Electronic Medical Records

What Is HIPAA Protected Health Information?

Recently, a physician in Indiana publicly revealed that a 10-year old child rape victim from Ohio had to travel to Indiana to get an abortion. Some in the media stated that the physician should be prosecuted for violating HIPAA privacy laws. But did she?

I recently encountered a second HIPAA question. When asked if she had received a COVID vaccine, an acquaintance who is opposed to vaccines told me: “If I told you, I would be breaking the HIPAA law”. But would she?

Both of these cases illustrates common misconceptions about HIPAA and how HIPAA can be weaponized, in the first case by abortion prohibitionists and in the second case by anti-vaxxers.

HIPAA is the Health Insurance Portability and Accountability Act of 1996 that set a national standard for the protection of certain health information. In other words, it set into law what a healthcare provider can and cannot say publicly about patients. The penalties for not complying with HIPAA are severe. Violators can be subject to civil penalties of $100 – $50,000 per violation (depending on circumstances) and up to $1,500,000 total per year. In addition, violators can be subject to criminal penalties of up to $250,000 and 10-years imprisonment. Hospitals, health insurance companies, and others who manage health information are highly motivated to maintain strict compliance programs to ensure that all employees adhere to HIPAA requirements.

At the core of HIPAA is protected health information that cannot be made public without a person’s consent. The law identifies 18 specific personal identifiers that are considered to be protected health information when those personal identifiers are associated with information about a person’s physical or mental health:

  1. Name (either full name or last name + first initial)
  2. Address and geographic locators smaller than a state EXCEPT for the initial three digits of a zip code if the geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people
  3. Dates (other than year) directly related to the patient including:
    1. birth date
    2. admission date
    3. discharge date
    4. death date
    5. age in years (only if older than 89 years of age)
  4. Phone numbers
  5. Fax numbers
  6. Email addresses
  7. Social security number
  8. Medical record numbers
  9. Health insurance beneficiary numbers
  10. Account numbers
  11. License and certificate numbers
  12. Vehicle license plate numbers and motor vehicle identification numbers
  13. Device serial numbers and identifiers
  14. Web URLs (uniform resource locators)
  15. IP (internet protocol) addresses
  16. Biometric identifiers (finger prints, voice prints, retinal prints)
  17. Facial photos or other personally identifying images
  18. Any other unique identifying number, characteristic, or code

The HIPAA law does not apply to everyone. The specific groups covered by HIPAA are: (1) healthcare providers, (2) health plans and insurance companies, (3) health clearinghouses, and (4) business associates. There are exceptions in order to permit a person’s health information to be disclosed for treatment, payment, and healthcare operations. For example, this permits a physician consultant to convey a patient’s health information in a referral letter to the patient’s primary care physician. It also permits a physician to submit payment for healthcare services rendered to the patient’s health insurance company. In addition, a person can give written consent for a physician or hospital to release their medical records, for example, for a life insurance application or for a disability determination.

HIPAA permits use and disclosure of personal health information, without an individual’s authorization or permission, for 12 specific national priority purposes:

  1. When required by law
  2. Public health activities
  3. Victims of abuse or neglect or domestic violence
  4. Health oversight activities (eg, Medicare audits)
  5. Judicial and administrative proceedings
  6. Law enforcement
  7. Functions concerning deceased persons (such as identification)
  8. Cadaveric organ, eye, or tissue donation
  9. Research, under certain specific conditions
  10. To prevent or lessen a serious threat to health or safety
  11. Essential government functions (eg, military operations and national security operations)
  12. Workers’ compensation

So, let’s go back and take a look at the first case. Did the Indiana physician violate HIPAA laws by publicly disclosing that a 10-year old from Ohio had come to Indiana to get an abortion? The child’s age (in years) was mentioned but that is permissible under HIPAA as long as the patient is younger than 89-years-old. No birth date or hospital admission date was listed. Neither the girl’s name nor any personal identifying images or numbers were listed. The physician disclosed that the girl lives in Ohio, however, it is permissible under HIPAA to disclose the state that the patient lives in. Although the physician did not disclose that the girl lives in Columbus (as was later reported by the Columbus Dispatch newspaper), the physician could have done so since the first 3 digits of the Columbus zip codes are 432.. and the total population of all 432.. zip codes is greater than 20,000 people.

The verdict: the physician did not violate HIPAA.

In the second case, the woman stated that she could not publicly reveal whether or not she had received a COVID vaccine. Would doing so have been a HIPAA law violation? HIPAA only applies to release of personal health information by healthcare providers, insurance organizations, and business associates. It does not apply to the general public and certainly does not apply to personal disclosure by oneself.

The verdict: voluntarily stating whether or not you have received a COVID vaccine does not violate HIPAA.

The HIPAA law provides important protections to the public by prohibiting release of people’s personal health information without their permission. But there are many misconceptions about HIPAA and it is often used as a justification for political or social agendas.

July 17, 2022

Electronic Medical Records Medical Malpractice Outpatient Practice

The REMS Program And Abortion Laws – What Every Physician Needs To Know

If you or the doctors at your hospital prescribe any of these 11 drugs and live in states that have abortion laws, you need to take action IMMEDIATELY. The medical malpractice implications of teratogenic drugs (those that can cause embryofetal damage) are changing and physicians who prescribe these drugs need to protect their women patients from fetal damage and to protect themselves against future lawsuits.

The FDA created the REMS program (Risk Evaluation and Mitigation Strategy) in 2007 as a way to be sure that physicians take appropriate precautions when prescribing certain high-risk drugs. Typically, the REMS program will recommend physicians to have specific training and certification before being allowed to prescribe these drugs. The problem is that hospitals and pharmacies rarely verify that a physician has been certified for drugs on the REMS list and as a consequence, many physicians prescribe them without having the proper certification. Currently, the FDA lists 60 such drugs on the REMS website. I am most familiar with the REMS drug, mycophenolate mofetil. During my career, I have prescribed mycophenolate… a lot of mycophenolate… typically as an immunosuppressant for various lung diseases.

Mycophenolate, a REMS medication

Mycophenolate mofetil is often sold under the brand names CellCept or Myfortic. It is commonly used in patients who have undergone organ transplant to prevent rejection of those organs. It is also commonly used as an immunosuppressant drug to treat various autoimmune diseases. When used properly, it can be life-saving and is considerably safer than older immunosuppressant drugs, such as cyclophosphamide. In many patients, it is also safer than corticosteroids such as prednisone. The biggest problem with mycophenolate is that it is highly teratogenic. Overall, about half of women who become pregnant while taking mycophenolate will have a miscarriage and 1 out of every 4 live births have serious congenital malformations. Because of the very high risk of embryofetal damage, mycophenolate was added to the FDA’s REMS drug list in 2012.

The mycophenolate REMS requirements are:

  1. Physicians need to apply to the mycophenolate REMS website and undergo an on-line training program before prescribing mycophenolate.
  2. Once certified to prescribe mycophenolate, physicians must educate patients about the risk of miscarriage and fetal harm.
  3. Physicians must insure that women of childbearing potential use adequate contraception – preferably either vasectomy, tubal ligation, or an intrauterine device. In the absence of any of these 3 methods, women must use 2 forms of other approved contraception (for example, birth control pills + condoms).
  4. Women should have a pregnancy test at every office visit.
  5. Woman should be counseled about emergency contraception (Plan B) in the event of intercourse without adequate contraception.
  6. Women must be given the printed REMS information about mycophenolate precautions.
  7. Women should sign an agreement form acknowledging that they understand the risks of mycophenolate and agree to the requirements of the REMS program (note: this requirement was discontinued in January 2021).

All too often, I would see women of child-bearing potential in my office who had been started on mycophenolate by other physicians and who had never been informed about the REMS program. Frequently, these women were not using adequate contraception and were not undergoing regular pregnancy testing. Until last month in Ohio, if a woman became pregnant while taking mycophenolate, we could recommend pregnancy termination. Now, that is no longer an option if it is more than 6 weeks after her last menstrual period and the Ohio legislature has signaled that later this year, it intends to make pregnancy termination illegal in all pregnancies from the time of conception.

The heightened risk of malpractice lawsuits

The implication of anti-abortion laws, such as Ohio’s, is that if a woman becomes pregnant while taking mycophenolate, then there is a 25% chance that her baby will have severe congenital deformities. Children with these deformities can require life-long care and can be very expensive for families. Women taking mycophenolate because they have had an organ transplant or because they have chronic diseases such as lupus are generally not in a good position to provide care for the life of a child with serious birth defects and usually do not have the financial resources necessary for that care. This is especially true for my patients who have undergone lung transplant – the life expectancy after transplant averages about 6 years so these women will not be alive to care for a child with severe deformities.

