Saturday, May 3, 2014

The Electronic Medical Record and Quality Control: Coming to a Doctor Near You

We all want high quality medical care. Does anyone out there desire low quality care?
It's one of those things a Senator can say, like "freedom" or "prosperity" and be assured of smiles all around.

And we all agree if a man bills for a service, whether he is a doctor or a mechanic, he ought to be able to show the person or organization which pays him that he actually did provide the service.

So far, everyone is happy.  Freedom. High quality. No fraudulent billing.

The advent of the electronic medical record has meant when you are sitting in front of your doctor in the exam room he is no longer looking you in the eye, or staring at the ceiling or out the window, or at the clock on the wall behind your head: He is now typing furiously on his computer throughout your interview.

But what is he or she doing in that computer he or she is so absorbed with?

The doctor  might be entering data, so he can refer back to it next time you visit or call, to track symptoms, laboratory results, to  track progress or lack of it.

Actually, what he is likely really doing is entering in "quality measurements."

What this means is he has asked whether or not you have had a flu shot and checked off the box that he has asked,  and he checks off a box to document he has told you to get one, never mind if you said "No."  There is another box for whether or not he has told you to stop smoking and another for "lose weight." Check those boxes. Doesn't matter whether or not he mumbled "Good" when you said you were still smoking. The important thing is did he ask and did he check the box. If he said, "ohthenyoushouldstop," when you said yes, then  can check that box, too. More credit.

And there is another box for "family history."   

Why would the powers that be care about whether or not the doctor asked about your father's health?  Actually, there can be valuable information about you in your father's history. 

Until we have a map of everyone's genome in your medical record, the low tech family history is the next best thing. Suppose, for example, you have a high cholesterol. You may be on the launching pad to start a statin drug to bring it down. 


Unless, it turns out your father also had a cholesterol of 300 and so did all his brothers and sisters and so did his father and every single one of them lived to be ninety-nine. Then we do not treat your cholesterol, and you are off the hook. We recognize there is something we don't know how to measure which is protecting your family against that high blood cholesterol, which, in your family,  does not stick to and penetrate the walls of your blood vessels but simply slips by the endothelium like a greased pig sliding down a water slide. 

Now, if your doctor should type in all that information in the "free form" box of your electronic medical record, he gets no credit at all;  but if he does ask and  fails to check the box in the fifth screen of "family history" then he is practicing bad quality medicine. If he scrolls through the screen and finds "father" in family history and clicks the box next to "father" then he has practiced stellar quality medicine and Medicare pays his employer. 

Of course, the doctor may not have asked about your father's cholesterol at all. No matter. All that matters is that he has found the box next to any "first degree relative" and checked it, which is to say, in the eyes of the bean counters, he has done a "reimbursable family history."  High quality medicine right there. 

Multiple that by two dozen other check off boxes on several score of screens and you've got yourself a medical office visit that is easy to score for "quality."
Van Gogh Field with Crows

Remember when you took a test in school and they gave you a multiple choice test about Walt Whitman or the Civil War or geometry or the art of Vincent Van Gogh?  These are not subjects which lend themselves to multiple choice questions, unless you get to some pretty superficial questions, but that multiple choice sheet can now be run through a machine and graded in an instant--even in the 1960's the teacher could lay down a perforated score card over your test answer sheet and grade it in less than a minute.

All of this scoring is about a system which can be graded and "quality controlled" mindlessly by someone who has not the least idea what actual good quality is. 

Can you imagine what playing such games does to the mind of the person in the white coat sitting in front of you? Is he now concerned about your cholesterol,  or morphing into  a mindset  closer to that of a teenager playing a video game?

What we are seeing now is that some minimally trained "health care providers" look better than physicians who have gone through some pretty rigorous training at some very intensive programs, stayed up long nights and undergone ruthless grilling by their professors.  Is the physician's assistant who scores higher on the computer searching his electronic medical record really just more high functioning than the doctor who scores low because the doctor did not check off that box but instead got into the details of your father's actual history?

There are likely ways to judge some physicians by computerized records, but that ain't what we got now. The minds of the "quality control" specialists feeding those bits into their computers are as empty as last year's bird's nest.

Back in the day, we used to say, "The better the surgeon, the worse the note."  There did seem to be that connection--the really wonderful surgeons, the guys you wanted doing surgery on you or your family were fantastic in the operating room, but desultory writing up what they did. Some of this changed when surgeons could dictate their chart notes, but even then it was often a difference between guys who played a good game and those who simply talked a good game.

And your doctor, now an employee, has to check off those boxes or face his employer in a disciplinary meeting which could end in his dismissal. How do you think that affects what he does when he is in the exam room with you?

"Quality control."  In medicine, a work in progress. Done about as well as the healthcare roll out. Well meaning people, not up to the task. And this is not Obama's fault. This has been in the works dating back to George W. It's embedded in government workers and in insurance company workers and in academics who have carved out their niche and drawn their salaries becoming "experts" in quality assurance.  If you cannot do, teach?  If you cannot practice high quality medicine, get a job dreaming up metrics.

Billy Bean of "Moneyball, " where are you now when we need you?


  1. Well Mad Dog, that's called advancement- the doctor's trained and keen observation skills focused on the computer, rather than the patient. Why have the physician troubling himself with what to ask next when the computer form does it for him so nicely and uniformly. Makes one wonder why the patient needs to be there at all, they could just phone in their responses to the questions. Just think of how smoothly and efficiently the doctor could complete the forms without the distraction of the patient....

  2. Maud,

    Actually, strange as it sounds, that's been proposed.
    Who needs the patient physically present?
    Also on line courses for medical training.

    Mad Dog