Are Electronic Medical Records A Good Thing? It’s Complicated
If you spend a lot of time reading medical records, and I know that, like me, many of you do, read this New Yorker piece by Atul Gawande, Why Doctors Hate Their Computers.
I have two problems with electronic medical records - the repetition is one. The other is that it appears that many have defaults which are set to "normal" or "denies." Example - client comes in to ER for severe headache, but then under ROS "headaches - denies." On the positive side they are legible!
7:03: that second problem is a significant one. I've seen ALJs use those "denies" entries to issue unfavorables, even when those treatment notes had nothing to do with the cause of the claimant's disability. (eg. claimant with a disabling back condition goes to the ER for pneumonia- ER notes "negative" on the physical exam fields when there's no way they performed one.)
If these sorts of issues go to appeal, what would be your best evidence that the ALJ relied inappropriately on a dubious entry in an unrelated ER record?
The possibility of repetition and auto-filling raises legitimate concerns, but what's the solution for disability purposes? The agency generally expects treatment records to accurately reflect the patient's reports and medical signs, and it expects medical opinions to be well supported and consistent with the treatment records.
If a doctor is willing to sign off on inaccurate treatment notes for whatever reason (e.g., it takes too long, or they're only relevant for insurance billing purposes), then isn't it reasonable to assume that the doctor's lax approach would spill over onto the disability paperwork?
Oh and don't we all love, "Patient works at Ralph's Wreck-It" showing up on visit after visit when the earnings record and the claimant's testimony indicates the claimant hasn't worked there in over two years.
My personal favorite was a note that was repeated over and over for well over a year. "Mr. Jones complains of low back that began six months ago while trying to move machinery at work".
I don't hear the reps complaining about the routinely carried-forward laundry lists of "diagnoses" / "problem lists" / "past medical history" that contains every speculation about every problem a patient has ever mentioned...
I have a hearing on Monday where the auto fill notes indicate that for two years, EVERY TIME claimant sees the doctor she is "doing better, can sit about an hour, walk about 30 minutes". During that period, she underwent a complex (3rd one) neck surgery, started using a walker, had multiple falls due to her right leg going out and is now facing lumbar spine surgery. Absolute garbage.
12:58 - Are you submitting a disability opinion from that doctor? Do you plan to address the contradictory treatment records or just focus on the evidence most favorable to your client?
2:25, suggesting proactive and reasonable approach to the situation. Isnt that cute. My bet is nothing will be done and just complain about it and gripe when denied.
Meds prescribed are not noted as discontinued by the docs offices that add them in the first place...I recently had a physical where the doc looked at my meds and said, "Boy you have a major problem with pain meds, don't you?".....But I wasn't on any.....It turns out that none of my temporary pain meds over several years of having a port put in, taken out and replaced looked like I was on 5 different kinds of pain pills at the same time.....the doc office that listed them does not have to update with discontinuations....no new doc will delete a med another doc listed...the doc at the physical stopped the physical, pulled out her cell phone and started to call the police before I could get her to compare the minor day surgery dates with the med prescribed dates..it was terrifying....
Funny thing about medical records is that they are yours and you have a responsibility to make sure your records are correct. Everyone wants to believe that the office is handling it, like we want everyone to handle things. Even banks make mistakes, credit card companies, the cable or phone companies. Cut off your ShowTime or cut back on your data plan and the consumer is all over it, but when medical is involved, consumers put on blinders. Not only do you have to take a stake in your care, but in your records and insurance life. Somehow, this is now considered a bad thing, like being bad at math has become acceptable. People have to learn to be in charge of their lives. I know it cuts into you binge time and social media life, but it is for your own good.
