the other.  The data scientists tell us how they are going to revolutionize medicine through their analysis of large data sets.  The theory is that there are patterns in the data that can be detected only with advanced computational methods.  Having gone through the spreadsheet era and seen how easy it is to prove almost any theory with a large spreadsheet, I am very skeptical of Big Data.  Just dredging through the data, looking for patterns and writing it up does not seem very rigorous to me.  It strikes me more like one of the popular TV shows where the agents are in the field but solidly connected to the computer whiz back at headquarters who is capable of pulling up any document, any floor plan, and hacking into any closed circuit TV system in order to get the information that is needed.  I don't think that science works that way.

On the administrative side, it is the worst of times.  The statistical efforts of administrators are frequently laughable attempts to legitimize the next genius idea to come down the pike.  Their mistakes in healthcare are legendary ranging from the promise of the electronic health record to the RVU based management of physicians as widget producers, all exhaustively documented with numbers.  I sat in a meeting one day that showed 95% of the physicians in the department were not "producing" enough to cover their salary.  The problem was that nobody had done the multiplication on "work RVUs".  When the appropriate multiplier was added it was a different story.  Administrators also tend to collect a lot of numbers that they think will be useful for an analysis, without thinking ahead to the data analysis and statistics.  They seem to have no idea about basic statistical analysis much less more advanced analysis like how to legitimately analyze data over time to detect real differences.  There is no better example than the state of Minnesota collecting PHQ-9 scores over time from anyone trying to treat depression in the state.  They seem to think that unconnected collections of those numbers at different points in time will have some kind of meaning. Administrators also have the habit of creating studies that confirm their vision of the world and when those studies are complete - that is all of the "proof" that is necessary.  The entire concept of managed care rests on many of those studies.

On the wisdom side of things I can think of no better example than a colleague who I said goodbye to today.  He worked with me for the past 2 1/2 years.  He is an Internist who is also an Addictionologist and is ABAM (American Board of Addiction Medicine) certified.  He has been a physician since the early days of the HIV/AIDS epidemic and treating those patients was a significant part of his early practice.  He has an encyclopedic knowledge of the care of those patients and how it has evolved as well as being an excellent Internist.  He is interested in psychiatry and can talk in psychoanalytic terms.  He is also an expert in LGBT issues and can speak with authority on that subject.  I certainly did not want to see him go, but for the purposes of this post, I can think of no better example of wisdom that comes with medical practice.  He could be consulted on any number of complex problems in his areas of expertise and provide a very well thought out answer based not so much on information, but on what works and what the potential complications are.  Any physician can tell you that these are the folks you want to work with.  When I think about data mining approaches toward these areas of knowledge, I think about the 31 page document that is available online that looks at the issue of medication interactions of psychotropic and HIV medications.  It is a compulsively great document, but lacks the wisdom to help you pick the best therapy for a manic patient on tenofovir.

Granted my position is a thoroughly biased one.   I make no apologies for wanting to work with physicians who have the greatest technical expertise and know how to apply it.  I don't mean people who can recite facts or even algorithms.  I mean the people who know all of that and can look at the patient with the most complicated medical situation and still come up with a plan of action and how that patient must be closely monitored.  They also know when it is better to do nothing at all and that is a difficult skill to acquire.  Practically everyone leaves medical school and residency with a strong treatment bias.  You are taught to be "aggressive" and that most of the treatments that you do will do some good even if there is not cure.  In clinical practice, that is far from the truth.  In psychiatry for example, you have to recognize that there are certain biological predispositions, clinical patterns, boundaries, and personalities that are the warning signs of disaster with certain treatments.

When I first started in medicine in the 1980s, the wisdom based model was still the predominate model in most clinical settings.  Now it is much less frequent and there are departments that are just looking for people to fill in the gaps.  They don't necessarily want to retain you they just want to "keep the numbers up."  They also don't want you spending a lot of time on complex cases, because the payment rates rapidly decline if you are not shuffling people in and out the door.    When the administrators start recruiting bodies based on their revenue models and Hollywood accounting,  I hope that I will always end up on the side with the wisdom, rather than a heap of useless information.

There is a lot of that going around these days.  



George Dawson, MD, DFAPA      



Supplementary 1:  I was going to jam in a section to comment on emotional and moral reasoning in view of the expected backlash to the Rosenbaum articles in the NEJM, but decided to add it here instead.  It would have strained the above essay.  It has been an interesting (and fully expected) exercise in political rhetoric.  Predictably the critical articles mischaracterize her position and ironically are at least as guilty of the fallacies that they accuse her of using.  In one case, a new fallacy is pretty much invented.  I think it is instructive to note that in these matters, logic goes out the window.  There is no pathway to a sound judgment.  It basically involves rallying the troops to see who can shout the loudest.  My self proclaimed bias above is part of the reason I am firmly on her side (but will refrain from the shouting).  For anyone who thinks like me, there is no convincing me that the appearance of conflict of interest is the same as actual conflict of interest.  There is no convincing me that free pizza and donuts will cause me to blindly prescribe a medication - probably because I have not eaten Big Pharma food since the early 1990s.  In fact, if I think of a more plausible thought experiment about how much cold hard cash it would take to pay me off to prescribe a drug, I can't come up with a figure but it would have to be absolutely stratospheric compared with the usual speaker fees that people are listed in the Sunshine Act database for.  All of that is based on the fact that I work for a living and treat real patients.  I am accountable to those patients.  If a medication does not produce real results or it causes too many side effects (like my early experience with paroxetine) it is off the Dawson formulary and I don't prescribe it again.

