Welcome to Touch Briefings

Elizabeth Klodas
American Heart Hospital Journal Volume 8 No.1

I was sitting in class the other day learning about the fine points of one of the electronic medical record (EMR) systems I would be required to work with and being spoken to like I was in second grade. I had to tab from screen to screen, click various radial buttons—no, not that one!—and try to comprehend a workflow that had nothing to do with the way I process information. Over the next few weeks I would be spending hours creating my own personal lists of standard statements to 'save me time' and ensure maximal coding potential. I would be helping create records that meet the payers' expectations—records that are so voluminous in size and so excruciatingly detailed, and so impersonal and repetitive, that paradoxically they will have lost much of their clinical utility.

I am representative of a torrential movement within medicine—to standardize, to automate, and, ultimately, to depersonalize.

If I try to unravel how we got here, I have to go back about 20 years. The EMR, as it currently exists, is simply a direct but unintended consequence of the relative value unit (RVU) payment system. I was a medical resident when the RVU system was proposed and published. I still remember intently reading the article in the New England Journal of Medicine outlining the rationale for the approach. I had no idea I was witnessing the beginning of the end of medicine as I had experienced it to that point. Everything about the RVU system appeared well-meaning at the time—finally, cognitive work would be valued on a par with technical work. However, little did we know that the devil was in the implementation, and that unintended consequences were inevitable.

It is easy to prove that you have done something technical—a patient either did or did not have his or her knee replaced. It is much harder to prove that you have spent time and effort thinking. So, although it takes as much education and experience to recognize amyloid cardiomyopathy as it does to learn to set a bone, the act of arriving at a clinical diagnosis is not as amenable to counting or timing (as you can with various procedures) for purposes of equalizing work units.

So, the act of thinking had to be deconstructed into chunks of data that contained enough buzzwords to satisfy a reader (without any understanding of the clinical dilemma at hand) to judge whether or not any, a little, or a lot of effort was put into a patient interaction. Synthesis of data was no longer prized—indeed, it could cost you valuable coding points and could make you vulnerable to accusations of fraud and abuse. What was prized was proving that what you did was hard and took time.

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