Technology isn't enough to improve healthcare. Doctors must be able to distinguish between valuable data and information overload.
As a doctor, I know the value of information, but I also know what's worse than not enough information: misinformation or too much information. In this information age, we seem to have plenty of both.
No matter what you think or believe, you can find proof of it on the Internet. You can also find a million and one ways to decorate your living room, making it overwhelmingly impossible to decide which ideas to use. The Internet is great at quenching our attention deficits by providing novelty at every click. Indeed, we can spend hours reading, watching, listening, or commenting without accomplishing anything at all. On the other hand, we get access to excellent resources and minds, beyond what was possible in a non-connected world.
Modern medicine also struggles with managing information. In our lust for data, we have created systems that store every keystroke, scan, or import, in a limitless cloud. Discrimination is no longer necessary. The pertinent and the frivolous are stored side by side. We no longer have data; we have "big data." This allows the detection of trends and patterns that could never be identified with our smaller data sets. We are just beginning to understand its power.
Interestingly, however, while computers are great at sorting through data quickly and efficiently, humans aren't. In fact, "more," often clogs our ability to discern and decide. Additionally, computers can't distinguish good data from bad data. At present, humans are still required to use the data to make decisions and care for patients. Until we have computers that can form therapeutic alliances, be compassionate, diagnose conditions, and provide and coordinate reasonable treatments, we are still dependent on fallible biologic beings to provide our medical care.
One of the hopes of electronic health records (EHRs) is that they will revolutionize medicine by collecting information that can be used to improve how we provide care. Getting good data from EHRs can occur if good data is input. This doesn't always happen. To see patients; document encounters; enter smoking status; create coded problems lists; update medication lists; e-prescribe medications; order tests; find, open, and review multiple prior notes; schedule follow-up appointments; search for SNOWMED codes, search for ICD-9 codes, and find CPT codes to bill encounters (tasks previously delegated to a number of people); and compassionately interact with patients, providers have to take shortcuts.
To simplify the more cumbersome and involved process of documenting in EHRs, we use templates, checkboxes, and default reports. This standardizes the entry and ensures that all of the necessary bullet points are included. While this documentation allows more accurate CPT coding, it often doesn't reflect reality. Numerous patients with abnormal physical finding or other distinguishing features suddenly have normal exams except for the specific abnormality surrounding the chief complaint. Comatose patients are often "alert and oriented," and all ear infections look exactly the same -- "red and bulging." Template-based records are notorious for including things that were never done, such as performing a complete physical exam on a patient who came in with a splinter in a thumb. Or the record might detail a full review of systems -- including questions about exercise-induced chest pain and feelings of anxiety -- on a visit with a two-month-old.
Some systems limit the number of choices to describe things or use unnatural language or simple checkboxes to convey things previously communicated by narratives. While computers may be able to use this data, humans who have to use the information to decide what is going on have a harder time reforming the story from this cryptic information.
Additionally, ICD codes often lack the specificity required to communicate what is going on. Patients who once had 16p11.2 microdeletion syndrome suddenly have a diagnosis of 758.33 OTHER MICRODELETIONS. A patient born with an unbalanced AV septal defect, pulmonary atresia, ventricular inversion, and bilateral superior vena cava who underwent patch augmentation of the left PA and placement of a central shunt, followed by a bi-directional Glenn and finally a Fontan procedure is now synthesized down to 746.9 UNS ANOMALY HEART. (Unfortunately, ICD-10 isn't going to make this a lot better.)
While these codes can allow computers to quickly generate reports, they often simplify or group things together in ways that aren't useful to care providers. Much can be lost in the translation, making it impossible to appreciate the uniqueness or specificity of a problem needed to make
David M. Denton is a board-certified pediatrician and member of the American Academy of Pediatrics. He is a partner of the Pocatello Children's Clinic in Pocatello, Idaho, and is affiliated with Portneuf Medical Center where he currently serves as the medical staff ... View Full Bio
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