We live in a litigious society. When faced with the birth of a child who will never grow up to be a normal adult and will incur large healthcare costs, women (or their widower spouses) will seek financial compensation to pay for these costs. Every personal injury attorney in the country knows that the person to name in a lawsuit is the person who has the most money. Hospitals and physicians are the ones with the most money. If a physician prescribed mycophenolate without having REMS certification to prescribe it or if there is no documentation that a woman was educated about pregnancy risks with mycophenolate, then that physician will be highly vulnerable in a malpractice suit.

The best defense for physicians is to get REMS certification before prescribing mycophenolate and adhere to the REMS requirements when prescribing it to any woman with child-bearing potential. The best defense for hospitals is to ensure that every physician prescribing mycophenolate has REMS certification. Electronic medical records make it easy for hospitals to determine which of their physicians are prescribing mycophenolate or other REMS drugs.

What other drugs are on the REMS list?

There are a variety of reasons that the FDA may put a drug on the REMS list. Some are on because of a high risk of anaphylaxis (Palforzia). Some are on because of a high risk of neurological toxicity (Abecma). Some are on the list because of risk of neutropenia (clozapine). Others are on the list because of a risk of over-sedation or addiction (buprenorphine). Of the 60 drugs on the REMS list, 11 are on the list because of the risk of embryofetal toxicity. The following is a list of these 11 drugs and what physician specialties are likely to be prescribing them.

A recent article in the American Journal of Obstetrics & Gynecology lists 141 drugs that are definite teratogens and 65 drugs that are considered to be potentially teratogenic. Of these 206 drugs, only 11 are included on the REMS list. However, the risk of embryofetal toxicity exists with all of these drugs and therefore the risk of medical malpractice lawsuits exists should a woman become pregnant while taking any medication known to be teratogenic and then develops fetal abnormalities.

Currently, 3% of all abortions performed in the United States are because of fetal abnormalities. This works out to about 28,000 per year. In states that ban abortion, these fetuses will go on to be infants with severe birth defects. The implication is that in the future, there will be potentially thousands of new malpractice suits filed each year against physicians who will be blamed for these birth defects because they prescribed a teratogenic drug to a woman who could not legally have her pregnancy terminated.

What physicians need to do right now

In medicine, doctors recognize that prevention is the best cure. The same goes for malpractice lawsuits. The best time to prevent a malpractice suit about a birth defect is before the woman becomes pregnant. To that end, there are measures that all physicians practicing in abortion-ban states should take now:

  • Know which drugs are teratogenic. The recent list from the American Journal of Obstetrics & Gynecology is a good starting point.
  • If you prescribe one of the 11 teratogenic drugs on the FDA’s REMS list, get your REMS certification and follow the REMS requirements.
  • If you prescribe a teratogenic drug that is not on the REMS list, develop a process for educating women of child-bearing potential about the risks of the drug.
  • Document, document, document. Include information in your office notes documenting patient discussions about drug teratogenicity, about contraception advice, and about any printed information that you gave them. 
  • Consider signed acknowledgement forms. In the past, this was a requirement of the mycophenolate REMS program. Even though it is no longer required by REMS, a signed form scanned into the electronic medical record is still a good practice since it can provide very strong malpractice defense.
  • Get comfortable recommending contraception. I have become at ease discussing contraception with my patients and their partners. If the woman is done having children, vasectomy is usually the safest and most effective option. For other women, I am a proponent of IUDs and although I do not place them myself, I know who to refer women to in order to get one. 
  • Educate women about Plan B. The “morning after pill” is available at pharmacies over the counter without a prescription and is effective up to 3 days after unprotected intercourse. Include information about Plan B in the educational materials you give patients when prescribing any teratogenic drug.
  • Understand your state’s abortion laws. In some states, it is (or will be) illegal for a physician to even discuss abortion with a woman or to advise her to travel to another state where abortion is legal. Be very careful what you write in the chart. A note in the electronic medical record stating: “She is 6 weeks pregnant while taking mycophenolate so I recommended she go to the Acme Abortion Clinic across the state line” could be your invitation for a prison sentence and revocation of your medical license. 
  • Do a malpractice insurance check-up. For physicians in Ohio who care for adults, there is a 1-year statute of limitations for filing a malpractice lawsuit. But for cases involving children, that statute of limitation extends to 1-year after the child’s eighteenth birthday. In other words, a physician who prescribed a teratogenic drug to a pregnant woman can be sued by the child 19 years later. Be sure that you either have a comprehensive claims-made policy or a tail coverage policy that will provide coverage long after you retire or leave your practice.
  • For hospital medical directors and administrators, use your electronic medical record’s prescribing database to identify physicians who prescribe REMS drugs and require that those physicians be REMS-certified.
  • For medical schools, education during pharmacology courses about teratogenicity and about the REMS programs has suddenly become considerably more urgent.

Abortion prohibitionists have long set their sights on laws to criminalize abortion. There are a myriad of unintended consequences of banning abortion and many of the the socioeconomic consequences will not be fully recognized for several years. For physicians, waiting several years to protect against medical malpractice suits for prescribing a teratogenic drug will be too late. The time for physicians and hospitals to protect their patients and themselves is right now.

July 16, 2022

Electronic Medical Records Outpatient Practice

We Need National Telemedicine Tumor Boards

Tumor boards have been shown to improve cancer outcomes by incorporating the expertise of many specialists in order to formulate a personalized treatment plan for each patient. These interdisciplinary management plans can give patients the best chance of cancer control or cure. Tumor boards typically consist of a surgeon, a medical oncologist, and a radiation oncologist but may also include a pathologist and a radiologist. Organ-specific tumor boards may consist of other specialists. For example, a thoracic tumor board may include a pulmonologist or a GI tumor board may include a gastroenterologist. Tumor boards allow specialists to bring their own expertise to an individual patient’s cancer treatment plan in order to determine the timing of surgery, the use of adjuvant or neoadjuvant chemotherapy, and the use of radiation therapy.

Summary Points:

  • Recent advances in cancer care have led to the evolution of different cancer-specific tumor boards
  • There is an unmet need to bring these cancer-specific tumor boards to rural and underserved areas of the country
  • Telemedicine tumor boards offer an opportunity to improve cancer treatment to all Americans
  • There are a number of obstacles that need to be addressed before national telemedicine tumor board implementation


Tumor boards have become even more important as advances in cancer genetics have resulted in many new treatments based on the molecular make-up of individual cancers. The advisability and timing of these newer treatments such as immunotherapy and driver-directed therapy can also be incorporated into the patient’s cancer treatment plan during tumor board discussions. Also, patients eligible for clinical trials of promising experimental treatments can be identified during tumor board discussions and enrolled in research studies.

In large medical centers, tumor boards typically meet once every week or two weeks. In smaller hospitals, tumor boards meet less frequently, often monthly. Each patient’s history, physical exam, radiologic staging study results, and tumor pathology results are reviewed. Specialists then develop a personalized cancer treatment plan tailored for that patient. A tumor board is far more efficient than having the patient see multiple physician specialists in their office for separate consultations and then having the physicians forward their individual recommendations to the primary care physician for coordination of care.

Survival of most cancers has improved significantly over the past several decades, largely due to development of new medications to treat cancers and to advances in cancer screening. But cancer is not one disease and cancer treatment has also become highly specialized. Oncologists used to be cancer generalists who were expert in the treatment of all forms of malignancy but now, medical and surgical oncologists specialize. The result is that there are different medical oncologists who treat lung cancer, gastrointestinal cancers, skin cancers, breast cancer, etc. As a consequence, tumor boards have also become specialized with different tumor boards for lung cancers, gynecologic cancers, and breast cancers. Large academic medical centers will often have 8-10 different tumor boards, each for a different type of cancer.

This specialization of oncologists and of tumor boards has posed a challenge for smaller hospitals and rural hospitals that do not have the luxury of multiple medical oncology specialists, surgical oncologists, or gynecologic oncologists. These hospitals either have to rely on general surgeons, general medical oncologists and general tumor boards or have to refer their newly diagnosed cancer patients to large medical centers for subspecialty evaluation that can sometimes be hundreds of miles away.

