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Checking Boxes

Regina Harrell

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."

Story editor:

Diane Guernsey

Comments   

 
# S Silverstein, MD 2014-01-15 19:23
The themes in this essay revolve around bad health IT robbing patients of care.

Bad health IT is IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy or otherwise demonstrates suboptimal design and/or implementation.

See my other comments at http://hcrenewal.blogspot.com/2014/01/wapo-when-treating-patient-with.html .

On health IT itself and its problems, see my academic site at http://cci.drexel.edu/faculty/ssilverstein/cases/
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# Dina 2013-10-31 10:41
How I so much agree! What has medicine become ! I hope someone out there is listening. I spend a fraction of my time speaking and caring for patients and the rest I'm overwhelmed with computer documentation and fitting things into boxes on computer screens.
Thank you
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# S Silverstein, MD 2014-01-15 19:25
You are not alone.

See "Doctors' Dissatisfaction With EHRs May Be 'Early Warning of Deeper Quality Problems'" at http://cnsnews.com/news/article/susan-jones/doctors-dissatisfaction-ehrs-may-be-early-warning-deeper-quality-problems-0

and my comments at http://hcrenewal.blogspot.com/2014/01/doctors-dissatisfaction-with-ehrs-may.html
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# Sharon Murphy 2013-10-21 11:20
I am so delighted that I lurk on this list, because I have found that the stories give me hope, with their honesty and self-reflection and truth as the writer knows it.

Plus, I loved discovering Alan Blum's drawings.

Along the same lines of this week's offering, I recommend Abraham Verghese's TED talk at:
http://www.ted.com/talks/abraham_verghese_a_doctor_s_touch.html
Especially, especially, the very last part.
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# Elaine Whitman 2013-10-20 13:49
Your description of struggling through the computerized record-keeping program was truly terrifying. My internist has installed a program like this in her office; when I go in for a visit, a laptop sits between us. As I talk, she types, peering at the screen, attempting to fit my symptoms and concerns into her system's pop-up menus.
She is a kind, compassionate doctor, and I am not motivated to leave her practice. But I worry that all medical practices are going this route: documentation to keep the computer happy, rather than to maximize patient needs.
My Dad, an internist in solo practice, always saw his patients in two rooms. First he examined his patients in an exam room; then the two of them would meet in his office, where they would discuss treatment & followup. I realize that this model is no longer feasible. But with all this focus on computers, we have swung much too far in the other direction.
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# Janice Anderson 2013-10-19 07:35
wonderful piece, and so timely. you captured what many of us are thinking.

i too teach. on my faculty evaluation just last week, one resident rightfully noted, "lately she's spending more time going over how to fill in the prenatal charts than she does on teaching prenatal care."

that comment, and your writing, are welcomed wake-up calls. we have to fix this. thank-you, thank-you, for getting us started.
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# Jackie Broadbent 2013-10-18 23:41
Thanks Regina, as a geriatrician I enjoyed this piece (if not the thought of all those boxes). I think you would enjoy NZ doctor Glenn Colquhon's poetry, especially the Mini Mental State poem which is a favourite of mine. See
http://www.beyond-the-pale.co.uk/backwards.htm
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# Carol 2013-10-18 23:41
Thank you so much for sharing about yourself and your patient & spouse. I am a recently graduated family NP, starting a job caring for people in "independent living communities," will see them in the exam room and the living room or bedroom, whichever works for us both...

