I’m not sure about you, but May 27 cannot come soon enough for me. Finally, after three years, we will get the next installment of Stranger Things and another round of monsters, friendships, and 80s memories. For those of us Gen X-ers who grew up when all that retro fashion and music wasn’t retro, it’s a return to simpler days. Thankfully we didn’t have to worry about demogorgons IRL back then. Now that the 80s are sadly over, and life has steered me into a career in family medicine, I find a strange similarity between using an electronic health record system and a pivotal season 3 plotline: the zombie blob. Feel free to read on for those not familiar with this entity and are not bothered by spoilers. A small Indiana town is mysteriously finding some residents acting peculiarly in the context of otherworld creatures and Russian espionage. It turns out that the bodies of these people have been taken over by an intergalactic creature called the mind flayer, and periodically they migrate zombie-style back to a warehouse where they melt back into a larger blob, all becoming part of this enlarging and morphing creature. What does this have to do with medicine? Well, possibly a lot. For the past three years, we have been using a widely used EHR, and chances are you either use it yourself or it has your medical records on file somewhere. Like all EHRs, this system is designed to have interoperability with others, allowing communication with other systems and integrating the creation of a longitudinal record that is accurate and all-inclusive. Whether a doctor or otherwise, any medical provider can contribute to it. We all may add diagnoses, classify them, review each other’s notes, and share the entire record with a patient (which is required by law and generally a good thing). The unintended consequence of this interconnection is that, like the blob, not everything is incorporated cleanly. In Hawkins, Indiana, this may mean a body part sticking out randomly before finally being “reconciled” into the greater gooey mass. A medical record translates to 4 different physicians entering similar but not identical diagnoses for what is all one disease or an ever-lengthening list of problems for even a relatively healthy person. For example, lower spine arthritis may be named as such by one physician, “L5 radiculopathy” by another, “lumbar DJD without myelopathy” by another, and “lumbar spinal stenosis” by another. A patient with diabetes with eye, kidney, and neurological complications ends up with multiple diagnoses that can easily conflict with each other. Why does this matter? It makes these problem lists long and clunky and can cause us to miss things with too much information. Nearly every time a primary care physician opens a chart, we receive a prompt that there are “external problems that need attention.” A patient goes to see a specialist who uses a different diagnosis, then we have to add or remove the new one. Then they see a surgeon for the same issue, and it happens again. The same patient goes to a hospital on a similar but not identical platform of the same record system, and the entire problem list gets duplicated, requiring it to be reconciled again and again when the patient returns to their PCP after each hospitalization. This same patient sees a dermatologist or ophthalmologist in another state or whose practice has also joined the same EHR. Those physicians may each add multiple specialty-related diagnoses that the PCP doesn’t need on the patient’s active problem list, and we have to reconcile those too. The system frequently identifies that a patient has a high BMI and thereby alerts us in the EHR equivalent of all-caps that we need to add and discuss the diagnosis of morbid obesity, even when the patient isn’t ready to talk about their weight. This even occurs when the patient is at the office for a specific problem such as migraines. By no means is it not essential to address obesity-related medical ailments, but there is a time and place for all things. It doesn’t sound like such a big deal, right? Isn’t this just part of our job to continually review and update problem lists? My point is that each time we are continually asked to reconcile more and more information, it’s more time that we are not spending talking to our patients; instead, we are scrolling through all this information either on our own time or during a visit, making eye contact and personal connection minimal. Is the interconnectivity of records important? Of course. If a patient had a significant diagnosis or treatment when they lived 1,000 miles away but forgot to tell us about it, the system can alert us to that, which is desirable and working as designed. It is the duplicative nature and the focus on classifying diagnoses to their highest degree of specification rather than the effect that these diagnoses have on the patient’s quality of life that has physicians feeling burned out. More importantly, it leaves patients feeling like their physician is also part of this blob. One suggestion I have posed for fixing this issue includes having specialists participate in keeping the problem list tidy. A more realistic and palatable solution may be to have the system itself be programmed so that it is held accountable for merging similar diagnoses into one automatically. Ideally, this may still include the subdiagnoses clearly visible under the main diagnoses. Otherwise, all these diagnoses remain listed on one long list, or each physician must manually sort them and categorize them to separate what they don’t need to see. By the time anyone reads this, season 4 will be streaming, and the blob from season 3 will probably be old news. The EHR will continue its gradual spread across the pumpkin patches and fairgrounds of the medical system while physicians and patients try to outrun it. Meanwhile, I will try to keep doing my job, one patient at a time, attempting to block out EHR minutia that is not patient-centric. It’s the only way to stay on the right side up of the Upside Down. Source