In the past, tumor boards were held in hospital conference rooms with physicians attending in-person. The COVID-19 pandemic showed us that multidisciplinary conferences could be just as effective when performed remotely. For more than 15 years, I led our medical center’s multidisciplinary interstitial lung disease conference which is the equivalent of a tumor board for non-cancer diseases such as pulmonary fibrosis. We found that our interdisciplinary discussions were just as easily done by a Zoom or Teams meeting as they were by in-person conferences. In fact, we had better attendance when the conferences went remote because physicians who practiced at off-site clinics could more easily attend.

A 2014 proof of concept study involving two Veterans Administration hospitals showed that virtual telemedicine tumor boards were both feasible and well-accepted by participants. The COVID-19 pandemic forced most hospital tumor boards to convert to virtual meetings. A study from the University of Pittsburgh demonstrated that virtual tumor boards during the COVID pandemic were very effective. But can we develop virtual tumor boards utilizing telemedicine technology to bring multidisciplinary expertise to smaller hospitals in order to improve cancer outcomes in rural and underserved areas of the country?

Lessons from institutional review boards

Institutional review boards (IRBs) are sometimes referred to as “human subjects committees” and are multidisciplinary groups that review clinical trials in medicine to ensure that medical experimentation involving humans is performed ethically and with appropriate study design. In the past, each hospital had its own IRB composed of volunteer reviewers. The volume of study proposals and the burden of IRB meetings by physicians, university faculty, and lay public members often resulted in long delays in getting clinical trial proposals approved.

In 1968, the Western Institutional Review Board was founded as an independent ethical review organization that allowed hospitals to outsource their clinical trial reviews for a fee. Hospitals no longer needed to rely on internal human subjects committees and Western was able to turn proposals over more quickly than the hospital IRBs. Our university outsources most of our clinical trial reviews to Western and this has greatly expedited research. Over time, more independent IRBs arose and consolidated. Now, most clinical trials undergo their ethics review by independent IRBs such as Western (now known as WCG IRB). These independent IRBs can match ethics and research specialists with specific clinical trials in order to provide superior reviews in a shorter period of time.

Our nation’s tumor boards can learn a lot from the independent IRBs. By assembling a large group of specialists in the treatment of each type of cancer, state-of-the-art recommendations individualized to each patient’s cancer can be made anywhere in the country, or for that matter, anywhere in the world. And those recommendations can be made faster, thus allowing patients to get started on optimal treatment as quickly as possible. A criticism of American cancer research is that racial and ethnic minorities are often underrepresented as subjects in clinical trials. By better reaching these minorities through telemedicine tumor boards and identifying clinical trial candidates, such disparities could be reduced.

Barriers that need to be overcome

There are several obstacles that need to be addressed before national telemedicine tumor boards can be implemented:

  1. Medical licensure. In telemedicine, the medical encounter is legally considered to occur at the patient’s physical location and not the doctor’s location. As a consequence, physicians providing telemedicine must be licensed to practice medicine in the state that the patient is in at the time of the telemedicine encounter. A physician in Ohio cannot legally provide telemedicine care to a patient located in Florida unless that physician has a Florida medical license. For this reason, state-specific telemedicine tumor boards would be easy to implement from a medical licensure standpoint but a national telemedicine tumor board would require physician participants to have dozens of individual state medical licenses. The development of the Interstate Medical Licensure Compact may simplify the process of obtaining medical licenses in many states but not all states participate in the Compact. A national telemedicine tumor board could perhaps most easily be implemented in the Veterans Administration system since VA-employed physicians can practice in any state as long as they are licensed to practice in any one state.
  2. Cost. Physicians participating in hospital tumor boards are generally not compensated for their time – they participate pro bono as part of their professional duties to the hospital. A 2021 study from a single academic medical center found that the total cost in physician time to participate in the hospital’s 9 separate tumor boards was $648,183 per year. Currently, there is not a mechanism to pay for national telemedicine tumor boards and this would need to be addressed by Medicare and commercial insurance policy changes. Alternatively, this could be financed by subscription fees charged to participating hospitals.
  3. Radiographic and pathologic review. Like medical oncology and surgical oncology, radiologists have become subspecialized. Chest CT scans of patients with lung cancer are reviewed by a thoracic radiologist whereas brain MRIs of patients with brain tumors are reviewed by a neuroradiologist. Pathologists have become similarly subspecialized. Tumor boards at large academic medical centers are usually attended by the subspecialty radiologists and subspecialty pathologists who originally reviewed the patient’s materials. Smaller hospitals will typically only have general radiologists and general pathologists. A mechanism would need to be in place so that subspecialty radiologists could review original radiographic images and subspecialty pathologists could review full slides of tumor biopsy specimens. There are existing telemedicine solutions to both of these challenges but this could require smaller hospitals to purchase equipment and software to transmit radiographic and histologic images.
  4. Malpractice insurance. When a physician’s name appears on a treatment recommendation, that physician can be named in event of a medical malpractice lawsuit. Several years ago, I was a defense expert witness in a malpractice case involving a patient with a rare eosinophilic lung disease. The pathologist reviewing the lung biopsy slides called a pathologist in a different city who was a national expert in pulmonary pathology and asked that pathologist over the phone about the diagnostic significance of all of the eosinophils that were present on the biopsy slides. The second pathologist was named in the suit, even though he had only spoken by phone with the initial pathologist and had not, himself, seen the actual biopsy slides or provided a formal pathology report. Malpractice insurance coverage would need to be worked out before implementing a national telemedicine tumor board. Board participants would either need to have immunity against civil litigation or would have to be provided telemedicine malpractice insurance.
  5. Medical record access. Tumor board participants must have access to patients’ medical records. Many factors need to be considered when formulating a cancer treatment plan including laboratory test results, radiologic images, medication lists, drug allergies, past medical history, family history, social history, and the physical exam. All of these data must be available to tumor board specialists for them to provide the best recommendations for any given patient. Electronic medical records have improved physicians’ ability to access medical information at other hospitals, such as the ‘CareEverywhere’ app on Epic’s electronic medical record. Nevertheless, not all electronic medical record software are equally good at permitting cross-hospital patient information transfer. The success of a national telemedicine tumor board would be contingent on development of robust integrated electronic medical record networks.
  6. Patient selection. Not every cancer patient needs to be presented at a tumor board. For example, the management of a patient with stage 1A non-small cell lung cancer is pretty straight-forward – they get a lung lobectomy. But cancer treatment guidelines change rapidly and it can be difficult for the general oncologist or the general surgeon in a small, rural hospital to keep up with these guidelines. Not too many years ago, the standard of care for stage 1B lung cancer was surgery alone but several years ago, adjuvant chemotherapy was added, followed more recently by neoadjuvant chemotherapy. Last month, a study showed that neoadjuvant chemotherapy plus immunotherapy was better still. There would need to be some process in place to identify those patients who would benefit most from a national telemedicine tumor board. One option could be to refer only those patients that general tumor boards identify as needing discussion at a subspecialty telemedicine tumor board.

Somebody is going to make a fortune

Successful entrepreneurs identify unmet consumer needs and then figure out a way to meet those needs. Those who are successful in a large consumer market become wealthy. Providing specialized cancer treatment recommendations is currently an unmet healthcare need in much of the United States and throughout most of the world. A national telemedicine tumor board has the potential to be an enormous commercial success and has the promise of making whoever can pull it off rich.

However, most physicians did not go into medicine just to be wealthy, we go into medicine so that we can improve people’s lives. I can think of few better ways of improving large numbers of people’s lives than by ensuring that every cancer patient in the U.S. has access to prompt treatment recommendations from specialists up to date on the latest in evidence-based oncology. It is time for national telemedicine tumor boards.

June 22, 2022

Electronic Medical Records Inpatient Practice

Are Verbal Orders A Patient Safety Concern?

Hospitals have a love-hate relationship with verbal orders. On the one hand, they can expedite care to the patient and can save physicians time. On the other hand, they can increase medical errors. Some groups believe strongly that the goal should be to have zero verbal orders whereas others believe that there should be no barriers to verbal orders. Electronic medical records have reduced the use of verbal orders in some situations but promoted the use of verbal orders in others.

