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Frankenrecord – The Monsters We Create

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization. 

By Burden S. Lundgren
March 11, 2019

During my clinical career, I spent the end of every shift documenting what had happened to my patients since I had assumed responsibility for them. Nurses did make occasional notes during the shift, but the end-of-shift note was both comprehensive and analytic. Physicians made the same kind of notes when they visited, as did clinicians of all sorts. There were also lengthier entries: the nurses’ and the doctors’ admission notes and—most importantly—the discharge summaries which reviewed the entire stay.

My first post-clinical job was reviewing medical records for a peer review organization. Records were still paper, and information was scattered throughout the charts, but it was possible to fashion a narrative of the patients’ experiences and the caregivers’ perceptions and actions during a hospital stay. Near the end of my tenure at that job, the largest hospital in our area switched to electronic medical records. A paper record then became an immense printout of data points with virtually no possibility of making any sense of the hospital experience.

Some years later, as a federal employee, I was involved in looking at the kinds of information that could be easily searched in an electronic record and used to improve quality of care. This looked like a giant step forward. It meant that researchers could move beyond administrative databases to acquire clinical information. I particularly remember one event from that period: sitting in a room of HMO medical directors who were practically begging us to regulate standards for electronic medical records. We didn’t. Lacking the requested standardization, I now sit in my doctors’ offices where they occasionally pay attention to me between making entries in my electronic record—a record good only in the system to which it belongs.

Electronic records have become a boondoggle for anyone wanting easily accessible information. Administrators add data fields for insurance, cost accounting and other purposes. Other data is added for quality assurance and utilization information. Databases for admitting diagnoses can be scanned by public health authorities for epidemic alerts. And electronic records create big data—clinical information on large patient populations that can be used for research.

But there are dark sides too. One is certainly privacy—although as someone who routinely went on to hospital units and read paper charts with no questions asked, I have to point out that privacy has always been a problem. Another, as I alluded to above, is the attention that must be paid by practitioners to recording their findings. If you have visited a hospital lately, you have noticed the nurses acting as acolytes to the unit computers. And doctors are paying more attention to screens than to patients. The incessant need for data entry seems to drive care more than the other way around, a fact noted by clinicians and cited as one of the top causes for physician and nurse burnout. It appears that there is a real patient and a virtual one with the latter being the one who matters. And the virtual patient may have little to do with the real one, a problem I experienced just this week with a physical therapy assessment where the computerized questions never addressed my actual problem.

Issues about regulating electronic medical records are ongoing, but before we address more peripheral questions, we need to ask what we want medical records to do. Traditional medical records tell the patient’s story and explain the clinician’s thinking in giving care. Indeed, the process of note-writing itself focuses the clinicians’ attention and provides a mental space for thoughtful analysis, something data entry cannot do. But now the focus has moved from a base of clinician/patient interaction to acquiring population data. As a health policy analyst, I am more than appreciative of the necessity for population data. But population data sets that drive policy are not the same as the records of interaction between a health care professional and his or her patient.  

And that, I believe, is where we should put our regulatory attention. Above all else the purpose of a medical record is to enable the practitioners caring for a patient to know what has already happened to that patient, and how their caregivers diagnosed and treated them. As one retiring physician has recently said, her patients’ paper records (which contain the actual stories of their care) are in a distant warehouse. What she leaves to their next doctor is their digital charts, “Full of computer-speak, cut and pasted into gibberish.” Clinicians should be enabled to write a story (yes, “Write”, not, “Enter”) in a way that makes clinical sense and informs the care given by the next practitioner. Telling that story is the clinicians’ responsibility, not entering administrative data, insurance data, cost accounting data, public health data, research data or anything else that takes attention from the patient. Health care professionals are not overeducated data-entry clerks. We need to separate the clinical record from administrative/population information capture. The latter is a just virtual construct. The patient is the one in the bed, not in the computer.

Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse, specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania. She can be reached at [email protected]

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