2:52 PM. HOW? In what way could you maker them correct? Most never see the real records. Yo tell the doctor 6-7 symptoms, 2-3 make it into thee records. The real problem is the inconsistency from doctor to doctor. On puts everything in the records. Another puts just the diagnosis. Many are overly confident in their treatments. Xxy is working well... Now try yyx because xxy didn't really work. Yyx working great... Yyx not effective... I don't know how doctors think your "doing well," then list 50 things wrong with you. Then you realise that the question "Hey, how are you?" wasn't rhetorical. So when you said, "Good," because that's what people do... Your saying, "hello." Smart people should be able to figure this out when you then tell them the pain your in. You simply aren't in the habit of telling people how you feel when they say what sounds like a greeting. You just don't tell people, "I am in so much pain that I want it to end... And death seems the only way out! or "My head feels like it is about to explode, and sometimes I wish it would, just to get it over with." Doctors write that you "ambulate normal" when they had you walk 5 feet. You ask the doctor to elaborate beyond the diagnosis, they tell you, "I write my notes for me, not Social Security." Do ALJs take this into account, or are they just looking to deny?
I thing I found interesting about the article was about "fitting things in boxes" and I immediately thought about the grids. Then I thought how woulwould you make boxes that fit people with multiple conditions, each accompanied by a variety of limiting symptoms of different types, such as joint pain , dizziness, headaches, nausea, diarrhea, fatigue, and many others with various amounts of how much and how often they effect you. Some might be infrequent, but impossible to ignore (abdominal cramps-feels like your guts are about to explode). Some are chronic, but mostly easier to ignore (tinnitis), though sometimes not (pulsating feeling in my ear). Others are far more disabling or distracting on a regular basisbasis . What I an getting at is , dizziness in the chart can mean a huge variety of persistence and intensity. When I said IBS was minor , I meant COMPARED to the other things I have to deal with . It doesn't mean that it doesn't have to dealt with. It still means several days a month with several trips to the can. When there are so many things a person has to deal with , is it really possible for someone to really understand what you're going through when they haven't gone through any of them? I do know that doctors who have had their own problems are much more understanding and sympathetic to you.
I have two problems with electronic medical records - the repetition is one. The other is that it appears that many have defaults which are set to "normal" or "denies." Example - client comes in to ER for severe headache, but then under ROS "headaches - denies." On the positive side they are legible!
ReplyDelete7:03: that second problem is a significant one. I've seen ALJs use those "denies" entries to issue unfavorables, even when those treatment notes had nothing to do with the cause of the claimant's disability. (eg. claimant with a disabling back condition goes to the ER for pneumonia- ER notes "negative" on the physical exam fields when there's no way they performed one.)
ReplyDeleteIf these sorts of issues go to appeal, what would be your best evidence that the ALJ relied inappropriately on a dubious entry in an unrelated ER record?
I’ll never forget what an ME at a hearing once said, which is that WNL on the records can stand for “within normal limits,” OR “we never looked.”
ReplyDeleteThe possibility of repetition and auto-filling raises legitimate concerns, but what's the solution for disability purposes? The agency generally expects treatment records to accurately reflect the patient's reports and medical signs, and it expects medical opinions to be well supported and consistent with the treatment records.
ReplyDeleteIf a doctor is willing to sign off on inaccurate treatment notes for whatever reason (e.g., it takes too long, or they're only relevant for insurance billing purposes), then isn't it reasonable to assume that the doctor's lax approach would spill over onto the disability paperwork?
Oh and don't we all love, "Patient works at Ralph's Wreck-It" showing up on visit after visit when the earnings record and the claimant's testimony indicates the claimant hasn't worked there in over two years.
ReplyDeleteMy personal favorite was a note that was repeated over and over for well over a year. "Mr. Jones complains of low back that began six months ago while trying to move machinery at work".
I don't hear the reps complaining about the routinely carried-forward laundry lists of "diagnoses" / "problem lists" / "past medical history" that contains every speculation about every problem a patient has ever mentioned...
