Clinical Summaries: Avoiding Gibberish Generators


I mentioned in my last post that I am growing to loathe "meaningful use" criteria.  I say that with a different perspective than most clinicians.  We went on EMR in 1996 with the belief  that it would improve our quality of care and make our workflow more efficient.  We succeeded, and are doing well with our EMR (despite the fact that it is not the cutting-edge software it once was [biting tongue]).  The goal was to make the visit as efficient as possible, making the clinician and patient end up with as much useful information as possible.  I had long planned on making some sort of visit summary that would give patients a written summary of their visit, giving them something tangible to go home with.  Most patients don't remember what was said in the office visit, so having a written record of things seemed like a good thing to do. Then came the "meaningful use" criteria, that allowed us to be paid for using our EMR "meaningfully."  We met most of the criteria automatically, with the exception of the inclusion of a "clinical summary" available for the patient at the end of every visit (given 50% of the time to meet the criteria).  Our first pass at a clinical summary met the criteria:

Clinical Summary – An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.

Source

It was easily printed out from the data we had from the visit and could be generated at the end of the visit by all providers.

There was a problem: it did nothing to help the patient understand what happened in the visit.  They gave me a confused expression after looking at it.  Why were these things on their problem list?  Why was generic advice about fever, etc. included?

So I went at it from the patient's perspective: what do they want and need to know at the end of each visit?

  • What do I have?
  • Did you rule out bad stuff?
  • What should I do about it?
  • What tests are you ordering?
  • What medications are you giving me?
  • What medications are you stopping?
  • What were the results of the tests done in the office?
  • How will I get the results of these?
  • Who are you referring me to?
  • How will this referral get done?
  • When do you want to see me back again?
  • When should I call if I have a problem?

While these didn't meet exactly with the criteria, they were a good jumping off point for the final product of my work (which was a lot of work).  Here's what I produced:

I do  admit that there is a lot of gibberish still on this, as the EMR is always a good generator of gibberish (cool aliteration!), but it gets the job done and answers the questions my patients want.  When they get this, they are happy with the information (and have often told me so).  They seem impressed I could generate this so quickly as well.

For those of you docs out there wondering how I did this, here are screen shots of my EMR forms (I use GE centricity) I made:

 

That is its "virgin" state, and below is the form after meds and tests are ordered.

Clicking "print handout" generated the handout I showed earlier.  Note that there is a "preventive care" box up top, which when checked produces a summary of preventive care (which is a work in progress):

This is "page 1."  I am trying to build information that will also give care management information for people regarding their specific medical problems, like diabetes, hypertension, or those based on their risk factors.  This is part of the "GPS" tool I mentioned in my last post.

So why am I growing to loathe "meaningful use?"  I was able to turn the criteria into motivation to produce something quite useful.  But several things make me, at best, nervous, and at worst, terrified:

  • Most EMR products produce the gibberish we first gave our patients.  It's far easier to produce gibberish than to produce meaningful (nice word) information for the patient.  It's far easier to meet the criteria than it is to do the right thing, and the majority of docs don't have the familiarity with their EMR that I do to create a good summary.
  • As the next set of criteria loom, it seems more time will be spent checking the boxes for "meaningful use," taking our focus away from the patient and on the government regulations.  It was my stubbornness that allowed us to get by with a form that is actually meaningful to patients, but it took a whole lot of time and effort.

We adopted EMR so we could use it in a meaningful way, and we were.  "Meaningful Use" is a promises us money with the price of changing our focus from the patient to the criteria.  Most docs will take the easy route.  I don't want to.  I don't want to be a gibberish generator

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