We Doctors Forget: Computers Came Because We Couldn’t Write Legibly
So many people used to joke with me, “Do you guys have a medical school class in poor handwriting?”
Atul Gawande wrote an excellent article outlining the frustrations many physicians — including this one — have about electronic medical records. He wrote:
Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.
This is because — due to the many, many regulatory rules that apply to the healthcare field — as well as the multiple rules by multiple payers to be able to bill for our services, we are plagued by a multitude of computer clicks and steps before we can finish our work on a patient. Gawande highlights an example of how electronic medical records can cause such frustration among physicians:
Each patient has a “problem list” with his or her active medical issues, such as difficult-to-control diabetes, early signs of dementia, a chronic heart-valve problem. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. [Dr. Sadoughi, one of Gawande’s colleagues] used to keep the list carefully updated — deleting problems that were no longer relevant, adding details about ones that were. But now everyone across the organization can modify the list, and, she said, “it has become utterly useless.” Three people will list the same diagnosis three different ways. Or an orthopedist will list the same generic symptom for every patient (“pain in leg”), which is sufficient for billing purposes but not useful to colleagues who need to know the specific diagnosis (e.g., “osteoarthritis in the right knee”). Or someone will add “anemia” to the problem list but not have the expertise to record the relevant details; Sadoughi needs to know that it’s “anemia due to iron deficiency, last colonoscopy 2017.” The problem lists have become a hoarder’s stash.
“They’re long, they’re deficient, they’re redundant,” she said. “Now I come to look at a patient, I pull up the problem list, and it means nothing. I have to go read through their past notes, especially if I’m doing urgent care,” where she’s usually meeting someone for the first time. And piecing together what’s important about the patient’s history is at times actually harder than when she had to leaf through a sheaf of paper records. Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information — an entire two-page imaging report, say — rather than selecting the relevant details. The next doctor must hunt through several pages to find what really matters. Multiply that by twenty-some patients a day, and you can see Sadoughi’s problem.
This problem is one of the major factors leading to physician burnout, a serious crisis facing our healthcare system. NBC news recently reported:
When Dr. Cori Poffenberger curls up on her couch after a long day at work, there’s no relaxing. She is an emergency room physician, and at night spends hours filling in patient charts and reviewing test results.
Poffenberger’s evening electronic record keeping comes after a full day of seeing patients, teaching medical students, preparing dinner for her family, and putting her children to bed. This after office hours work is what doctors call “pajama time,” and experts say it is a leading cause of physician burnout.
I share this frustration, especially with subpar electronic medical records, or EMRs for short. At the same time, we physicians need to be honest with ourselves. With all the burdens on physicians that come with EMRs, we must not forget a big reason why they were adopted in the first place: physicians’ atrocious handwriting.
As Dr. Gawande wrote above, “Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information — an entire two-page imaging report, say — rather than selecting the relevant details.” That’s true. At the same time, you can at least read the copy and pasted note on the computer screen. Very frequently, if not most of the time, you couldn’t read a physician’s handwritten note, no matter the length.
Back when I was in private practice, I would come across days and days of handwritten notes that I could not read whatsoever. After a while, I would just skip them and not waste my time trying to decipher another colleague’s chicken scratch. There may have been very important information contained in those notes. It didn’t matter, however, if I couldn’t read them.
Nowadays, among my other duties, I do some consulting work for hospital systems, and I come across physicians’ handwritten notes, sometimes very long ones, that are completely unintelligible. I am asked to render a judgment about the medical necessity of a hospital stay, and I can’t tell what is going on with the patient and what the physician wants to do with him or her. It is extremely frustrating.
In fact, it was a joke among non-physician friends and family members about doctors’ handwriting. I’ve lost count of the time people would say to me, “Do you guys take a class in poor handwriting in medical school?”
Now, I can’t share a copy of an actual medical record, as this would run afoul of patient privacy laws and is inappropriate. Thus, let me give an example of a fictitious patient note that I would write if I did not have an EMR:
My handwriting used to be neater than this, but as I have aged, my notes have become more and more brief and more and more sloppy.
It was not that long ago that I would overhear a unit secretary ask someone near him or her, “Can you read what this order says?” Sometimes, these orders would be for critical medications, and an educated guess could place a patient at risk.
In fact, it has been well documented that prescribers’ poor handwriting has led to medication errors. This fact led to the first foray of computers into hospitals: namely, CPOE or computer physician order entry.
It was definitely more work for us physicians, but it was absolutely the right thing to do. While a computer order entry system does not eliminate medical errors, it nevertheless eliminated the guesswork over which medication a physician wanted to prescribe due to illegible handwriting.
It was not long after CPOE came on the scene that electronic physician documentation in an electronic medical record followed. Again, more work for us — as Gawande’s article expertly noted — but at least you can read the progress note that was generated by said EMR.
While there are many great things about EMRs — and they have brought many benefits — this is not to say that EMRs are perfect. They are not. They have caused a tremendous amount of stress on a great number of healthcare professionals. This has to change.
At the same time, while it is true that the advent of EMRs was likely inevitable, we must never forget that it was us — and our horrific penmanship — that accelerated their arrival.
The opinions expressed in this post are my own and do not reflect those of my employer or the organizations with which I am affiliated.