This is of course like arguing with Democrats and Republicans.  I know that some pro-appearance of COI=COI will strongly dislike my experience and the way my thoughts on this matter are anchored in the way I practice medicine.  That is the nature of arguing about emotional and moral reasoning in what the Institute of Medicine (IOM) describes as an ethical vacuum.  The recent editorials certainly don't prove a thing.

The usual focus of these debates also leaves out the big picture that many entire University departments (math, science, engineering) actively collaborate with industries and in many cases actively invite industry participation in order to advance those fields.  The notion that physicians are not able to do that because they have a sacred trust to patients and would be somehow compromised remains implausible to me, particularly when nearly all of the major decisions that physicians make in this country have been seriously tampered with if not controlled by managed care companies and pharmaceutical benefit managers for nearly 30 years.

That is a massive conflict of interest that nobody talks about and it affects 80% of all of the healthcare in this country.

Supplementary 2: The graphic at the top of the post is from Shutterstock.

No Information From The EHR - An Ongoing Problem

Like most physicians - I like the concept of an electronic health record (EHR).  It is just that the real EHR as it exists is a far cry from the concept.  The proponents of the current EHR,  especially those who want it mandated by legislative activity continue to brag about the savings and all of the benefits.  Any physician looking for information or an ability to enter and move information without ending up in a click fest of mouse clicks knows the reality.  Any physician looking for a note that reflects an intelligent conversation between a physician and a patient is also left wanting.  Reading the electronic or printed out version of the EHR usually results in very choppy documentation.  Lists that are the result of not very intelligent coding by EHR IT engineers, notes produced strictly to meet billing and coding bullet points, and notes produced because they could be rapidly compiled with features like smart text.

All of this can be a nightmare for a compulsive physician like myself who wants to use all of the relevant information in patient care.  My career has been treating patients with complex medical conditions who are also on complicated combinations of medications.  Many have known heart disease and take combination of medication that can adversely affect their cardiovascular status and interact with psychiatric medications that I prescribe.  All of that needs to be considered.  Since ziprasidone (Geodon) hit the market in 2001, psychiatrists have been preoccupied with the QTc interval.  The QTc interval is the electrical interval that corresponds to the contraction and relaxation of the left ventricle.  In cases where this interval is too long it predisposes the patient to ventricular arrhythmias some of which are potentially fatal.   The FDA had a warning on ziprasidone about the potential for QTc prolongation and subsequently came out with warnings about citalopram.  In the course of clinical practice, many psychiatrists had already encountered this issue with older antipsychotic medications and tricyclic antidepressants.  The FDA makes these pronouncements but gives physicians no guidance on what to do about the clinical situations.  I have a practice of looking at ECGs and any Cardiology evaluations that have been done.  That is the only way the QTc interval can be determined and even then there are various factors that can affect it.

Rather than order an ECG, I will ask whether they have already been done and get the patients consent to have them faxed to me.  That result is frequently disappointing, especially in the case of the EHR.  I will often get a series of cryptic sheets, that look like a sparsely populated medical record.  There are often no coherent notes from physicians or if they are there, they do not contain standard information that I am looking for.  I have never seen an ECG tracing contained in these stack of records.  The best I can hope for is a brief note that lists an impression like "NSR - no acute changes."  An added bonus would be an actual description of the critical intervals.  For the tracing at the top of this page it would say:  "PR interval - 164 ms; QRS duration - 100 ms; QT/QTc - 434/415 ms."  That is really all of the information I need to know.  But the most important issue with the EHR is that all of this visual information is usually lost, unless I submit a second or third request and it usually has to say "send me the ECG tracing."  The medium that purports to provide a lot of information to physicians and put it at their fingertips is a bottleneck.  By the time I see the information I need to see, it is not necessary.  I have moved on and not recommended a treatment that I could have recommended if the ECG was normal.  That practice has been reinforced by getting an ECG after the fact and realizing that not only was there a prolonged QTc interval, and it was read that way by a Cardiologist but reported as "normal" in the EHR.

I will be the first to admit that there is minimal evidence that my tight QTc surveillance has saved any lives.  But my threshold is really to prevent any complications.  I am not treating acute heart conditions.  I am trying to make sure that I don't cause any by the medications that I prescribe, by ignoring a critical drug interaction, or by not recognizing the significance of a patients physical illness and how it needs to direct the therapy that I prescribe.

That doesn't end at ECGs.  I would throw in imaging studies (CT and MRI), EEGs, and even routine labs.  If the EHR is supposed to convey the maximum information why wouldn't all of the visual information of an episode of care be included?  Why can't all of the brain imaging studies be sent along as a disk or e-mailed to me?  Why do I have to read a 200 page fax and try to reconstruct all of the lab results  in a coherent manner that are spread randomly across those pages so that I know what happened in the hospital?

The EHR as it currently exists is a tremendous burden to physicians.  It takes far too long to enter data and quality notes about care are rare.  If you happen to lack online access to the program where the record is constructed, good like trying to piece together the information that you need for clinical decision-making.  Politicians are good with ideas, but none of them seems to be aware of the real problems that exist in these systems.  Despite that lack of knowledge they continue to insist on the wide implementation of these systems and that is really a tax on physicians that is being used to subsidize the development of EHRs and fund this industry.

Hopefully that will pay off someday, but the current problems have been there for at least a decade and there are no signs that they will be going away soon..



George Dawson, MD, DFAPA