How can we possibly get to standardization in medicine? And is that a good thing?

Standardized checklists save lives; rigid procedures for sterilization of equipment saves lives; universal compliance with recommended beneficial treatments saves lives. And while it’s sometimes a wonderful thing to let a surgeon solve a problem creatively or to allow a patient visit to go overtime in order to let the full story come out, for many other things, standardization is worth achieving.

As our massive institution moves towards a unified electronic medical record (EMR), there has been a well-meaning effort to standardize how we do things across every part, in every clinical setting. As you can imagine, this raises a lot of issues, creates a lot of resistance among those being asked to change their behaviors and how they interact with the EMR, and often an enormous amount of frustration. It is clear that as multiple voices have given input into how the “new” electronic medical record is built, and how we use it in so many different ways, that we’ve ended up with a mishmash of systems that far more often get in the way of caring for patients than really doing what we think it needs to do.

The “superuser” and the “piler on”

Take something as simple as documenting an office visit in the outpatient setting for the ongoing care of a couple of chronic medical conditions or an acute complaint. We’ve seen at our practice, as well as other sites, that people use the functionality of the electronic medical record with widely varying degrees of skill.

We see “super users” who engage every bell and whistle, every macro and doodad, clicking every box and invoking every smart phrase and fast-track templated solution. There are those that we call the “pilers on,” those who simply take the last office visit note and add on the update, what’s happened since they’ve been seen last, what’s happening today. And there are those who do the bare minimum, clicking just the boxes that need to be clicked, and getting on with things. Finally, there are those who use the EMR only as a word processor, opening up one text field and typing away their entire SOAP note, and then calling it a day.

Wait — there’s one more type, those who still hand-write their notes on old lined pieces of hospital chart paper, and then scan that into the system.

I’m not going to speak to which one of these styles is best, and I don’t think we’ll ever be able to teach all the old dogs to do all the new tricks in all the same way. But the whole point of an electronic medical record is to make our lives easier, to communicate our thoughts in the moment of taking care of our patients, and leave a record that helps make sure the next person taking up the care of that patient knows what came before.

The questionnaire conundrum

We have been working on a process to standardize many of the screening questionnaires that are asked across our institution, whether screening for domestic violence, substance use disorders, depression, or suicidality. Large workgroups with multiple stakeholders have put in countless hours trying to figure out the best way, the best questions to ask, the best way to present this to help our patients answer these things in a safe and private environment, to help us give them the care they need. We have been working closely with the development team of the electronic medical record, and we are getting close. But just recently, I discovered that the same questions, these same questionnaires, are not going to be the ones that will be used when our patients are seen in psychiatry.

Pain scores are another example. For years at our practice, we’ve included pain scores in the vitals that our medical technicians take when they bring the patients into the room at the start of a visit. Their blood pressure, pulse, respiratory rate, oxygen saturation, temperature, height, and weight. And then they hear that ubiquitous question, “Are you having any pain?”

Since pain was added as the fifth vital sign many years ago (which, some people argue, may have contributed to the development and furtherance of the opioid crisis as doctors and other providers were encouraged to drive pain scores ever closer to zero), it has been a Joint Commission requirement and a “hard stop” within our electronic medical record. You cannot finish a visit, cannot close an encounter, cannot send out a bill for the care you provided, until a pain score has been noted in the chart. So even if a patient is just there for a blood pressure check, or to go over their labs, or to have us perform any one of a myriad of medical care that really don’t need to know whether they’re in pain, we need to put some number in the system.

Leaving aside whether this has created a lot of mythical pain-free patients, I just recently discovered that they don’t have to document pain scores at our pain management clinic.

Too many cooks in the broth

Things like this have developed from having multiple different cooks spoiling the broth, too many people coming at the healthcare system with their varied agendas, their bureaucratic requirements, their efforts to do quality improvement or performance enhancement. When an insurance company tells providers that they need to show them how often they do X or Y, somewhere someone gets excited about this and adds it into the system so that we need to report on X or Y without fail, in order to get a good report sent off to those who asked for it.

Collecting accurate data, and creating effective functioning charts for patients, are noble goals we should all aspire to. We hope that the opportunities are there as electronic medical records continue to develop for the voices of those taking care of patients to be heard more clearly as we cry out for help. Data can be amazing and can help us determine whether we are missing certain healthcare opportunities for our patients, and it can lead to efforts to address and remove healthcare disparities.

But if we do it one way at one practice, and another way somewhere else, then we’re never going to be able to compare these apples and oranges. As systems get more and more sophisticated, and we begin to be able to mine data directly from the text we write about our patients, then the ways we record this information needs to become standardized, and ultimately will become more relevant and useful. So if you’ve got pain in the emergency department, then you should have pain here in my practice, and you should have pain in cardiology. If we’re required to reconcile your medications list at every office visit in adult internal medicine and pediatrics practices, then surely we should have to do the same in neurology, urology, and surgery.

I can only hope that the electronic medical record that we build across our vast institution is not only kinder and gentler, but more intelligent, more streamlined, and more standardized, making the lives of our patients and all of our providers go more smoothly.

If not, then there’s lots more pain to come.

Fred N. Pelzman is an internal medicine physician who blogs at MedPage Today’s Building the Patient-Centered Medical Home.

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