Earlier this week, I was pleased to learn that my practice had achieved a statistically significant increase in box clicking.

In reviewing data from our accountable care organization, graphs were shown to us demonstrating improved compliance with several of the measures that they’ve instituted institution-wide for the purpose of reporting back to Medicare on how well we are taking care of our patients.

One of these measures is the ever popular “falls prevention” button.

This one, along with several other measures, is presented to the provider within the electronic health record over the course of a patient’s visit.

Providers are supposed to document that they have screened patients for falls, by asking whether or not a patient has fallen in the past six months, and if they have, what is being done about it.

Clearly, this is being done with the best of intentions. As I’ve discussed multiple times before, falling for our patients is, in general, a bad thing.

As part of putting these initiatives into place, the institution has gone practice to practice and tried to figure out ways to increase compliance with getting these boxes clicked.

The institution needs to report on how we are doing on these measures, as someone farther up the line has decided that these are reflections of the quality of care we provide.

We know that during the course of each visit there are countless different things that pull our attention in multiple different directions, and that it is often hard to remember to get to all the things we need to get to.

Are their vaccines up to date? Has appropriate cancer screening been done? Are they taking their medicines? Have disease-specific testing and referrals been appropriately ordered and completed?

But did we not learn our lesson from mandating pain as the fifth vital sign?

Years ago, our electronic health record was changed so that a pain score had to be entered for every patient at every visit in primary care. (Interestingly, this is not mandated in other locations where pain might be relevant, such as pain management clinic or surgery.)

None of the rest of the vital signs, no matter how “vital” we consider them, are mandated as “hard stops.”

So patients with hypertension can be seen for a blood pressure check without having their blood pressure measured, but they cannot leave our practice that day without us knowing what their pain score is.

Similarly, another hard stop in the EHR is medication reconciliation.

Incredibly important, maintaining an accurate medication list will prevent innumerable mistakes, potential harm to patients, dangerous drug-drug interactions, and even save lives.

But as we’ve often seen, this button gets clicked without the actual work of medicine reconciliation being done.

Earlier this week we saw a patient who had a really long list of medicines on her chart, including many that she had not taken for many years. A look back at multiple notes across multiple practices where multiple providers had seen her from multiple specialties showed that everyone had happily clicked the medication reconciliation button, while no one had really cleaned up the med list.

Pain: 0. Medications reconciled: check.

Getting back to falls prevention.

If we can figure out a way to prevent our patients from falling, that’s a really good thing.

Falls lead to fractures, concussions, pain and misery, and worse.

But look at the choices that are made available in the EHR as actions to take when the patient screens positive for having fallen.

These include referring the patient to physical therapy, and/or reviewing their medication list for possible culprit medicines that lead to an increased risk of falls.

What I wonder is, did the people who decided that this was something we needed to measure, and that these were the interventions that were going to be suggested to us, ever really study patients who have fallen, to find out whether taking these actions actually did some good?

There will certainly be instances where a frail, elderly patient that is at increased risk of falling, or someone who has already fallen, may be brought to our attention through this mechanism, and thus force the provider to re-examine their medication list and possibly remove extraneous medicines that are associated with imbalance and increased risk of falling.

And certainly, physical therapy may be of enormous benefit to patients who are deconditioned or in need of an assistive device, and should be part of what we all do for our patients at increased risk of falling.

But we’ve accepted that these boxes, this clicking, should be how we let our patients get care, and maybe the only way we end up addressing their fall risk.

Do we know that clicking these boxes that say we are going to change their medicines actually led to changing medicines?

And do we know that clicking “referred to physical therapy” actually led to any actual physical therapy?

And do we know that our patients fall less as a result of these interventions?

Perhaps people smarter than me are studying these things, collecting data, analyzing away in the background.

But as far as I can tell, mandating that we click a bunch of checkboxes has really, as it has so many times in the past, only led to us clicking more boxes.

What I really want is a comprehensive, all-encompassing, deep-dive evaluation of all of our patients, to make sure they don’t succumb to whatever it was that made them fall, or whatever it is that is going to make them fall.

Better predictive models, better evaluations in the office, mandatory care instead of mandatory clicking.

Wouldn’t it be wonderful if new machine learning programs and artificial intelligence could take a look at our patients as they walk into the practice, or even better walk from the parking lot or the subway towards our office, and pinpoint those with an abnormal gait, a hesitation or stumble, something that the computer is smart enough to figure out and tell us “this patient is going to fall.”

Then by the time they arrive in our office, we will be ready to attack them full force with a pharmacist to go over their medicines and remove offending agents, a physical therapist to develop a strengthening program and recommend assistive devices, a community care worker to go into their home to do a falls safety assessment, and engagement of their family and the rest of the care team to help make sure Grandma doesn’t fall down.

Just the other day, one of my partners walked into my office with an exasperated look on her face. She had just gone through her mail for the past week, and received multiple letters from multiple different insurers, each one containing huge reams of data on her performance on dozens and dozens and dozens of measures.

Some were highlighted green, some were yellow, and some were red.

Red is bad.

She asked me, am I in trouble? What am I supposed to do with all this? How am I supposed to figure out which patients these apply to, and what can I possibly do to make it better? Am I a bad doctor?

Everyone’s gotten into the measuring business, but measuring for the sake of measuring won’t make our patients better.

Free up our nurses, so they can spend time with patients, not prior authorization. Give our providers time so they aren’t rushing into the exam room, staring at the computer screen, feeding the EHR, and running out.

Resources, time, clinical support, and a community of providers with multiple skill sets all practicing up to their licenses, is the only way that our boxes are all going to get clicked, our measures will all be green, and our patients will truly be better.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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