The Joint Commission, the Leapfrog Group, the Institute of Medicine, and the Institute for Safe Medical Practice have all called for reducing or eliminating verbal orders. Nursing groups often see verbal orders as dangerous because of the risk that a verbal order error will place nurses in a position of liability. The Health Systems Management Society that determines best practices in hospital medical record keeping has set a goal that verbal orders should be < 10% of a hospital’s total inpatient orders and < 5% of a hospital’s total outpatient orders.  The literature is rife with anecdotes of the nurse who thought a doctor said to give a patient 10 mg of Viagra when the doctor actually said to give 10 mg of Allegra. The reality is that verbal orders can both improve patient safety and worsen patient safety.

Electronic medical records have reduced verbal orders

Much of the literature on verbal orders is from a pre-electronic medical record era. 15 years ago, most hospital orders were written in the patient’s paper chart that was kept in a nursing station. For a physician to place an order, that physician had to go to the nursing station hand write the order. If the doctor was out of the hospital or was on a different floor of the hospital, then entering an order was not possible and verbal orders proliferated. A bad phone connection, a doctor with a foreign accent, or a lot of background noise in the nursing station helped to foster mistakes. Although physicians had to eventually sign those orders, signing often didn’t happen until weeks after the patient was discharged when the patient’s chart was flagged by the medical record department as containing an unsigned order. Every physician who practiced in the 1990’s can remember weekly trips to the medical record department where each physician would have a stack of discharged patient charts requiring signatures.

Pharmacy orders were a particular problem. In the by-gone era of the physician’s prescription pad, a hand written prescription was given to patients at the time of an office visit or when being discharged from the hospital. But if that patient called in with an acute illness or needed a prescription refill, then the doctor had to call the pharmacy to give the pharmacist a verbal order for a medication. On nights that I was on-call, I would almost always have to phone in a verbal prescription to a pharmacy for a patient needing an antibiotic or an asthma inhaler; the options were either a hand-written prescription or a verbal order.

With the advent of electronic medical records, a physician no longer had to be physically in a specific nursing station to place an order. Doctors could now access the patient’s chart from a computer located anywhere and can even place orders from an app on their phone. I have not hand-written a prescription on a prescription pad in years. Even when I am on call, I find it easier and faster to send in a prescription by computer or by an app on my phone than to call a pharmacy (and be put on hold for several minutes). It is now easier than ever before to place an order electronically and this has reduced the need for verbal orders.

When verbal orders are a good thing

There are times when a physician simply cannot safely place an order in the electronic medical record. For example, the surgeon who is scrubbed in the middle of an operation cannot break scrub to place an order for the nurse to give the patient a fluid bolus. The family physician who is at a restaurant having dinner and gets a call from a patient with bronchitis cannot easily walk away from the restaurant, drive home, get on a computer to access the electronic medical record, and then send an electronic order for an antibiotic to the patient’s pharmacy. When a physician is driving to work in the morning is called from the ICU about a patient who is seizing, that patient needs to receive a dose of lorazepam immediately and not 15 minutes later when the doctor has access to a computer to place the order.

The reality is that most hospital locations have to use verbal orders some of the time in order to ensure timely care of patients. But there are some areas where a higher percentage of verbal orders (> 10% of the total) is more necessary than other areas:

  1. Operating rooms
  2. Intensive care units
  3. Cardiac catheterization labs
  4. Endoscopy labs
  5. Dialysis units
  6. Cardiac echo labs
  7. Emergency departments
  8. Radiology areas
  9. Patient emergencies anywhere in the hospital

When verbal orders are a bad thing

Although electronic medical records are ubiquitous today, most hospitals have only adopted them in the past 10 years. Consequently, there are many physicians who are still unfamiliar with the use of electronic medical records. Probably every hospital in the country has that doctor who still has not figured out how to place an order in the electronic medical record and gives all of his/her orders as verbal orders to a nurse. As younger, more computer literate physicians replace older, less computer literate physicians, this will be less of a problem in the future.

It can take time for a physician to enter orders in the computer and having someone else do it for you can improve your efficiency and allow you to spend more time actually talking to the patient. Consequently, many physicians like having a nurse that they can dictate orders to follow them around in the clinic or during hospital rounds, entering those orders into the computer as the doctor goes from one room to the next. This is an expensive use of a nurse and most physicians in small private group practices realize that it is financially untenable. However, hospitals have to court certain specialties, particularly surgical specialties, to keep them from moving their practice to another hospital in town. So, hospitals are often willing to provide an order scribe to the surgeon who brings a lot of high value surgical procedures to the hospital’s operating room. They know that they stand to make more from the surgeries than they will lose in the cost of the nurse to do order entry. The hospital can stand to ignore the hospitalist who says “Let me give verbal orders or I will leave” but cannot ignore the joint replacement surgeon or neurosurgeon who says the same thing.

There are situations when orders are generally not emergent and the risk of a medical error from an incorrect verbal order is just too great:

  1. Chemotherapy orders
  2. “Do not resuscitate” orders
  3. Orders for narcotics when the nurse/pharmacist cannot confirm that the person calling in the order is actually the doctor

Minimizing the risks of verbal orders

Given that the use of verbal orders is beneficial to patient care in certain situations and essential to patient care in others, complete elimination of verbal orders is neither practical nor possible. However, there are certain steps that the hospital can take to reduce the chances of verbal order errors:

  1. Use “read-back” of the order by the nurse or pharmacist so that the physician can confirm that what he/she actually said was what the nurse or pharmacist heard.
  2. Avoid using abbreviations. “QID” can sound too much like “QD” on the phone. Saying “K” for potassium can be confused for vitamin K.
  3. Beware of “sound alike” medications. It is easy to mistake “Tramadol” for “Toradol” or “clonidine” for “Klonopin”.
  4. Keep the noise down. A lot of people talking loudly in the nursing station makes it harder for the nurse taking a verbal order to hear that order correctly.
  5. Beware of accents. Regional American accents, foreign accents, and speech impediments can make it difficult for the nurse or pharmacist to understand the doctor accurately.
  6. If it doesn’t make sense, confirm it. If the ER physician tells a nurse to do a pregnancy test on the patient in bay 5 and the nurse walks in to find that the patient in bay 5 is a 70-year old named Joesph Smith, then it is best to double check with the doctor before asking for a urine sample.

Despite what some would have us believe, verbal orders are not inherently evil. However, they can create vulnerability from both a patient safety and medical-legal standpoint. Hospitals do need to regularly monitor for judicious use of verbal orders.

February 22, 2020

Electronic Medical Records

The Problem With The Problem List: when electronic medical records go rogue

Prior to the 1960’s, medical records were largely illegible, unorganized, and non-uniform. It was difficult for a doctor to keep track of his/her own patient’s histories and nearly impossible for a doctor to tell what was going on with a patient by reading another doctor’s notes. Enter Lawrence Weed, MD, a Professor of Medicine at the University of Vermont who invented the S.O.A.P note and taught generations of medical students to organize their hospital notes into the 4 sections of Subjective, Objective, Assessment, and Plan. He was also the father and champion of the  Problem-Based Medical Record, a way of organizing and filtering the various signs, symptoms, and diagnoses that a patient has in order to coordinate the diagnostic effort and to provide optimal longitudinal care of that patient.

When the Center for Medicare and Medicaid Services (CMS) wanted to encourage the widespread use of electronic medical records, it rolled out the “meaningful use” program as part of the HITECH Act of 2009. Physicians who adopted electronic medical records with several provisions were eligible for incentives of up to $44,000 to help offset the cost of purchasing and implementing an electronic medical record. Those electronic medical records had to:

  • Use computerized order entry for medication orders.
  • Implement drug-drug, drug-allergy checks.
  • Generate and transmit permissible prescriptions electronically.
  • Record demographics.
  • Maintain an up-to-date problem list of current and active diagnoses.
  • Maintain active medication list.
  • Maintain active medication allergy list.
  • Record and chart changes in vital signs.
  • Record smoking status for patients 13 years old or older.
  • Implement one clinical decision support rule.
  • Report ambulatory quality measures to CMS or the States.
  • Provide patients with an electronic copy of their health information upon request.
  • Provide clinical summaries to patients for each office visit.
  • Capability to exchange key clinical information electronically among providers and patient authorized entities.
  • Protect electronic health information (privacy & security)

And so, the problem list because a necessary part of every electronic medical record program in the country. On the surface, this sounds like a great idea – an easy way for multiple physicians using the same patient’s chart to quickly and easily see what is going on with that patient. However, the problem list rapidly morphed into a monstrous of list of often redundant words that became unusable for their originally intended purpose. So what happened to the innocent problem list?

