File it under fiction

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including "How to Say No to Your Toddler." E-mail him at [email protected].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including "How to Say No to Your Toddler." E-mail him at [email protected].

Doctors once received a free pass when it came to penmanship. We wrote our prescriptions in Latin. So, it was okay that everything else we scribbled looked like Greek. Referrals and consultations occurred in hospital corridors or doctors’ lounges. Documentation was spotty if it happened at all. Our handwriting was a joke. As long as we could sort of decipher our own scribbling, that was okay. But, the laughing stopped when third-party payers began to ask for proof that they were getting their money’s worth for our services – a proof that they could read.

Dictation with transcription was the obvious solution. It was efficient and produced a legible result. Whatever was lost in transcription resulted in humorous and usually harmless errors. As a card-carrying cheapskate, I typed my own letters. My typos added a kind of homey touch to my communications, and they were certainly more readable than my scrawl.

Dictated and transcribed reports seemed to be a relatively accurate reflection of what had occurred at an office visit, and it kept the payers happy for a while. Most physicians continued to handwrite their office notes. But, it was clear that handwriting was coming off the walls. Insurance companies, the government, quality control folks, and risk assessment managers all wanted more documentation. Computerization seemed to offer a reasonable compromise. The payers got the data, and physicians could take advantage of the efficiencies that electronic records promised.

The software vendors’ sales pitch went like this, "Doc, aren’t most of your visits pretty much the same? History, physical, lab, diagnosis, plan? And, you do pretty much the same exam on everyone? And most of the stuff is normal, right? We’ll show you how to make some templates that will save you a ton of time without all that repetition – done in just a couple of mouse clicks."

So, the templates were made, sometimes with the physician’s help, but often without. And accuracy was sacrificed in the name of legibility and efficiency. The problem is that patients with the same diagnosis aren’t all the same. Their examinations are as different as snowflakes.

What makes a normal ENT exam normal? Is the absence of tonsils worth noting? A bifid uvula? It depends. What does the template include in its definition of normal? More importantly, does the physician remember or did he ever know what his computer considers normal? With a single mouse click, he can create a crisp, laser-printable document that because of its legibility and level of detail appears to be the gospel truth.

But of course, sometimes and certainly too often, it’s not the truth. I recently received an e-mail from a pediatrician who said that he files the EHR records from specialists, emergency departments, and urgent care centers in the "fiction section." He cited an example of a report from a neurologist about a 10-month-old that included a "normal sense of smell" and a warning against driving while taking the medicine prescribed. I can’t top that; maybe you can. But I certainly have received numerous reports that clearly bore little relationship to what had transpired in the clinic or specialist’s office – complete neurologic exams that would have taken 30 minutes to perform, normal tympanic membranes in children with PE (pressure equalization) tubes or cavernous perforations.

Although I frequently complain about the sad state of the physical examination, a bigger problem may be the reliance on the EHR to document the result of the exam. I fear there is little incentive to correct the problem because of the malpractice lawyers’ mantra, "if you didn’t document it, it wasn’t done." Unfortunately, that has come to mean that if it’s legible and detailed, it must be the truth. I would enjoy hearing from you some examples in which you know this clearly wasn’t the case.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including "How to Say No to Your Toddler." E-mail him at [email protected].