Better patient care doesn’t require more mouse clicks

FRED N. PELZMAN, MD | TECH | SEPTEMBER 15, 2013

Here are just a few of the mouse clicks, key strokes, and computer screens I need to make or navigate to

get through my day: Control-Alt-Delete. User Name. Password. Double click on the icon to load the

electronic health record (EHR). User Name again. Password again. Schedule. In-basket. Results. Patient

Calls. Rx Requests.

And that is just to get started. Before I finish my first cup of coffee.

Every patient interaction that needs to be charted for an office visit uses the visit navigator in our EHR. Best

practices and healthcare maintenance. Chief complaint. HPI. PMH. PSH. Tobacco. Alcohol. Drug use.

Sexual activity. Family history. Social history. ADL’s. Review of systems. Medications. Allergies. Vitals.

Physical exam. Diagnoses. Orders. Assessment and plan.

Each and every one of these has many layers of options to click. Endless choices and options. Multiple

requirements for the Joint Commission, meaningful use, PQRI, and more.

Do all these mouse clicks and key strokes demanded by our electronic health record really do any good?

Has anybody shown that we take better care of patients, are more efficient, do less unnecessary testing,

improve communication between physicians? Is the finished document that comes out at the end of all this

clicking really a better medical record, a more accurate tool for others to know what happened in that

healthcare interaction?

At the end of an encounter I have literally clicked that mouse dozens and dozens of times. I could have

pressed a wooden stick into soft clay tablets and recorded the whole thing in cuneiform before I am finished

with all this clicking. At least that’s how it seems.

When we first started using our new electronic health record, the nutrition department decided we needed

to include nutrition screening questions in the middle of our visit navigator for every patient. Eight questions

embedded right in the middle of every office visit.

The providers balked after a few weeks of this, and finally we got it winnowed down to a single screening

question: “Does the patient have any nutrition-related risk factors that warrant a nutrition referral?”

But if you try to skip the question, the EHR gives you a hard stop: “Unanswered advised questions in:

ADULT NUTRITION SCREEN (>20 YEARS). Do you still want to close the section?” You have to click yes or

no.

Now I’m not saying that I’m opposed to screening my patients for nutritional deficits, I really believe that

most of our patients could use all the nutritional help we can get them. But somehow smack in the middle

of the office visit seems like we have misplaced our priorities.

Right now a colonoscopy done at our institution “satisfies” the colon cancer screening field in the

healthcare maintenance section of the EHR. However the system automatically says the next one is due in

10 years; that’s the preset default we set up on day one. But that same report may have in it written text

that says a repeat is due in 1, 3, or 5 years. Manually overriding the screening frequency in the system

requires 12 clicks of the mouse.

We need to move towards making all this technology work for us instead of making more work for us.

If all this clicking could somehow become useful, allow us to do more doctoring, lead to better outcomes,

people might be less opposed to how crazy it makes our day. Moving tasks away from the providers to

more efficiently engage the patients in the process of actually getting something down and building better

patient data registries might be a good place to start.

As part of our effort to build a patient-centered medical home, we are trying to reconfigure how data gets

into the chart, and who can use it, and authorize more people to be able to act on it.

For instance, pre-visit planning and screening of patient-entered data can simplify our days. Much of this

information is needed for appropriate care, but in our efforts to become high tech we have added an

overwhelming amount of noise to the system.

Perhaps we even need to rethink how we build and keep our charts, what their true purpose is, and change

the mindset behind medical records to allow a more useful, living, breathing document to come into being.

Fred N. Pelzman is associate professor of medicine, New York Presbyterian Hospital and associate director,

Weill Cornell Internal Medicine Associates, New York City, New York.