Electronic medical record (EMR) companies designed the EMR so that the problem list was the central repository for all lists used in the chart. Elements of the past medical history fed into the problem list as did billing diagnoses, admitting diagnoses, and discharge diagnoses. Similarly, the problem list could be used to select the billing diagnoses, admitting diagnoses, and discharge diagnoses. Because the problem list was used to assign the billing diagnoses, all 69,000 diagnoses in ICD-10 had to be selectable in the problem list. And thus all of the weird and obscure ICD-10 codes suddenly became available to add to the problem list (such as V91.07XA: Burn due to water skis on fire, initial encounter).

What Is A Problem, Anyway?

Medical diagnoses are clearly problems. But there are other elements that are not so clear. Should the family history be included in the problem list? What about the social history? Should the patient’s list of surgeries be added to the problem list? What about non-specific symptoms – should the patient with I50.23 (Chronic systolic heart failure) also have orthopnea (R06.1), history of cardiomegaly (Z86.09), and pedal edema (R60.0) on the problem list?

Duplicate Problems

Each physician who sees a patient might use a different word to describe the same thing and this led to multiple duplicate symptoms on patient problem lists. For example, if a patient with breathlessness gets admitted to the hospital, the emergency room physician might add add the ICD-10 code “R06.00: Dyspnea“, the hospitalist might use “R06.02: Shortness of breath“, and the cardiologist might use “R06.09: Dyspnea on exertion“. By the end of the day, the patient’s problem list will include all three symptoms: dyspnea, shortness of breath, and dyspnea on exertion.

Multiple Layers Of Specificity

Similar to duplicate problems, many diseases can have many different ICD-10 codes for different degrees of specificity of that particular problem. And so “type 2 diabetes” can have a general code and also have many different subcodes, each of which gets its own place on the problem list. For the patient with diabetes who is seeing a family physician, a nephrologist, a cardiologist, an ophthalmologist, and a vascular surgeon, there can be 15-20 different diabetes-related problems on the problem list.

Immortal Problems

Unless someone actively cleans up the problem list, then signs, symptoms, and diagnoses that have resolved can stay on the problem list, causing further clutter. So, Right arm bruise, initial encounter (S40.021A) from an office visit in 2011 persists in perpetuity with Runny nose (R09.89) from an office visit in 2015. Similarly, the patient who had Hyponatremia (E87.1) during an office visit in June and then had Hypernatremia (E87.0) in July can end up with both hyponatremia and hypernatremia on their problem list. Old diseases don’t go away, they just stay around forever on the problem list.

Whose Problem Is It?

Most would agree that the primary care physician should be permitted to add problems to the problem list. But what about the specialist, the emergency room physician, or the hospitalist? Should advanced practice providers such as nurse practitioners, physician assistants, nurse anesthetists, or midwives be allowed to edit the problem list? What about nurses, pharmacists, psychologists, and dietitians? There is no universal agreement about who the stewards of the problem list should be.

Don’t Touch My Problem

Many physicians are very possessive about their additions to the problem list and can get angry if another physician deletes one of their problems without talking to them. So, the patient who was rude to the office staff at the surgeon’s office might have gotten Negative attitude (F60.2) added to the problem list; when the same patient was a delight to the staff in the endocrinologist’s office, the endocrinologist might have deleted F60.2 from the problem list and then the surgeon later gets mad because he wanted that reminder to the staff that the patient was a handful during the last office visit.

Forcing Review Of The Problem List

For many electronic medical records, an outpatient visit cannot be closed until the physician attests that he/she has reviewed the problem list. Typically, an alert box will pop up when trying to close the encounter reminding the physician to review the problem list. By that time, the patient has left the office and the physician just wants to get done with the day’s charting so the physician will typically scroll down to the bottom of the problem list and click “problem list reviewed”, without actually looking at the problem list. Problem list fatigue is just as much of a challenge as alert fatigue in our offices and hospitals.

More Is Less

In the spirit of Dr. Weed, some physicians will organize their progress note in the electronic medical record by importing the patient’s entire problem list into their daily office note. This can result in progress notes that are the length of a small novel making the note unnavigable to any reader and making it more difficult for other physicians to figure out what the author of the note was actually trying to say.

Too Many Problems

Every physician who sees a patient adds her/his problems to the problem list. When I see a patient whose primary care physician and other specialist physicians use a different EMR than I do, I am the only person adding to the problem list and so that problem list is small, relevant to my practice, and manageable. However, the more physicians using a common EMR a patient sees, the longer the problem list becomes. List of 30, 40, or 50 problems are not uncommon for patients with several chronic medical problems seeing multiple specialists or for patients with several hospitalizations.

Erroneous Problems

Errors in the problem list are rampant. For example, a patient fills out a pre-visit past medical history form and checks the review of systems box for “impotence”. The nurse reviews the form and transcribes the checked boxes into the past medical history and accidentally types the first 4 letters as “impr” rather than “impo”. The first diagnosis that comes up under “impr” is imprisonment and so it gets entered into the past medical history that then feeds into the problem list and now “imprisonment” shows up on the patient’s problem list. There are a myriad number of ways that erroneous problems find their way into the problem list and once they are there, they often stay there indefinitely.

High Maintenance Costs

The currency of work effort in ambulatory medicine is the number of mouse clicks necessary to perform any given task. A typical office visit lasts about 15 minutes and there is a lot of things that have to be done in those 15 minutes. Reviewing and editing the problem list costs time and mouse clicks and usually falls down to the bottom of the priority list of things to accomplish during those 15 minutes. Spending an extra 30 seconds per patient to truly review and update the problem list means that over the course of the day, that doctor will see one less patient than he/she otherwise would have seen. One solution that has been suggested is to partner with the patient so that the patient reviews the problem list to help identify resolved or erroneous problems. However, trying to explain what “suprascapular entrapment neuropathy of left side” means to the patient with a sore shoulder can often add 2 minutes to that office encounter.

“Need for…” Diagnoses

Some tests and vaccinations cannot be ordered unless they are associated with a “need for” diagnosis. For example, if you are going to order a flu shot, you have to use the diagnosis of “Need for influenza vaccine” (Z23). Some insurance companies will not pay for a bone density study unless the order is accompanied by the diagnosis of “At risk for osteoporosis” (Z91.89). If you want to see if a patient could have lead poisoning, you need to include “Need for lead screening” (Z13.88). These diagnosis codes often find their way into the problem list and do not add anything to the long-term management of that patient.

Diagnoses Required For Ordering Tests

Similar to the “need for…” diagnoses, many tests cannot be ordered unless the physician uses a specific ICD-10 code or one of a group of codes. These are so-called “allowable codes”. Many electronic medical records will present an alert box if a non-allowable diagnosis code is associated with an ordered test, such as a glucose level or a cardiac echo. The physician will then either keep adding diagnoses to the diagnosis list until she/he comes up with a diagnosis code that the insurance will accept or they will scroll through the list of allowable diagnoses in the alert box and pick a diagnosis code that is covered, whether or not it perfectly matches the real indication for that test. These diagnoses are necessary for the physician to order the test but may be irrelevant to the longterm management of that patient; nevertheless, the codes often end up on the problem list permanently. Physicians hate the alert boxes – they cost mouse clicks and time. Consequently, physicians, like Pavlov’s dogs, undergo operant conditioning and to avoid those alert boxes, they find a diagnosis that insurance companies accept for any given test and always use that diagnosis whenever they order that test. Thus, there are legions of physicians who always use “Other forms of dyspnea” (R06.09) for every cardiac echo that they order because they know that diagnosis works.

When used right, the problem list is a great tool for patient management. But a number of unintended consequences of electronic medical records have resulted in problem list monstrosities that are often irrelevant or a hinderance to medical care. As physicians, we are the main users of the problem list and it is up to us to truly make “meaningful use” of the problem list. We have met the problem of the problem list and the problem is us.

October 8, 2019

Electronic Medical Records

Why Your Electronic Medical Record Upgrade Feels Like A Downgrade

All software undergoes periodic upgrades. This may happen every few years (think Windows or the Macintosh operating systems) or every few months (think Microsoft Word and Powerpoint). Electronic medical records are no different. Sometimes, software upgrades are for improved security, sometimes for better user-friendliness, and sometimes to provide additional features. But whenever they happen, they cause temporary disruption in user efficiency.

