If it’s not right there in the electronic health record, did it really happen?
Every once in a while (maybe more often than that), a patient comes to see us after a brief or prolonged hospitalization, some major surgery, or a new diagnosis and treatment that has occurred. Sometimes this stuff is very recent; sometimes the patients still have dressings and drains, and actively healing surgical scars.
And sometimes, whatever this is has been developing over a period of time, 1 or 2 years — sometimes longer — a terrible diagnosis, extensive evaluations, medical decisions, a course of treatment, and complications. Sometimes they come out okay at the end, and sometimes things never quite get back to where they were.
But sometimes a lot of this stuff goes on and nothing really makes it into the chart. How often have we in primary care seen a patient after they were admitted for a cholecystectomy, an appendectomy, or a resection of a part of their colon for cancer, and none of this has made this onto their Past Medical History or Past Surgical History in the chart?
Sure, when they come to see me, it’s not that much work for me to add “Colon Cancer” to their Past Medical History and “left hemicolectomy” to their Past Surgical History fields in the electronic health record. But the system always wants to know the details: the stage of the cancer, the treatment plan, which side the surgery was done on, and so on. To figure this stuff out, to get it right, often requires lengthy investigations, poring through charts that sometimes have reams and reams of documentation without much gleanable knowledge and no clear picture of what actually happened.
Sometimes, when our patients are diagnosed with cancer, they see a couple of specialists, they get some tests done, they start treatment, they see that specialist multiple times over many months or years, and then when they come out the other end, they come to see us. It would be great if these diagnoses were added to the Problem List, were added to the Past Medical and Past Surgical History, so we didn’t have to clean up the charts.
True, we could just ignore it. They didn’t bother to put it in, so why should we? But somehow, I think we feel responsible; we feel that keeping a good chart, an updated Problem List, Past Medical History, Past Surgical History, and Medications and Allergies somehow finally belongs on our shoulders.
The electronic health record, in so many ways, makes our lives and the lives of our patients better, more reliable, and safer. Incredible functionality prevents a patient from getting the wrong medicines or something they’re allergic to, or it can prevent a missed opportunity to improve their health. But if everybody doesn’t do their part, things might slip through the cracks.
I know the subspecialists and the surgeons are all incredibly busy, but they seem to have more people on their teams working with them, people who should be able to make sure that medication lists have been updated, that medicines patients took in the past are removed, and that some treatment the patient stopped because they developed a side effect is captured and reported so it won’t be given again. That way, everyone else who sees the patient can get a clear picture of what’s going on, without having to read through page after page of copied-forward progress notes.
Perhaps it’s time for us to invoke and build some better systems, some smarter tools, that can make sure this stuff is captured as it happens, or at least when the patient is ready to go home. I’m talking about you, Artificial Intelligence.
Just as I think a discharge summary could probably be better generated by a smart computer system that was able to read the charts and put together a comprehensive story about what just happened, I believe that if a patient undergoes surgery while in the hospital — say a left heminephrectomy — and the pathology is renal carcinoma, then at the time of discharge you’d think we could build a system that could prompt everybody, before they sent that patient home, to endorse whether or not this was the truth, and add it all in the chart in the correct place.
Sure, this runs the risk of a bunch of checkboxes that people click off just to get through and out of the way, but more likely if you’re a surgeon, and you removed someone’s kidney, and the system on the day of discharge says “I see that you removed part of their left kidney; would you like to add that to their Past Surgical History? Click yes or no”, we’d probably be better off and all living and working in a better, cleaner, happier electronic health record.
A system that’s smarter than me should be able to go through the medication list, note who is prescribing each medication and for what purpose — and who should be able to refill it. It could also have everyone endorse whether or not the patient should continue taking a particular medication, and for how long.
I know that a surgeon’s time is valuable, and that when they’ve finished with one cholecystectomy the most important thing is for them to get on to the next one, and I know they don’t want to spend a lot of time clicking in the chart (none of us do), but it would be really nice if they had a really smart virtual assistant running along beside them and cleaning up after them — as well as everyone else who swims in the pool.
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