Even though it resulted in accusations of an insecure ego, I am glad that I kicked the hornets nest in my previous post. This discussion made me realize something that has been bothering for a long time. Now I know what is so painful about medical records and what causes medicine to be so difficult to practice. It's something most clinicians like myself have accepted without question (albeit with a few complaints). It takes a huge chunk of time out of my day and causes patients' problems to be overlooked. What is it? Fluff.
When I say fluff I refer to the packaging-material of medicine - the information that surrounds, obscures, and dwarfs the really useful information. By fluff I mean the thousand words it takes to obscure a picture. By fluff I mean E/M coding requirements, lab panels, and unhelpful descriptions of specialists.
You see, one of the biggest impediments to good medicine (which is not possible much of the time) is not the lack of information, tools, or good minds; it is the lack of communication. Patients are batted around from doctor to hospital, from specialist to PCP, from lab to pharmacy like shuttlecocks but the information that goes between the providers is wrapped in so much fluff that much of it gets ignored.
But I am not just a victim of fluff, I am an expert at generating it as well. Ironically, the tool that is key in the drive to improve communication between providers has also enabled the production of vast amounts of fluff. Yes, campers, I am talking about EMR. EMR's are veritable fountains of fluff.
Let me illustrate. I recently saw a patient who was doing very well. We discussed medications and some side-effects he was having, and made a plan on how to deal with this. I gave him about 20 minutes in the visit, but it was mainly social chat. Here is the note I generated by my EMR for that visit (HIPAA Compliant - don't worry):
Now the truly useful information is highlighted:
The rest is fluff. I count 750 words in this document, 700 of which are fluff. This is a healthy patient, but sick patients have much larger notes. I suspect the fluff to pertinent ratio (I'll call this the fluff index) is similar in most notes.
The reasons this fluff exists are numerous:
- Fluff protects against lawsuits (sometimes).
- Fluff allows us to code at a higher level because fluff proves we worked harder.
- Fluff has a remote chance of containing truly useful information so we keep it all around "just in case" (which means fluff is just like the cardboard boxes in my garage).
- There is a long tradition of fluff. The correct use of fluff is rigorously taught by medical schools, with harsh lectures laid upon students and residents who fail to include enough of it.
- Fluff is lazy - instead of weeding out pertinent information, I send a bunch of fluff.
- Insurance companies seem to want more fluff (as does the government). Doctors who grow tired of fluff end up charging less than those who master fluffing. The best doctors don't make the most money; the best fluffers do.
There are lots of locations of fluff in our system besides the notes in my records:
- The 20 Gazillion ICD-9 and CPT codes are almost 100% fluff. They don't help with care. They don't help with communication. They simply take more time and obscure what is actually important.
- Radiology and other procedural reports contain a ton of fluff (as illustrated in previous posts). The radiologist uses 200 words to say the word "normal" (that is a fluff index of 200 for those of you keeping score). The cardiologist uses 500 words to say an echocardiogram is normal.
- Lab tests are not ordered individually, they are ordered in panels (again, as stated in previous posts). This means that for me to get useful information, sometimes I have to order 20 pieces of fluff for every 1 piece of useful information.
- Nurses are experts at fluff too. How many of nurses' notes in the hospital are written, never to be read again? Hospitals, however, seem to have found a way to charge for fluff (I think they tack it on in the $10 charge for the Tylenol).
- Notes from specialists are mostly fluff. Specialists mysteriously want to tell me the past history of the patient I sent to them. Somehow they feel I might not remember the person I referred. It's OK, though, I always skip through that part completely and just read the impression and recommendations, but it would be much easier to not have the fluff.
- Old records are have a 10,000 fluff index. They are the fluffiest thing there is, with 1-2 items useful out of the entire record. I don't need the last 10 mammograms. I just need the last one.
This may sound like I am making light of the problem (pun intended), but as I said before: fluff kills. People die because doctors spend so much time picking at and making fluff that they don't pay attention to patients. Fluff does not help. It doesn't help that I have to look through 50 different codes for "neck pain" to figure out which one will be paid for by the insurance company. Fluff makes doctors' communication so difficult, that most doctors choose to ignore what other doctors have said (it takes too long to find meaningful information in the fluff) and instead almost always start from scratch.
Fluff also costs a bunch of money. For an administration staking its legitimacy on reforming healthcare while cutting cost, cutting fluff will have the greatest impact on care.
Here is what I would like to see as a physician:
- Let my notes be about care, not fluff. Make my goal keeping patients healthy, not keeping fluff-obsessed coders happy.
- Let me order only what I need. I want to be able to order a Hemoglobin, Platelet count, and WBC count when I get a CBC. If I need to drill down further, then let me do that; but I don't want to have to wade through fluff.
- Focus on efficient communication. Doctors are so immersed in the fluff culture that they fluff each other all the time. The purpose of notes needs to be for communication. Connecting EMR systems could be a god-send, as communication would be much easier; but it could be a door to the pits of fluff hell as well.
I feel sorry for patients who get their records from me. It's not that they are bad records - they are better than 99% of doctors (we have been on EMR for 13 years). But they are totally engulfed in fluff - this makes important information very difficult to find, and some is even wrong.
I had a patient today who got a copy of a note I had written. He got very upset when he noticed some past indiscretions that were listed in the present tense. He is now more mature and beyond this behavior. The note no longer represented him - instead casting him on a negative light. He was mortified; it felt as if an old wound had been opened when he saw the record. The inaccuracy was there because I spend most of my time in the chart generating fluff, and so have little time to ensure its accuracy.
I was embarrassed and apologetic. He understood why it had happened (and I quickly fixed it), but the whole event made it clear that I spend far too much of my time wading through and generating fluff, and far too little time taking care of people. I hate this about our system.
Fear the fluff.