Every few years, the grocery store that I shop at re-organizes all of the aisles and all of a sudden, the cans of tomato sauce is where the paper towels used to be and the bacon is where the produce used to be. For a couple of weeks after the re-organization, the manager will post employees throughout the store to help customers find the new location of all of the stuff that they came there to buy. Every time they do this, it feels like my world has been turned upside down, I get angry with the store, and I swear that I’m going to start taking my business to a different grocer down the street. And then after a few months, I’ve figured out how to navigate the new aisle configuration and life is back to normal again.

The same thing happens with electronic medical records. When there is a major upgrade, it immediately becomes hard to navigate the system: orders have to be entered differently, progress notes are organized differently, and a lot of the features that you used to use regularly are seemingly nowhere to be found. All of a sudden, your 15 minute patient encounters are taking 20 minutes and your frustration mounts exponentially. That is the moment that you think that the EMR upgrade was really a downgrade.

Eventually, just like at my grocery store, you get used to the new version of the electronic medical record and life goes back to normal again. But one of the things that is unique about electronic medical records is that doctors don’t have a choice in using them. If you can’t stand the re-organized grocery store aisles, you can take your grocery business to a different store. If you don’t like the new model of the Toyota Camry, you can keep your old one or buy a Honda Accord instead. But with your EMR, you have no alternative, you have to use the new version.

I think that is what makes EMR upgrades so unique – that we have no control. As physicians, we can’t just switch our individual practice to a different EMR and we can’t just decide to individually opt-out of the new version. We have to use the new version and there is no going back. So, what can we do?

For the electronic medical record designers:

  1. Resist software changes that are done simply for change sake. EMRs are not like fashions – with clothing, new styles come out every year to attract new customers and sell more clothes. EMRs are totally different, hospitals generally stick with the same EMR that they have been using and don’t change EMRs every year based on the newest style. If the EMR upgrade was done simply because the new software programmer at the EMR company needed something to do, then it is a downgrade.
  2. Upgrades should prioritize reduced numbers of keystrokes and mouse clicks to perform tasks. Every keystroke adds time and opportunity for data entry errors. If the EMR used to require 10 mouse clicks to order a chest x-ray and with the upgrade it now takes 13 mouse clicks, then it is a downgrade.
  3. Navigation in the EMR windows should always be designed from the perspective of physicians. Doctors think differently than computer programmers – for the programmers, the EMR is their life’s work and passion – their entire work day revolves around the EMR. But for physicians, the EMR is just a tool that we use for the larger purpose of taking care of patients. If navigation within the EMR is done just because the program designer liked a similar configuration in the latest version of Fortnite, then it is a downgrade.

For the physicians:

  1. Don’t put your head in the sand and pretend that an EMR upgrade is not coming. The time to learn about the upgrade is not on the day that the upgrade rolls out.
  2. Lighten your load on the first day. If you double book your outpatient clinic or agree to cover one of the other hospitalists’ patients in addition to your own on the morning of the upgrade roll out, you are going to have a very, very bad day. You are better off leaving a few empty outpatient visit slots on your schedule or bringing in an extra physician or nurse practitioner to help with inpatient rounding that morning.
  3. Practice ahead of time. Most EMRs will have a practice version of new upgrades available that physicians can use with make-believe patients in order to get used to the new program before it rolls out. A few years ago, our family took a trip to rural France for a week – before the trip, I got on Google Maps street-view photos and practiced the route that I was going to be taking in the rental car from the train station to the town that we were staying in 30 miles away. I was glad I did because when we got there, I was half-brain dead from jet lag and the train trip so knowing which lane to be in at turns and what the street signs should look like kept me from getting lost in the French countryside.
  4. Take advantage of “superusers”. These are people who have already been trained in the new upgrade – often IT personnel – who wander around the hospital and the clinics for a week or two after an upgrade to assist doctors and nurses in figuring out how to use the new version of the EMR program. In our health system, they wear easily identifiable red jackets and we call them “redcoats”. They can save you time and prevent you from undergoing spontaneous combustion when you can’t figure out where all of the vital sign reports went to.
  5. Take heart, it will get better. In 1969, Dr. Elizabeth Kübler-Ross published her book On Death and Dying and in it described the 5 stage of grief when confronting a terminal illness: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. You are going to go through exactly the same stages when confronting an EMR upgrade. Eventually, you are going to accept it and you might even find that once you get used to it, that you wouldn’t want to go back to the old version. The only problem is that by then, there will be a new version of your EMR and another upgrade.

August 17, 2019

Electronic Medical Records Outpatient Practice

Should A Physician Pre-Chart For Outpatient Visits?

There is a subtle difference between inpatient and outpatient medical practice that nobody ever talks about… time management. With inpatient practice, you see patients at your own pace during rounds and if you want to stop for a moment to have a cup of coffee or speak with a colleague, it doesn’t disrupt your workday. But with outpatient practice, you can work leisurely at your own pace before office hours and after office hours but during office hours, you are in a constant state of demand for time efficiency.

In my own practice, my office hours come in 4-hour blocks, either 8:00 AM to 12:00 noon or 1:00 PM to 5:00 PM. During those blocks, I schedule 15 minutes for return visits and 45 minutes for new patient visits – every minute is scheduled and the only way that there is a break is if one of the patients doesn’t show up for their appointment. During that 4-hour block, I have nurses, schedulers, and registration staff who all need to be working in order for the office to function in a financially viable way. But for them to stay constantly busy, I have to be constantly busy.

10 years ago, before we adopted an electronic medical record, each patient would have a paper chart and I would make a few shorthand comments on a piece of progress note paper and then at the end of office hours, dictate letters to the referring physician for each patient, clean up my orders for the day and fill out billing sheets. In other words, I “back-loaded” my work day with a couple of hours of charting after I was done seeing patents. Once we adopted an EMR, I tried to do a lot of that work while I was in the room with the patient. The result was that I didn’t have as much dictation and chart work after office hours but the EMR documentation encroached on the time that I was with the patients. I continued to allocate the same amount of office time per patient but I seemed to have fewer minutes just talking with my patients. And because the EMR results in the physician doing more of the work of documentation than in the past, I still was spending an hour or two at the end of the day finishing referral letters and closing encounters in the EMR.

This was reflected on my CGCAHPS patient satisfaction survey results. Patients were happy with the care that they got but they were not happy about the time they spent in the waiting room when I ran behind and they often commented that they didn’t get enough time to spend with the doctor once they were in the exam room.

So 5 months ago, I tried a different approach, pre-charting for my outpatient visits. The day before my office hours, I start my progress note for each patient by selecting the appropriate return visit note template (I have different templates for different diseases: one for interstitial lung disease, one for asthma, one for COPD, etc.). I pre-populate any new test results and pre-populate my final “impression” by pasting in the diagnoses that I manage for that particular patient from their previous note. For new patients, I insert the appropriate new patient template (again, I have different templates for different pulmonary conditions) and pre-populate the note with any test results, radiograph image review, pulmonary function tests, etc. that are available for that patient, either from our medical center or from other hospitals that I can access through the “CareEverywhere” function in our EMR (we use Epic). As a result, I spend about an hour prior to each 4-hour outpatient block pre-charting, sometimes longer if I have a new patient with a lot of records that require reviewing. After 5 months, I’ve found that there are advantages and disadvantages:


  1. I am less likely to get behind on my schedule and so my patients are spending less time in the waiting room.
  2. I have more time to spend just talking with my patients since I am not trying to furiously type into the EMR as much when I am in the exam room with the patient. As a consequence, I find that I actually enjoy my time in the outpatient clinic a lot more than I used to.
  3. I anticipate improvement in two of the CGCAHPS survey questions: During this visit did this provider seem to know the important information about your medical history? and During this visit, did this provider have your medical records?
  4. I finish the day’s work earlier because I do less charting at the end of the day by front-loading all of that charting before office hours.
  5. I have now started billing CPT code 99358 about 2-4 times a week. This code pays you for review of medical records prior to seeing the patient in the office, as long as you spend at least 31 minutes doing the review. In my own outpatient practice, most of my patients have already had pretty extensive evaluations and in about half of the new patients, I spend > 30 minutes sifting through office notes, lab tests, cardiovascular tests, chest CT images, pulmonary function tests, etc. This pays 3.16 RVUs (about $114 in Medicare reimbursement) and I now find myself getting paid for the work that I was previously doing for free. And this adds up… I estimate that my clinical receipts will increase about $13,000 per year from this CPT, alone.
  6. I have x-rays available when I see the patient. Most of my patients are sent to me from physicians at other hospital systems and so most of their chest x-rays and CT scan images are not in our hospital’s computer system. By pre-charting, I have been able to identify where those radiographs were done so that my office staff can contact that hospital’s radiology department and have the images sent over the internet before I see the patient – in the past, I often had to schedule a second visit with the patient just to go over x-ray images that I requested after I first saw the patient for an initial consultation.
  7. I have been able to do a “huddle” with the nurses just before the start of office hours to let them know about anything special that they will need to do to prepare for each patient’s visit.


