Why A Patient's Story Matters More Than A Computer Checklist
As I walk to the door of my patient's house on a dirt road outside Tuscaloosa, Ala., I step gingerly. Mrs. Edgars says that she killed a rattlesnake in her flower bed last year.
She is at the door, expecting my visit. Mr. Edgars sits on the couch, unable to recall that I am his doctor, or even that I am a doctor. But he is happy to see me nonetheless.
We chat a moment, then we move on to Mr. Edgars' arthritis. Early on in his dementia he wandered the woods. His wife was afraid he would get lost and die, although the family agreed that this was how he would want it.
Now his knee arthritis has worsened enough that it has curtailed his wanderings. I suspect that Mrs. Edgars is cutting back on his pain medicine to decrease the chance he'll wander off again.
We talk about how anxious he grows whenever she's out of his sight, and how one of his children comes to sit with him so that she can run errands. I leave carrying her parting gift, a jar of homegrown pickled okra.
Back at the office, I turn on the computer to write a note in the electronic health record, or EHR. In addition to recording the details of our visit, I must meet the new federal criteria for "meaningful use" that have been adopted by my office, with threats that I won't get paid for my work if I don't.
Under history, I enter "knee pain." Up pops a check-box menu: injury-related (surely the chronic wear on Mr. Edgars' knees as a farmer is an injury, but I don't think that's what the programmer had in mind); worsening factors (none apply, as he couldn't give his own history); relieving factors (there's no check box for a sleep-deprived wife who's purposely keeping the dose of acetaminophen low); and so on. Nothing fits, so I exit and type in "follow-up". It cedes a blank screen.
I type the Edgars' story in my own words, so different from the computerspeak generated by the check boxes.
Then I move on to the review of systems--another pop-up menu. I used to write "patient is an unreliable historian" for this section, but the computer doesn't understand that this applies to the entire review. Using a template, it generates 13 phrases, one for each body system, that says, "Positive: Other: unreliable historian."
Sometimes I wonder if it is disrespectful to a patient to say 13 times in one progress note how unreliable a historian he is, but I remember that this is great data to mine for research, so I plug on.
Next is the physical exam. The check boxes ask if the person is oriented to person, place and time. Mr. Edgars is oriented to person and place; he knows his wife and home, and he is happy nowhere else. He no longer cares what year it is. There isn't a check box for that.
At day's end, I review my meaningful use. I spent more time checking boxes than talking to patients and their families.
There aren't enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for. I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.
I spend more time talking to the information technology team than I do answering messages from patients.
As a teaching doctor, my feedback to the residents now consists mainly of explaining how to document their visits so that we will all get paid, instead of teaching them how to take care of elders in their homes.
I look at my pickled okra, and I think of the patients and their families. And I know where my meaningful use lies.
Dr. Regina Harrell is an assistant professor in the College of Community Health Services at the University of Alabama. This essay was first published in Pulse, an online magazine about people's experiences with health care.
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