The photo above shows what “visit notes” from a doctor appointment might look like in the era before computers. Just two days before my first speech where I said “Gimme my damn data,” I had an ENT visit, and on the way out I asked for a copy of the doctor’s notes. The clerk snickered out loud and showed it to me, saying, “If you really want it….”
No joke; this is what the doctor had recorded.
The horrible usability of many of today’s EMRs has understandably caused a lot of bitching from their users (clinicians). I totally empathize and I want it fixed. I’m grateful for the dozens of very smart people whose years of study, training, and clinical experience helped save my life in 2007, and I want them to have a good life, not one filled with horrible machines.
But the remedy for usability problems is not to go back to paper, it’s to force vendors to fix it. (I spoke in 2010 and blogged the video in 2011 about a major reason for the usability problems: the EMR executive who was strongly rumored to have said that usability would be a system criterion “over my dead body.”)
Another example: Peter Elias MD (retired), my colleague in the Society for Participatory Medicine, says that when he repeatedly asked his employer (a large medical center in Maine) to grant patients access to all their chart data, every time the management said they couldn’t, because the data is such poor quality.
Peter loves wisecracks and perverse aphorisms; his email signature says “The chief cause of problems is solutions.” We cannot assess solutions to system problems without remembering why the systems were needed in the first place: pages of crap like that were of no use in improving healthcare, or even in knowing what was going on nationwide. (Imagine being an E.R. doctor or someone providing coverage for a doc on vacation, and having to practice medicine based on that sheet.)
p.s. I bet that ENT’s experience is that patients have no clue what’s going on.
For healthcare to achieve its potential, the information gathered by smart clinicians must get digitized, same as all the other information in every other industry in the world. If the systems to do that are bad, we should insist that the vendors fix them – not return to scribbles.
Edited same day to correct the date of the visit relative to that speech. The speech was 9/17/2009, and this visit was 9/15, two days before the speech. (Originally this post said 9/5, approx. two weeks before.)
Eloquent and exactly right.
Twitter user Gaetano Lardieri @NewarkGuy said “Actually I can read and understand it perfectly however understand your point!” So I invited him to please come transcribe it into a comment here!
From LinkedIn:
Lori Nerbonne
RN, Patient Safety Advocate & Patient Engagement Specialist:
My mother’s Heparin, Lovenox and aspirin dosing orders looked like this before she suffered an anticoagulant overdose.
Also from LinkedIn, Andrew Gallan:
From JAMA 1997: Z-Pak confused with Ice Pack, and patient suffered needlessly for days until the issue was resolved.
https://jamanetwork.com/journals/jama/article-abstract/418794
Dave, I love this image. May I please have permission (with attribution) to use your image in my Medical Informatics classes?
Yes, but per my private note, let’s dig a little deeper – in particular see the comments here, where I’m trying to collect stories of harm or danger that have ensued from such unclear notes.
Thanks, yes, you’re right. There have been studies dealing with misreadings of hand-written prescriptions.
In my classes on EMRs, one of the pros of EMRs I deal with is that hand-written prescriptions and notes cause problems because of illegibility. Unfortunately, the examples I have are usually from textbooks (unsurprisingly, getting authentic examples is a little difficult :-). so, this would be a useful example to ask the students to try to decipher.
First, Ken, I’d love to see a list of those studies, to educate readers who may not be aware. (I continue to be disappointed at how many people on Twitter and LinkedIn are arguing about this post.)
I’m also disappointed at the couple of people (noted above) who said they can read it but haven’t come through. I have, though,
Finally, I’m trying to figure out which doctor this was, to find out whether he did indeed send me a letter from these notes, which I’ve lost. (My PCP says he did not get one.) This will take some digging with my then-insurance company.
And in the interim I’ve taken a guess at what it all might be. I’m going to blog that.
Please do send some info on unclear handwriting. My pubmed search is turning up problems with OTHER people’s handwriting :-), but not with clinicians’.
p.s. And here’s a huge thank-you to all the clinicians who WROTE CAREFULLY when it was all done on paper! Kudos!
Dave, you started it all ten years ago “give me my damn data” and the power of poor penmanship to drive EHR development . KUDOS
Dave, I’m afraid I don’t have a list of such articles (it’s not an area of my research), but I do use this (Open Access) article in my teaching:
http://dx.doi.org/10.1080/20786190.2016.1254932
1. That paper begins by referring to other papers, so you might be able to that to follow the trail.
2. Although the focus of that paper is the use of a technological device in prescriptions, Part 1 of the study has normal hand-written prescriptions, and then they tested to see how many docotrs, nurses and pharmacists could correclty read those prescriptions. From their abstract: “From the 300 measurements, 88% of the doctors read the prescriptions correctly, compared with 82% of the nurses and 75% of the pharmacists. A potential fatal error was lorazepam injection 4 mg, which was read as 40 mg (lethal dose) by 20% of healthcare workers (HCWs).”
I hope that helps.
Dave,
Are you looking for someone to translate it and post it here?
If I have your permission to reveal all of the PHI, I’ll give it a shot.
-Rodrigo
LOL fascinating twist on the whole thing – your question implies that the PHI is well concealed at present!
Heck yes, I already posted it, so HIPAA’s not a factor, and besides you’re not a “covered entity” providing services to me so HIPAA wouldn’t apply anyway. BUT I expect you said it out of human decency, not regulations!
Yes, please do. Thanks.
By the way, all, I have contacted the doctor’s office, and with luck in a few weeks I’ll know what’s on file: did he transcribe this into a more complete note? (Someone on Twitter had wondered out loud about that.)
Interesting process:
– Since the sheet contained no identifying info about the doctor, I contacted BC/BS of Massachusetts, which was my insurance at the time.
– They dug out the archives and found that the provider’s name was Bruce Suzuki. Easy – thanks BC/BS!
– Googling found him; I think he still works at the same office (not sure). But he’s now attached to Mass. Eye & Ear Infirmary, which is part of the Partners (Mass General) health system.
– I called them, and they said I need to talk to medical records. Left a message there and got called back this week. Very helpful & informed people.
– They said that I could fill out a records request, but I could also just go look myself, because all my records should be on their Epic system’s portal, Patient Gateway. “It has all records back to 1939,” they said. Seriously??
– I went there and created an account, and it says “You have no medical history on file.” :-) (I also had a visit with a dermatologist long ago (but after 1939!) and that’s not there either.)
So I wrote to their support people, and here’s what the promptly replied (good!) – it’s priceless: (emphasis added.)
=====================
The information listed in your account comes from your Partners HealthCare medical record. Your complete medical record is not available on Partners Patient Gateway.
To request medical records using Partners Patient Gateway, please follow the directions below.
Visit https://patientgateway.partners.org and log in with your username and password.
1. Click on “Health” from the menu bar
2. Under Health Tools select “Request Records”
Please review the information presented on the screen
3. Click “Request Online”
4. Complete the request form
5. Click “Submit”
After submitting your request to medical records, a copy of the request will be kept in your “Sent Messages” folder. Once your request is processed, an email will be sent notifying you that the records are available in Partners Patient Gateway. You will be able to access them in the Requested Records section, in Health Information Reports.
Note: Not all providers have adopted the functionality to allow you to request your records through Partners Patient Gateway. If you cannot request your records online, you will receive notification through Partners Patient Gateway when your provider does adopt this functionality.
As always, you will continue to be able to request your records by filling out a form provided by your hospital or provider.
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Sometime soon I’ll try that.