Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Saturday, January 30, 2010

One Simple Question

A patient of mine brought her father down to live with her because he was having some problems living alone. She called me in a panic to tell me he was having trouble swallowing, so I rushed over to make a house call (yes, I still make house calls) to see what needed to be done.

It turned out that he'd been having the problem for months. He'd complain (loudly) he couldn't swallow -- yet was able to speak just fine through the episode. Then it would stop as abruptly as it started and he'd be fine, eating and drinking with no problem.

With that history, it was extraordinarily unlikely that there was something seriously wrong organically. Symptoms of an esophageal tumor wouldn't come and go like that. Nothing else really bad came to mind either. Still, it deserved at least a cursory workup, even though the guy was in his 90s. The daughter even told me that she was certain her father had seen the doctor for this problem, although she couldn't remember what testing, if any, he had already had, at his previous doctor's at Geisinger.

As anyone who reads anything about health care economics knows, Geisinger is one of the large multispecialty organizations specifically mentioned as the epitome of efficiency, delivering high quality care with better outcomes at lower costs. These accomplishments are attributed both to the corporate culture of cooperation between specialists and primary care physicians, but also in large measure to the fabulous efficiencies provided by their system-wide electronic medical record system. It should be a fairly simple matter to find out if he had had either a barium swallow and/or an endoscopy to evaluate his swallowing issues. Either of those negative studies would be enough to reassure us that there wasn't anything immediately life-threatening going on.

Piece of cake! The patient signed a release. Three weeks later* I get a half-inch thick sheaf of papers printed out from Geisinger's EMR. I wade through page after page of beautifully documented outpatient visits, complete with nurses notes, medication reconciliation, exam findings; all kinds of crap. Yes, dysphagia (difficulty swallowing) is listed as a diagnosis, but I can't see any record of it having actually been addressed at any visit. I couldn't find any labs, x-rays, other imaging studies, or procedures anywhere in the records.

Hm. Seventy-five pages that didn't say jack.

Then again, there were some notes about a hospitalization. Too bad all it said was, "Hospital follow up visit." Perhaps he had had studies done in the hospital, and those records, although not included in my printout, were easily accessible to someone actually on the system.

So I picked up the phone.

Actually, I had to do it twice. The first time around, my call was dropped somewhere between the voicemail system and any actual liveware. When I called the second time, I tried a different tack. Instead of asking to talk to an actual doctor, I decided to try letting the system do its thing. After all, I just had a very simple question: has this patient had either an upper endoscopy or a barium swallow?

Guess what? She can't tell either. There's nothing written anywhere in Geisinger's much vaunted EMR about the workup of a medical problem this patient has had for the better part of a year.

Riddle me this, boys and girls: what the hell good is a medical record if you can't tell what tests a patient has already had?!? Just by way of comparison, previous studies -- or specific notations about what the patient has NOT had -- are part of my history of present illness (HPI) every time I see a patient for a new problem. Not only that, but because of the way I keep the papers filed in my chart (that's right: still paper), I can put my hands on the report of a barium swallow or endoscopy in about six seconds (and that's only because I have to be careful of sharp paper).

And this is Geisinger; one of the groups identified BY NAME as a model that the rest of us should emulate. Really? When they can't manage to answer one simple question about a patient's care?

I don't think so.

*By comparison, I usually get medical records in the mail the next day; by the end of the week at the latest.


At Sat Jan 30, 10:01:00 PM, Anonymous Anonymous said...

I periodically have difficulty swallowing. I can talk through the episode (although, I don't usually want to talk when it's happening)

Trouble has only been documented with a swallowing study 1 time ..when I was recovering from myasthenia crisis.

with MG, swallowing is often a problem, but rarely documentable (not never, just not nearly as frequently as occurance)

I have a friend with MS, same issue. Friend with Lupus, same issue ...

I'm lucky enough to have a neuro that recognizes issues even when they're not 'documentable'

At Sun Jan 31, 08:39:00 AM, Blogger #1 Dinosaur said...

