Records

After spending some time in the clinical setting, I've realized how ridiculous hospital records can be. The first time I saw a chart, I spent an inordinate amount of time shuffling through extraneous papers, trying to figure out each page, through insurance forms and intake forms and where-the-patient's-belongings-are forms. Then there are the actual notes. Notes communicate between providers (and keep a legal record). But there are so many kinds of notes; do I read the medical student note or the intern note? The brief operative report or the lengthy summary with details of a procedure I don't need to know? The social worker's notes? The physical therapist's notes? The nursing notes?

Obviously, the best answer is to read everything. But the truth is, time and workload make this impractical. All the other notes in the chart simply dilute down the content of what's there, making it harder for me to sift through and find the pertinent information. Thus, chart biopsies can easily miss the pathology and return nonspecific debris.

Furthermore, it bothers me that physicians sometimes spend an unreasonable amount of time obtaining outside records. At a tertiary care center, many of our patients have been transferred from outside hospitals and getting those records can be surprisingly difficult. We spend time navigating operators and medical records, and then the charts faxed over are incomplete. We sift through the morass of paper, wondering whether trees and shredders would be better served if we had an improved system of communication between hospitals.

This is why electronic health records were (and perhaps are) considered one of the holy grails of inter-provider communication. Imagine a system where you could easily filter notes to see only consultations or arrange things by date or read discharge summaries. Imagine a system where you could simply have the outside hospital push over the information online, allowing you to instantly access radiology and EKGs. It makes no sense to me that three major UCSF hospitals each use different electronic health records, and that even within a hospital, there might be multiple systems (outpatient, ED, ICU).

Why make it so hard for doctors to do their job? Our skill set isn't geared towards calling for records, troubleshooting poor fax images, sorting through papers to find that one lab we want. It wasn't until third year of medical school that I appreciated how difficult and frustrating those tasks can be. I don't know whether electronic medical records will fix everything in our health care system, but I do think a universal standardized access system for sharing patient information between privileged providers would make my life so much easier and my work so much more efficient.