  1. In the past, I defined my workday as being complete when I finished all of the work for the patients that I saw on that particular day and the administrative duties I had for that day. Because pre-charting is often relegated to the last thing that I do each day (since it is usually the least urgent), pre-charting becomes the task that keeps me at work an hour longer each day and so I now negatively associate it with being the thing that steals my time away from my family in the evening.
  2. I often have residents and fellows in the office with me. I worry that by doing the pre-charting, I am detracting from their experience of independently analyzing the patient. Personally, I believe that the trainees learn a lot about how to comb through old records for diagnostic clues efficiently by actually doing it themselves and when I pre-chart, I am depriving them of this opportunity.
  3. I’ve created this nagging sense that I am becoming obsessive-compulsive.

Every time management strategy in the outpatient clinic has a trade-off between advantages and disadvantages. I don’t think that pre-charting save me any of the total time I spend on any given week but I don’t think it requires any more of my time either – it just shifts some of the documentation time around from after the clinic hours to before the clinic hours. But I think that it makes both my patients’ experience and my experience with the time spent in the exam room a little better. So, for now, I’m going to keep pre-charting.

November 28, 2018

Electronic Medical Records

30 Million Mouse Clicks And Then You Die

Someone once said that every person is born with a fixed number of heart beats and that our lives count down with each beat like grains of sand in an hourglass. I think the same thing happens with mouse clicks. If you do the math, it works out to about 3 billion heart beats during the average person’s life in the United States. In a previous post, I noted that the typical emergency department physician does about 4,000 mouse clicks per shift. That works out to about 25 million mouse click over the course of an ER doctor’s career. Add in another 5 million or so during medical school and residency and you get to 30 million.

So, if we can reduce our mouse clicks, can we live longer or have longer careers in medicine?

I figure that each mouse click takes about the same amount of time it takes me to speak a word. 30 million words would fit on 54,000 pages and fill 134 average length books. That is a lot of spoken words. Many physicians (and their patients) lament the amount of time that the physician spends staring into a computer monitor and clicking with a mouse during patient office visits. So, if our careers tick down one mouse click at a time, is there anything we can do to prolong them and reduce those mouse clicks that steal away the words we could be speaking with our patients? Electronic medical records are not going away, at least not any time soon. But there are some tangible things we can do to decrease our mouse clicks.

EMR designers need to engineer efficiency into the physician interface. When it comes to mouse clicks, less is more. The fewer mouse clicks it takes to navigate through a patient’s encounter, the better. This will often require the EMR to be able to be custom-configured by individual physicians so that the navigation through an encounter can take on the unique needs of that individual physician.

Staff must work at the top of their license. Whenever state and federal regulations permit, the medical assistant, LPN, and RN should be able to do as much in the EMR as they are allowed to do. Every mouse click that the MA can do is one less mouse click that the physician has to do and that equates to one more word that the physician can speak to or hear from the patient.

Physician should periodically re-train with their EMR. Most electronic medical records release periodic updates that improve on past versions. Optimization allows the physician to take advantage of these periodic updates in order to become more efficient with their EMR. But most physicians still use their EMR the way that they first learned how to use it when they went through their first EMR orientation. The strategic use of smartlists, smartphrases, and webpage customization can greatly diminish the number of mouse clicks it takes to complete a patient encounter.

Regulatory agencies need to eliminate unnecessary documentation burdens. In the interest of attempting to ensure high quality care, Medicare and insurance companies require physicians do document all kinds of things in the medical record. For every patient visit, we have to click to acknowledge that we have reviewed that patient’s problem list, allergies, medication list, and smoking history. The cold reality is that most physicians click through those items without really doing them – they are prompted to review these things before the encounter can be closed and the bill submitted – often after the patient has already left the office. The path of least resistance in this case is usually to go to the problem list page, scroll to the bottom of it, and then click on the button that says you have reviewed the problem list – most physician just click the button and never review or edit the actual problem list, which is often 30 or 40 entries long. And then there is all of the mouse click associated with billing – a click to link a specific diagnosis with each individual billing code, a click to add a -25 modifier whenever a procedure is done on the same day as an office visit, a click to add a -GC modifier if there was a resident or a fellow with you when you performed that office visit. These things add very little value to the actual care of the patient but steal away words that can be spoken with the patient.

Maybe reducing mouse click won’t really make us live longer or extend our practice careers. But reducing mouse clicks will free up a few extra minutes each day that we could be listening to our patients and talking to our patients.

November 4, 2018

Electronic Medical Records

Electronic Medical Record Whack-A-Mole

Mondays… I really don’t like Mondays. The only thing worse than a Monday is a Tuesday after a 3-day weekend. And the only thing worse than that is the day back to work after a week of vacation. Don’t get me wrong, its not that I don’t like being back at work being a doctor, its that I have to play Whack-A-Mole on the electronic medical record.

For the uninitiated, Whack-A-Mole is a carnival game where you use a giant mallet to smash down on wooden rodents that randomly briefly pop up from holes in a large table. The goal is to smack down as many of the moles as you can in a fixed amount of time. The problem is that the more moles you smack down, the more moles pop up.

So, what does a game that you play at the county fair have to do with electronic medical records? Well, the EMR has this feature called an “inbasket” where all of your patients’ test results, phone messages, email messages, verbal orders for signature, and medical record updates appear. As physicians, we “clear our inbaskets” by clicking on each item then acting on it; once completed, it disappears from the inbasket. It might be phone call from a patient you have to return, or an CT scan report that you have to review, or a medication refill that you need to send in to the pharmacy.

The goal of the EMR Whack-A-Mole game is to click on everything in the inbasket so that by the end of the day, the inbasket is completely empty.  On a typical Tuesday through Friday, EMR Whack-A-Mole goes at a pretty steady pace, you click on a message that a patient called about some new symptoms, call that patient, enter a telephone call note in the EMR, route an order for a medication to the patient’s pharmacy, then close the telephone encounter in the inbasket. A few minutes later, a new item will pop up in the inbasket and you have to open it, review it, and act on it. On a Tuesday, Wednesday, Thursday, or Friday, EMR Whack-A-Mole is pretty do-able so that the average physician can keep up pretty easily and have an empty inbasket at the end of the day.

But Mondays are something else all together. On Mondays, EMR Whack-A-Mole is played at a furious pace. There are 2 additional weekend days of pent-up volumes of patient phone calls, email messages from patients, medications that need to be refilled, and lab test reports. The result is that by mid-morning on Mondays, as soon as one inbasket item is opened, acted on, documented, and then closed, another item appears on the inbasket menu. A doctor can pretty much just sit in front of the computer clicking on inbasket messages and not do anything else for hours. By early afternoon, the speed of EMR Whack-A-Mole speeds up: for every 1 inbasket item that you open, read, act on, and close, 2 more items pop up. The best analogy is from the I Love Lucy TV show when Lucy and Ethel are trying to wrap candies coming down a conveyer belt.

After a 3-day weekend or a vacation, the pace of EMR Whack-A-Mole gets even faster. No sooner as you whack one thing out of your inbasket, 3 more pop up. The faster you whack your inbasket, the faster it fills up again. Pretty soon, the inbasket has grown into an enormous-sized monster. Patient phone calls come in faster than they can be returned and test results grow like rabbits fed Viagra.

By about 5 o’clock on Mondays, the inbasket slows down and you can whack out messages faster than the new ones appear. By about 7 o’clock, the last inbasket message gets whacked and you can go home. And then you can look forward to Tuesday for another game of Whack-A-Mole…

September 29, 2018

Electronic Medical Records Outpatient Practice

Why The Medication List In Your Electronic Medical Record is Wrong

The importance of an accurate medication list for every outpatient cannot be overstated. In theory, the electronic medical record should improve the accuracy of the medication list but in reality, medication lists are very often inaccurate. The act of verifying the medication list is called “medication reconciliation” which sounds so easy on the surface but is so hard in reality.

