The map is not the territory: medical records and 21st century practice

Stephen A Martin & Christine A Sinsky
The Lancet
Published: 25 April 2016

Summary

Documentation of care is at risk of overtaking the delivery of care in terms of time, clinician focus, and perceived importance. The medical record as currently used for documentation contributes to increased cognitive workload, strained clinician–patient relationships, and burnout. We posit that a near verbatim transcript of the clinical encounter is neither feasible nor desirable, and that attempts to produce this exact recording are harmful to patients, clinicians, and the health system. In this Viewpoint, we focus on the alternative constructions of the medical record to bring them back to their primary purpose—to aid cognition, communicate, create a succinct account of care, and support longitudinal comprehensive care—thereby to support the building of relationships and medical decision making while decreasing workload.

Here are two excerpts:

While our vantage point is American, documentation guidelines are part of a global tapestry of what has been termed technogovernance, a bureaucratic model in which professionals' behaviour is shaped and manipulated by tight regulatory policies.

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In 1931, the scientist Alfred Korzybski introduced the phrase "the map is not the territory", to suggest that the representation of reality is not reality itself. In health care, creating the map (ie, the clinical record) can take on more importance and consume more resources than providing care itself. Indeed, more time may be spent documenting care than delivering care. In addition, fee-for-service payment arrangements pay for the map (the medical note), not the territory (the actual care). Readers of contemporary electronic notes, composed generously of auto-text output, copy forward text, and boiler plate statements for compliance, billing, and performance measurement understand all too well the gap between the map and the territory, and more profoundly, between what is done to patients in service of creating the map and what patients actually need.

Contemporary medical records are used for purposes that extend beyond supporting patient and caregiver. Records are used in quality evaluations, practitioner monitoring, practice certifications, billing justification, audit defence, disability determinations, health insurance risk assessments, legal actions, and research.

The article is here.

Engaging Patients Through OpenNotes: An Evaluation Using Mixed Methods

Tobias Esch, Roanne Mejilla1, M. Anselmo1, B. Podtschaske, T. Delbanco, J. Walker
BMJ Open, published online Jan. 29, 2016.

Abstract

Objectives 

(A) To gain insights into the experiences of patients invited to view their doctors’ visit notes, with a focus on those who review multiple notes;

(B) to examine the relationships among fully transparent electronic medical records and quality of care, the patient-doctor relationship, patient engagement, self-care, self-management skills and clinical outcomes.

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Results 

Patient experiences indicate improved understanding (of health information), better relationships (with doctors), better quality (adherence and compliance; keeping track) and improved self-care (patient-centredness, empowerment). Patients want more doctors to offer access to their notes, and some wish to contribute to their generation. Those patients with repeated experience reviewing notes express fewer concerns and more perceived benefits.

Conclusions 

As the use of fully transparent medical records spreads, it is important to gain a deeper understanding of possible benefits or harms, and to characterise target populations that may require varying modes of delivery. Patient desires for expansion of this practice extend to specialty care and settings beyond the physician's office. Patients are also interested in becoming involved actively in the generation of their medical records. The OpenNotes movement may increase patient activation and engagement in important ways.

The article is here.

Kaiser Permanente cited for EHR mental health violations

By Jennifer Bresnick
EHR Intelligence
Originally published on March 20, 2013

Kaiser Permanente, the largest healthcare provider in California, has been cited by the California Department of Managed Healthcare (DMHC) for keeping two sets of patient records: an official EHR that it showed to state inspectors, and a parallel paper record that hid violations of the state’s “timely access” law that mandates shorter wait times for mental healthcare than Kaiser was able to provide.  The inaccuracies involved in the HMO’s dual record keeping system meant that mental health patients may have waited weeks longer than the law stipulates for appointments, resulting in illegal denials of access to care for schizophrenia, autism, depression and suicidal ideation, among other serious conditions.

The problem stems from Kaiser’s double appointment keeping procedures.  While there is an electronic version – the version that gets reported to government officials – Kaiser also used paper lists in some facilities, rendering its electronic appointment wait time calculators useless.

The entire story is here.

Thanks to Ed Zuckerman for this story.

Prosecutors Allowed Access to Loughner Notes

By Michael Kiefer
The Arizona Republic

The judge in the Tucson mass shooting case has ruled that prosecutors can have access to notes made by Jared Loughner's prison psychologist over the course of her evaluations of his mental health.

The suspected shooter is undergoing restoration to competency at a federal prison hospital in Springfield, Mo., and his lawyer asked that federal prosecutors be denied access to the psychologist's notes because of self-incriminating statements Loughner made during sessions with psychologist Christina Pietz.

The entire story is here.

Inviting Patients to Read Their Doctors' Notes

Patients and Doctors Look Ahead

Patient and Physician Surveys

Original Research: Improving Patient Care

Annals of Internal Medicine

By Jan Walker, RN, MBA; Suzanne G. Leveille, PhD, RN; Long Ngo, PhD; Elisabeth Vodicka, BA; Jonathan D. Darer, MD, MPH; Shireesha Dhanireddy, MD; Joann G. Elmore, MD, MPH; Henry J. Feldman, MD; Marc J. Lichtenfeld, PhD; Natalia Oster, MPH; James D. Ralston, MD, MPH; Stephen E. Ross, MD; and Tom Delbanco, MD

Abstract

Background: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors' office notes.

Objective: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.

Design: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors' notes.

Setting: Primary care practices in 3 U.S. states.

Participants: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.

Measurements: Doctors' and patients' attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.

Results: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.

Limitations: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.

Conclusion: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.

Primary Funding Source: The Robert Wood Johnson Foundation's Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.

The entire story is here.

Thanks to Ken Pope for this story.