Pax et bonum,

Carol
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# Pat Shahamiri 2013-10-18 22:28
The hospital I attend for clinic visits with resident doctors has a newly deployed electronic system. It may have been on sale due to its' obvious out of date qualilties and lack of integrated information such as the clinic info is not available to the hospital. Big waste of time. Now each visit is spent with the resident nervously peering at the computer screen, typing in info after asking questions read from the screen without ever looking at me. 15 minutes goes by until I become the focus of the appointment. There is little time left for an exam, prescriptions are refilled, and I try to discuss why I have come in. The resident finishes quickly to run everything by an attending, comes back with final words of well just keep what you've been doing and we'll see you in four months. I leave wondering sometimes why I have gone through this exercise again. It's so frustrating and really is a waste of time. Checking the boxes to renew prescriptions and little else except typing...
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# Pam Mitchell-Bernadt 2013-10-18 20:32
Thanks so much for writing this so eloquently. In fact, I am forwarding to Mr. Obama and asking that he pass it on to the bureaucrats,muc h as I respect him.
This is the reason I left hospital nursing earlier than planned and am now doing a private practice seeing people in their homes.Hurrah to the return of wealth based on relationships! And hurrah to you Regina!
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# Nancy Speas 2013-10-18 20:28
Love this article. I want to say that all the same could be said of the Rehab professions. The bottom line emphasis on $$$ has taken the humanity out of actual patient care and treatment. I, too, spend more time charting and recording according to someone else's demands than I do in meaningful care of the patient. Sometimes the connection or relationship itself between patient and rehab therapist is the key to functional improvement; but, there is no apparent way to bill for this...

Nancy Speas MA CCC-SLP
Speech-Language Pathologist
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# Laurence Bauer 2013-10-18 18:32
thanks for this piece. Last weekend our organization sponsored a Direct Primary Care National Summit. 160 participants for 2 days talked about how freeing it is to not be trapped by this silliness. It's time for docs like you to take back the energy that is consumed by this so the people you seek to serve can be served.

Larry Bauer
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# Nereida Savoy 2013-10-18 18:28
So enjoyed this story. This is what is on my mind almost every day. Thank you for writing it.
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# David Power 2013-10-18 18:06
Love it! Great story - beautifully written. Thank you!

My patient whom I visited at home till he died 4 months ago, still remains on my 'diabetes panel' and apparently will do so until at least 2 years have passed - hmmm?

I know that in years to come we will realize that we have done ourselves, patients and society a disservice by populating EHRs with incorrect, templated text. For example: "I didn't discuss or examine HEENT or neuro systems during today's visit - but I didn't take the time to delete the templated defaulted text so now it looks like I did address these systems in the note". Hmmm?, meaningful use - or is that - at times - meaningless use?.. that is the question. Let's continue to document our narratives about the characteristics of our patients that are relevant - and true - and that matter.
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# Marita Grudzen 2013-10-18 18:02
Thank you, Regina, for letting accompany you in all the dimensions of your day. We each take our lessons away some of us more quietly than others. Nonetheless, all of us feel you breaking through our isolation.

Many thanks, Marita
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# Ron Banner, MD 2013-10-18 17:50
Great story, told well. Lot's of courage!

Let's come up with our own check list of places to send the story to, starting with the White House and down to all the hundreds of bureaucrats and academicians that think that they have come up with the magic answer of how to improve medical (read disease) care in the US.
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# Charlotte Cohen 2013-10-31 10:16
Yes, Regina, send your essay to NYT, mass-market periodicals and wherever else you think your story, rich in compassion and frustration, might motivate changes in our government's young, work-in-progres s.
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# Aaron Newberg,M.D. 2013-10-18 22:02
I think I retired at the right time! Government controlled medicine is starting to show it's adverse side. Young doctors today will never know how enjoyable medicine was 40-50 years ago!
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# Lois Gerber,RN, BSN, 2013-10-18 17:46
Regina,

Very accurate description of an elderly couple trying to stay independent with their compassionate doctor's help. Her challenges managing the time involved with the EMR add to the story. As a former home care nurse, I can relate to that as well as the pickled okra.
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# Sarah 2013-10-18 17:46
Thank you for the work that you do! I am a medical student and I am really amazed every time I hear about or meet a physician who does house calls.

I think that it is so important for the next generation of physicians to be exposed to doctors who are going out of their way to care for their communities. So thank you for your writing and thank you for the work that you do!
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# David Power 2013-10-18 18:16
Thanks Sarah! We're always looking forward to students like you joining our ranks - and carrying the torch! In primary care, we do get reimbursed for house calls - it's just a matter of making the time and caring enough.
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