The Agency for Healthcare Research and Quality (an agency of the U.S. Department of Health and Human Services) says that there should be a single medication list that is the “one source of truth” for the patient and that medical practices should standardize and simplify the medication reconciliation process in order to make the right thing to do the easiest thing to do. But in most outpatient practices, mediation reconciliation is neither standardized, simple, or easy. Pull up any patient’s electronic medical record and if that patient sees more than 1 physician, there is a pretty good chance that the medication list is not accurate. Here are some of the reasons why:

  1. No stop date on short-term medications. Recently, I opened a patient’s chart and found that the medication list included amoxicillin. I asked the patient who said she wasn’t taking amoxicillin. So I pulled up the medication history and found that she had gotten a 7-day course of amoxicillin in 2009 (8 years ago) but it had never been taken off of her list. With electronic prescribing, a physician can set a duration of therapy (or set a stop date) and after that time, the medication falls off of the medication list. However, even if only 14 pills are prescribed with no refills, if the physician does not set the duration or stop date, then that medication stays on the list in perpetuity. I prescribe a lot of short courses of prednisone and antibiotics and so I have my own prescriptions for these commonly prescribed short-term medications in my “preference list” in our electronic medical record and these include a fixed number of days duration. But many physicians don’t have a preference setting for every antibiotic or other short-term medication that they prescribe and so if they don’t manually enter the stop date every time they write a prescription, that medication will continue to appear to be a long-term maintenance medication forever.
  2. Restricted hospital formularies. Hospital pharmacies cannot stock every single medication that is on the market. First, it is too expensive to maintain that wide of an inventory. Second, each hospital negotiates with various pharmaceutical companies or medication wholesalers for the least expensive of therapeutically equivalent medications in order to keep their costs down. As a consequence, when, for example,  a patient with asthma taking the inhaler Advair gets admitted to a hospital that does not have Advair on the formulary but does have the similar inhaler, Symbicort, then the admitting hospitalist will prescribe Symbicort while the patient is in the hospital. When that patient gets discharged, it is very easy for Symbicort to show up on the discharge medication list but since the patient does not know that Advair and Symbicort are equivalent drugs, that patient will start taking both inhalers. When that patient then sees a primary care physician, the medication list will include Symbicort instead of Advair even though the patient is now taking both drugs.
  3. “Don’t mess with my medication list”. Frequently, the responsibility for maintaining an accurate medication list falls to the primary care physician and in large, multi-group practices, specialists are often told not to take anything off of the patient’s medication list unless checking with the primary care physician first in order to insure that the list is, in fact, correct. The problem is that nobody has time to check with a patient’s primary care physician every time a patient says that they are not taking a medication that appears on their list so the path of least resistance is for specialist to never delete a medication from the list, only add new medications that they prescribe.
  4. Leaving medication reconciliation only up to the doctor. Medicare sets the rules for what nurses or medical students can document in the medical record and what the physician has to document. The “past medical history” is a chart component that nurses and medical students are permitted to document. The past medical history is supposed to include the patient’s medication list. Consequently, in many practices, the first time a patient is seen in that practice, the nurse will record the past medical history, including the patient’s allergies, previous surgeries, and current medications. Because it takes a lot of time to enter a long list of medications (including dose, frequency of administration, etc.), it makes sense to have a nurse or medical assistant do all of that documentation, thus freeing the physician’s time up to see more patients. But in many parts of the country, medication reconciliation is considered to be equivalent to prescribing a medication and so physicians are the only ones who can do medication reconciliation which includes taking medications off of the list when a patient reports that he/she is no longer taking them. Thus, the nurses can add to the list but only the physicians can delete from the list. This creates duplicate work and confusing responsibilities and as a consequence, errors occur. In the hospital, deleting a medication from the medication list directly affects the patient’s treatment and should only be done by a physician; however, in the outpatient setting, deleting a medication from the medication list is more justifiably done by a nurse if the patient says that they do not take that medication any longer. It is very important to distinguish the role and responsibility of the nurse in adding/deleting medications from the medication list in the inpatient setting versus the outpatient setting. Your practice has to decide whether maintaining an accurate medication list in the outpatient electronic medical record is part of recording the past medical history or a part of the medication prescription process – if you consider it part of the past medical history, then empower the nurses to do it.
  5. Medication lists cluttered with non-medication orders. In most electronic medical records, a lot of stuff that gets ordered ends up in the medication list because the EMR doesn’t know what else to do with it. Thus, disability parking placards, the influenza vaccine that the patient received 3 years ago, home oxygen, and wheelchairs will show up in the medication list. This ends up making the list excessively long and more confusing for anyone who is looking at it.
  6. What is the truth, really? Is the “one true source” a list of what the patient says that he or she is actually taking or what the doctor thinks that they are supposed to be taking? If you ask 100 doctors, 50 of them will say it is what the patient is actually taking and the other 50 will say it is what was actually prescribed. So, if a patient was prescribed a medication for gout, but never filled the prescription because it was too expensive, should that medication be on the patient’s list? One the one hand, it is the medication prescribed to treat the gout so you want to have that as part of your on-going medical record. But on the other hand, if the patient isn’t taking it, then should it keep appearing in the medical record? This is controversial and there is no perfect answer.
  7. Samples. If you give a patient a sample of a medication in the office, then you want to have documentation of them getting that medication, for example, a small tube of a steroid cream that a dermatologist gives a patient for their poison ivy. But once again, if there is not a stop date when you enter the sample in the medication list, then it stays on the list until someone else takes it off of the list at a later date.
  8. Bad data from other institutions. Many EMRs have the ability to interrogate other hospital systems that the patient has visited to pull in medications from that hospital system’s medical record. Even if the physicians in your hospital system are tediously compulsive about keeping an accurate medication list, unless the other hospital system’s doctors are equally compulsive, you can pull in errors into the patient’s medication list.
  9. There just isn’t enough time. When a patient gets admitted to the hospital, usually there is a nurse, a pharmacist, and a physician, all reviewing the patient’s medications. The patient is usually in the hospital for a few days so there is ample time for a thorough review and reconciliation with checks and double checks. But in the outpatient physician office, the responsibility for medication documentation often all falls solely the physician. Even if the office nursing staff participate, the time that the patient is in the office is so short that it is hard to get everything done. A typical physician’s return office visits are scheduled every 15 minutes. That means that in those 15 minutes, the physician has to review the patient’s history and any new test results, take an interval history from the patient, do a physical exam, discuss their findings and recommendations with the patients, order any new tests or medications, document a note, create a letter to the referring physician, enter their billing charges, and do the medication reconciliation. Often, there simply just isn’t enough time to do all of that and frequently the first corner to get cut is to skip the medication reconciliation. Some people would say that the answer is to schedule patients every 20 minutes, rather than every 15 minutes. However, over the course of a full day, that would equate to 25% fewer patients being seen that day and the reduction in revenue associated with 25% fewer patients would put most practices out of business.
  10. Poorly designed EMR workflows. A physician will naturally go to three windows in the electronic medical record: the progress note window, the test results window, and the orders window. Anything else and they will need a prompt. If the nurses in the office are permitted to mark medications for deletion but are not actually permitted to delete those medications from the medication list, then there has to be a prompt for the physician to go to that medication list window to approve those deletions. Otherwise, they will close that encounter without ever deleting those medications. Either the nurses should be empowered to delete medications that the patient says they are no longer taking or there needs to be a hard-stop to go to the medication list window before the physician can close the encounter.

The good news is that there are some concrete things you can do to reduce the inaccuracy of the medication list. Here are a few:

  1. Be sure that all short-term medications and samples have a  stop date in the initial prescription.

  2. Develop an agreed-upon consensus among all of the physicians in the organization about whether they define the medication list as the list of medications prescribed for the patient or what the patient says that they are actually taking.

  3. Develop an institutional policy that all physicians are allowed to delete medications from the list – the primary care physician or any specialist.

  4. Allow office staff to work at the top of their license with respect to adding or deleting medications from the outpatient’s list.

  5. Develop a simple practice to ensure that therapeutic substitutions made for inpatient formulary reasons at the time of admission to the hospital are substituted back to the patient’s normal outpatient equivalent drug.

  6. Create workflows in the office that are consistent so that everyone knows their role in maintenance of the medication list and performs that role on every patient.

  7. Design the electronic medical record so that the physician’s tasks for outpatient medication reconciliation becomes a natural part of the workflow or so that medication reconciliation is required before the encounter can be closed.

  8. Involve the patient by printing a copy of the medication list when the patient arrives to the clinic and having him/her review the list for additions/deletions.

November 6, 2017