I am a primary-care doctor who makes house calls in and around Tuscaloosa, Alabama. Most of my visits are in neighborhoods, but today my rounds start at a house located down a dirt road a few miles outside of town.
Gingerly, I cross the front walk; Mrs. Edgars told me that she killed a rattlesnake in her flowerbed 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 happy to see me nonetheless.
We chat about the spring garden and the rain, then we move on to Mr. Edgars' arthritis. Earlier on in his dementia, he wandered the woods, and his wife was afraid he would get lost and die, although the entire family agreed that this was how he would want it.
Now, in a strange twist, his knee arthritis has worsened enough that it's curtailed his wanderings. I suspect that Mrs. Edgars is undertreating the pain in order to decrease the chance that 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. She shows me a quilt remnant found in a log cabin on their property; it likely belonged to her husband's grandfather, making the rough-edged fabric about a century old. I leave carrying her parting gift, a jar of homegrown pickled okra.
When I get back to the office, I turn on the computer to write a progress note in Mr. Edgars' electronic health record, or EHR. In addition to recording the details of our visit, I must try to 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 the History of Present Illness (HPI), I enter "knee pain." Up pops a check-box menu: injury-related (surely the chronic wear on Mr. Edgars' knees from his work as a farmer is some sort of injury, but I don't think that's what the computer 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 tired, sleep-deprived wife who's purposely keeping the dose of acetaminophen low); and so on. Nothing fits, so I exit the HPI and type in "follow-up" (f/u), for which my EHR doesn't have a pop-up menu. It cedes a blank screen.
I type the Edgars’ story in my own words, so different from the computerspeak generated by the check boxes. I move on to the Review of Systems--another pop-up menu.
I used to simply write "patient is an unreliable historian" at the beginning of this section, but the computer doesn't understand that this statement could apply to the entire review. Using a template, it generates a page of thirteen sentences, one for each body system, and, under each sentence, the option "Positive: Other: unreliable historian."
Sometimes I wonder if it is disrespectful to a patient to say thirteen times in one progress note how unreliable a historian he or she is, but I remember that this is great data to mine for research, so I plug on.
Under Physical Exam, there is a template for geriatrics. I pretend that the computerspeak it generates creates logical sentences, although I know better. In the check boxes, a person can be oriented to person, place and time, or not. Mr. Edgars is oriented to person and place; he knows that he is with his wife and at home, and is happy nowhere else. He no longer cares what year it is. There isn't a check box for that.
I remember that I must go back to the Social History and document tobacco use. It occurs to me that if you have not tried tobacco products by your eightieth birthday, you are unlikely to suddenly change your mind. Especially when you can't remember where the store is to buy them. So I slog through the series of check boxes for "never smoker," an extra six mouse clicks.
After fifteen minutes, the note is finished. And on goes my day of house calls--five in all. 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.
At day's end, I review my meaningful use.
I spent more time checking boxes than talking to patients and their families.
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 on paper or using an EHR that created a logical note within the same amount of time. But that is not an option.
The reality is that I spend more time talking to the Information Technology people about internet connections, firewalls and box-checking than I do answering messages from concerned family members.
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 frail elders in their homes.
Then I look at my pickled okra. I think of the hands that I've held, the shoulders that I've patted, the words and smiles that I've exchanged with my patients.
And I know where my meaningful use lies.
About the author:
Regina Harrell is a geriatrician and assistant professor in family medicine at the College of Community Health Sciences, University of Alabama, Tuscaloosa, Alabama. She teaches the art and science of home visits to undergraduates, medical and nursing students, residents and anyone else who will shadow her. “In my head, running around at all times, are thoughts about my patients, my home to-do list, a new idea for one of my hobbies (canning and sewing are current favorites) and a story, which sometimes jumps out onto paper.” She offers special thanks "to my colleague Dr. Alan Blum, who has patiently encouraged my writing."