Doctors Use EHRs To Do 'Chart Biopsies'

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As the number of hospitals with electronic health record systems grows, a new study finds that inpatient physicians who receive patients from the emergency department have begun to do "chart biopsies" of electronic records to prepare for the handoffs.

Although the study in the Journal of the American Medical Informatics Association (JAMIA) doesn't reach any conclusions about whether chart biopsies are an improvement over traditional handoff methods, it points outs that "chart biopsies appear to impact important clinical and organizational processes. Among these are the nature and quality of handoff interactions and the quality of care."

The study defines a chart biopsy as "the activity of examining a patient's health record to orient oneself to the patient and the care that the patient has received in order to inform subsequent conversations about or care of the patient." To understand how this process works, the researchers studied general internal medicine physicians and surgeons who received patients from the ED at the University of Michigan Health System (UMHS) for a two-year period.

At UMHS, hospital physicians had access to two EHRs: one was for inpatient and outpatient documentation, and the other was used in the ED. When ED doctors and nurses entered data into their EHR, the inpatient doctors could view that data immediately. Over time, they began to review the ED charts before having a conversation with the ED physician who admitted the patient.

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The three main functions of chart biopsies, according to the study, are getting an overview of the patient, preparing for handoff and subsequent care, and defending against potential biases.

The latter refers to a "defense mechanism" that some receiving physicians use to question an ED physician's understanding of the patient and guard against "diagnosis momentum," in which a prior clinician's diagnosis informs all subsequent diagnoses and treatments. In some cases, this attitude can be a valuable corrective. For example, an ED physician claimed that one patient had meningitis, but the hospitalist who did a chart biopsy noticed a positive result for strep throat in the lab work. After he discussed it with the ED doctor, they concluded that the correct diagnosis was strep throat, and that the patient wasn't admitted.

In a number of instances, receiving physicians used chart biopsies to question whether a patient should be admitted or whether he or she was being sent to the correct inpatient service (e.g., whether the patient should sent to the general floor or to the intensive care unit). However, the inpatient doctors did not always draw correct conclusions from the ED record, the study noted, because some records were incomplete, out of date, or even inaccurate. Such misunderstandings had to be worked out during handoff conversations, which actually reduced the efficiency of the communication between the ED and hospital doctors.

In an interview with InformationWeek Healthcare, lead author Brian Hilligoss, an assistant professor in Ohio State University's College of Public Health, noted that the study was not intended to find out whether chart biopsies resulted in better care or better outcomes. While they sometimes prevented patients from being sent to the wrong inpatient department, he noted, even in that context, hospital politics often influence the disposition of cases.

Current EHRs don't lend themselves to chart biopsies, the study notes, partly because they're not set up to help clinicians look at longitudinal data on a patient's care and the trajectory of his or her illness. Hilligoss said he didn't know whether EHR vendors were trying to address these issues, or were even aware of chart biopsies.

According to Hilligoss, every UMHS physician that he observed did some kind of chart biopsy. But they didn't do one in every case--sometimes they were too busy--and every doctor did them differently. Hilligoss did point out, however, that doctors in hospitals other than UMHS were also starting to perform chart biopsies; fellow academics at other institutions have told him this. "It isn't something that anyone has preplanned for, but because the EHR is there, they're naturally doing it," he said.

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