Hello! Apples v. oranges, known neuromuscular diagnosis vs. previously healthy 90+ year-old. I'm talking about documenting actual investigations, not whether or not a symptom can be documented. All I wanted to know was if the studies had been done, and they couldn't even tell me that!

At Sun Jan 31, 02:36:00 PM, Anonymous mamadoc said...

Tell me again about how great EMR is. I've had this experience multiple times and it just reinforces my conviction that EMR isn't so great. My psper records are much better. And security is pretty simple, too.

At Sun Jan 31, 09:08:00 PM, Anonymous Anonymous said...

Garbage in, garbage out.

At Mon Feb 01, 08:04:00 PM, Blogger chrissoup said...

A poorly designed system will never work very well.

I am a member of a well-known HMO in California that uses EMR. Not only can any doctor in the HMO see which meds and tests have been given, so can I, but logging on to my med record.

In contrast, when I requested my mother's paper records from her non-EMR-using physician, I got a ton o' paper covered with chicken scratches.

A poorly-designed system works badly. A well-designed one can work well.

At Mon Feb 01, 08:10:00 PM, Blogger Jon said...

GIGO, definitely. See it every day at work. Model of efficiency. Right.

Even the best designed system won't work if data is not put in properly. And therein lies the problem.

At Tue Feb 02, 12:31:00 PM, Anonymous BBrashearMDFamilyDOC said...

Enjoy your blog, but I have to take issue with your straw man EMR bashing. In your example, you are asking for evidence of a test having been ordered (or not). I assume you know that it is quite difficult to prove some thing has NOT been done. If we presume we are all in the paper system, then (your point seems to be), you would have been able to get your answer immediately. I have to disagree.
With most paper charts, if the doc has ordered a test the results are easy to find. If not, then no amount of searching can give the searcher certainty that said test has NOT been ordered. (i.e. it's hard to prove a negative) You say you always document what you have or have not done in the HPI. Kudos. I don't think that is the norm, but more importantly, just because you say in your notes that a test has not been done, it does not really "prove" that test was not ordered by a specialist or another doc, or heaven forbid, maybe your memory failed you at that moment.

Secondarily, I think that you did actually get your answer, you just wanted an answer that matched how you personally like to document. When you said the staff could find no evidence of the test in their vaunted EMR, that (to me) would be enough evidence to say it has not been done. Also, you say you wanted to know if the "investigation has been documented." Asking for the results of any swallowing tests and finding none, pretty much answers your question. Not with 100% certainty, of course, but enough to tell me whether I needed to order it myself or not.
It seems that you were looking for a statement in the chart that says "test (A)" has NOT been done yet. If you need that statement listed somewhere in the EMR for every test possible, good luck finding the hard drive space for all your folks...

At Tue Feb 02, 01:48:00 PM, Blogger #1 Dinosaur said...

@BBrashear: Please don't ruin my lovely rant with, you know, logic. Reading between the lines, allow me to be appalled that Great and Mighty Geisinger had never gotten around to addressing a problem newly listed in their diagnoses that was quite bothersome to the patient. I still hold that well-maintained paper records are comparable to the vast majority of EMRs, and markedly superior to many of them.

At Tue Feb 02, 06:22:00 PM, Anonymous tom said...

I don't see this as being supportive or non-supportive of an EMR. I do see it as an indicator that even THOG may have failed to LISTEN TO THE PATIENT, "I have troujble swallowing". By the way I just read about Obama's tax plan,, I too am having difficulty swallowing

At Sat Feb 06, 03:22:00 PM, Blogger RoseAG said...

Not to defend Geisinger, I know little about them, but consider that this 90 y/o recently landed with his daughter because of problems managing everyday life.

Perhaps before he came to live with her he'd had problems communicating with his physicians. He goes for an appointment, mentions the swallowing problem, they mention a test where they stick something down your throat, he doesn't follow-on. Or he mentions a swallowing problem, but doesn't mention enough about it to get someone excited about further testing.

I think unless you were there you can't really know whether he thought it was important enough at the time to demand further treatment. I do know enough about systems like Geisinger to know that if you mention something but don't act like you think they need to do something they won't always do anything.


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