A Country Doctor Writes:

I wish CMS and my EMR would stop treating me and everyone who reads my office notes as if we were all amnesiacs.

I also wish they would recognize that primary care is not something that happens only once, in a fifteen or thirty minute visit, and never again.

If we accept these two premises, we are a long way toward health care, or at least primary care, reform.

Before EMRs I used to secretly smirk inside at how much better family physicians’ medical records were than internists’:

Family doctors had the patient’s active problems and their medical, surgical, social, family and health maintenance history on the inside left of the chart, along with medications and allergies. Our office notes, filed in reverse order to the right, were to the point and only dealt with the things we had time to talk about that day. But the background information was always in view and on our minds. We even used to scribble little side notes, like the names of pets and grandchildren, hobbies or favorite travel destinations and sports teams. The problem list helped us see our patients as individuals, not just “the chest pain in room 1”.

Internists, I thought, were like bag people. They carried all their belongings with them, or, they told each patient’s story over from the beginning in every visit, like this:

“This 62 year old male with a 40 pack year smoking history, psoriasis on methotrexate, well controlled diabetes, hypertension, prior myocardial infarction with two bare metal stents and ongoing Plavix therapy, current EF 59%, has a history of mild GERD managed with OTC omeprazole and a history of a normal colonoscopy at age 50 has a baseline hematocrit of 39 but was recently rejected at a company blood drive due to a low hematocrit. He comes in today for a swollen left knee.”

(Every office visit would start about the same way, and almost every visit would touch, at least briefly, on each diagnosis.)

Oh well, when EMRs came into being, the internists’ office note, albeit in bullet form, came to be the model we all follow. Sure, we have side bars with some background information, but all the background information shows up in every single office note, even though all that history is visible on the same computer screen or only a click away.

Somebody seemed to think doctors are all amnesiacs, and that we really need the thumbnail sketch of every patient, every time. Or (Gasp!) some of us may have wanted to give the impression that we truly ask about all that history from scratch at every visit just to score a higher reimbursement.

Of course, the internist way of story telling is modeled after the hospital record, which tells the story of a distinct “episode of care”. And now hospital thinking has crept into and contaminated primary care with disastrous consequences.

The primary care record doesn’t just tell stories of separate “episodes of care”; it is more like a quilt of many story lines, which play out simultaneously and over extended periods of time at different speeds.

Why, then, are our office notes modeled after institutions that deliver nothing but episodic care, and who view a returning patient as a treatment failure?

Primary care is practiced over time; we have more than one opportunity to ask those sensitive questions, offer that immunization or have that talk about smoking or obesity. In fact, there is a right time and many wrong times for most things in life. The right intervention at the wrong time can be insensitive, insulting and counterproductive.

In today’s office visits, we force our way through laundry lists of items our patients never asked us to cover, and we are obligated to fill up our office notes with them.

The cumulative effect of bulking up the office note with historical data that belongs in a sidebar, and the misguided idea that primary care doctors may have only one single shot at delivering preventive care and all the social interventions the Government has now shifted from the public health sector to the health care sector have caused primary care to slow down to a crawl.

Because we are so stuck on the idea that we must provide comprehensive care in every single visit with extensive documentation of what is almost a spinal reflex for experienced physicians, we are seeing many fewer visits than we used to.

We are turning away patients in need of primary care and we are limiting patient access to timely care by making it too cumbersome for primary care practices to see patients for simple problems like sore throats, ankle sprains and rashes. This results in unnecessary emergency room visits and fragmentation of care through the use of unconnected urgent care facilities.

Here is a solution to the mess we are in:

Put those items that are not immediately relevant to the chief complaint or diagnosis of today’s visit in side bars and flowsheets, which would give summaries and timeline documentation of all our efforts at comprehensive care over time. Then, let us refer to these when we make an entry or simply review their contents, but please deliver us from the onus of including every detail of it in every visit. Even if we auto-import them, it makes our own office notes too long to even have time to review the next time we see a patient. And when we get outside records on patients transferring in, it is impossible to find anything relevant in the reams of printed notes we get, because every visit runs 6-8 pages and each one contains virtually the same information.

Let us do well by the patients we are entrusted to care for by paying enough attention to the problem they’ve come to see us about, instead of touching everything in a superficial, perfunctory manner and accomplishing little or nothing except creating an illusion of comprehensive care only meant to impress or placate insurance billing people and public health bookkeeping types. You can only cover so many topics in fifteen minutes.