Tuesday, August 14, 2001

Charting for Patient Care—Is There Only One Way?

A recent issue of The Journal of Cost and Quality included a letter from the editor; Bruce Gipe, MD; about charting http://www.cost-quality.com/restpast/v7i1lfe.html (sorry, the link is no longer active) in which he questioned the use of template charting and asserted that "templates are robotic; narrative charts try to tell a story." Doctor Gipe followed with, "I can’t prove this, but the process of actually writing things down seems to result in thought, questioning, introspection, review (‘If I write this Assessment down, can I actually defend it, based on the data noted in the rest of the chart?’). Doctors are supposed to think, question, review, muse—that’s what we were trained to do, that’s what patients want us to do for them. To be, or not to be—a robot—that’s the question."

Why do we have to define things as "either-or?" Why do we have to prescribe only a single approach? Why do we insist that "Doctors are supposed to think, question, review, muse . . ."? Consequently, concluding that templates are bad and dictation or legible handwriting is good. Why can't we use both, each in its proper role? Why do we as leaders create this and other false dichotomies?

In these pages commenting on quality of care (QoC) as a subset of quality of service (QoS), this past April, I asserted, "The debate is long over because reliable measurement of quality-of-care remains elusive, while quality-of-service measurement has become codified for the ED through the institutionalization of patient satisfaction surveys and measurement of patient throughput intervals."

Perhaps as professionals we've convinced ourselves that our patients want us to think, but is that always the best way to deliver and document the care as our patients seek it? I'm not so sure. From my perspective as Chairman of a busy, urban ED what I hear from patients and their families and what I’m persuaded our patients really want—at least in the ED—is expeditious, compassionate, clinically appropriate and correct care delivered without error.

Some fraction of care delivered to patients in any setting is "routine." In many emergency departments it may run as high as 80-85% of patient presentations. Feel free to argue with my estimate—that’s fine, but don't argue the number to dismiss the point that clinically routine care is best delivered in a clinically routine fashion and documented accordingly. Now, that doesn't mean unthinkingly. To the contrary, it means that best practices have been identified, codified and taught to the care providers: physicians, mid-level providers, nurses, techs, etc. Furthermore, care is monitored to assure that the best practices are adhered to and best practices are monitored to assure that complacency doesn't overtake excellence, since we know that best practices evolve based on science, patient preference and practice.

Note that I've focused first on clinical aspects of delivering care. I did that despite the fact that patients are mostly not judging that aspect of care—in the ED. Most ED patients have come to assume that the care available to them is clinically appropriate and that emergency physicians are pretty much all capable of delivering clinically appropriate, correct care. You and I may disagree, but most patients won't, until they have a life-threatening illness and then they’ll research where to go for care on the Internet. For most ED visits, they won’t, not yet, anyway.

Organizing to deliver and document clinically routine care "routinely" allows for the building of system efficiencies that enable both excellent QoC and excellent QoS. This is where reduction in variation directly benefits patients by allowing physicians the opportunity to think about their patient, not about their chart. Yes, I believe physicians should think, I just don't believe that every patient encounter—especially not the "routine" visits—requires a Pulitzer Prize winning chart. This opportunity to think about the patient, rather than remembering what and how to chart, may allow for recognition of a disease pattern—a thinking function at which the human mind excels—which otherwise would be overlooked, suppressed by the necessity of remembering—a thinking function at which the human mind frequently fails.

If physicians would more generally adopt systems that allowed for routine accomplishment of routine work—including documentation; I believe physicians would find themselves liberated to expend their greatest energy, intellect and knowledge on behalf of those patients whose problems are not routine—and better recognize when that is the case. Some patients do require the most profound, thoughtful and creative professional effort of the physician to garner the best possible outcome for the patient. I believe that most emergency physicians would find practice in this manner challenging, fulfilling and less prone to the pitfall of narrow diagnostic focus.

I believe it is the responsibility of physician leaders to bring this message to the profession and to help individual practitioners, groups and other practice organizations adopt the tools that facilitate continuing improvement of QoS and QoC for "routine" patients while enabling physicians to expend enormous best efforts on behalf of those—fewer in number—whose clinical circumstances and complexity require remarkable efforts for best possible outcome.

No service organization uses only one process to address all users all of the time. For example, when occasionally the magnetic ink on your check isn’t readable your bank processes that check with extra steps, requiring a clerk to attach a strip with the same characters that are magnetically readable. This "exception process" may only apply a tiny fraction of the time, but it’s necessary to deliver full-service. The bank makes no false dichotomy and no false economy by omitting this step when necessary.

So too, we, in emergency medicine, must not omit necessary steps nor create a false dichotomy by insisting that documenting our care must always be done in the same way. Yes, our patients require our consistent best efforts, but mostly those efforts are best documented through a structured process that supports systematically organized, highly consistent evidence-based care readily available, delivered by affable and able emergency physicians who do their work quickly. Nonetheless, in exceptional circumstances, as we deliver the most profound, thoughtful and creative professional effort on our patient's behalf, we will find structured tools—template charting—limiting. We will need more—typewriting, dictation and transcription or handwriting. Why can’t we fit the tool to the circumstances? Why can’t we have both?