ReplyDeleteI have a hearing on Monday where the auto fill notes indicate that for two years, EVERY TIME claimant sees the doctor she is "doing better, can sit about an hour, walk about 30 minutes". During that period, she underwent a complex (3rd one) neck surgery, started using a walker, had multiple falls due to her right leg going out and is now facing lumbar spine surgery. Absolute garbage.
ReplyDelete12:58 - Are you submitting a disability opinion from that doctor? Do you plan to address the contradictory treatment records or just focus on the evidence most favorable to your client?
ReplyDelete2:25, suggesting proactive and reasonable approach to the situation. Isnt that cute. My bet is nothing will be done and just complain about it and gripe when denied.
ReplyDeleteMeds prescribed are not noted as discontinued by the docs offices that add them in the first place...I recently had a physical where the doc looked at my meds and said, "Boy you have a major problem with pain meds, don't you?".....But I wasn't on any.....It turns out that none of my temporary pain meds over several years of having a port put in, taken out and replaced looked like I was on 5 different kinds of pain pills at the same time.....the doc office that listed them does not have to update with discontinuations....no new doc will delete a med another doc listed...the doc at the physical stopped the physical, pulled out her cell phone and started to call the police before I could get her to compare the minor day surgery dates with the med prescribed dates..it was terrifying....
ReplyDeleteFunny thing about medical records is that they are yours and you have a responsibility to make sure your records are correct. Everyone wants to believe that the office is handling it, like we want everyone to handle things. Even banks make mistakes, credit card companies, the cable or phone companies. Cut off your ShowTime or cut back on your data plan and the consumer is all over it, but when medical is involved, consumers put on blinders. Not only do you have to take a stake in your care, but in your records and insurance life. Somehow, this is now considered a bad thing, like being bad at math has become acceptable. People have to learn to be in charge of their lives. I know it cuts into you binge time and social media life, but it is for your own good.
ReplyDelete2:52 PM. HOW? In what way could you maker them correct? Most never see the real records. Yo tell the doctor 6-7 symptoms, 2-3 make it into thee records. The real problem is the inconsistency from doctor to doctor. On puts everything in the records. Another puts just the diagnosis. Many are overly confident in their treatments. Xxy is working well... Now try yyx because xxy didn't really work. Yyx working great... Yyx not effective... I don't know how doctors think your "doing well," then list 50 things wrong with you. Then you realise that the question "Hey, how are you?" wasn't rhetorical. So when you said, "Good," because that's what people do... Your saying, "hello." Smart people should be able to figure this out when you then tell them the pain your in. You simply aren't in the habit of telling people how you feel when they say what sounds like a greeting. You just don't tell people, "I am in so much pain that I want it to end... And death seems the only way out! or "My head feels like it is about to explode, and sometimes I wish it would, just to get it over with." Doctors write that you "ambulate normal" when they had you walk 5 feet. You ask the doctor to elaborate beyond the diagnosis, they tell you, "I write my notes for me, not Social Security." Do ALJs take this into account, or are they just looking to deny?
ReplyDeleteI thing I found interesting about the article was about "fitting things in boxes" and I immediately thought about the grids. Then I thought how woulwould you make boxes that fit people with multiple conditions, each accompanied by a variety of limiting symptoms of different types, such as joint pain , dizziness, headaches, nausea, diarrhea, fatigue, and many others with various amounts of how much and how often they effect you. Some might be infrequent, but impossible to ignore (abdominal cramps-feels like your guts are about to explode). Some are chronic, but mostly easier to ignore (tinnitis), though sometimes not (pulsating feeling in my ear). Others are far more disabling or distracting on a regular basisbasis . What I an getting at is , dizziness in the chart can mean a huge variety of persistence and intensity. When I said IBS was minor , I meant COMPARED to the other things I have to deal with . It doesn't mean that it doesn't have to dealt with. It still means several days a month with several trips to the can. When there are so many things a person has to deal with , is it really possible for someone to really understand what you're going through when they haven't gone through any of them? I do know that doctors who have had their own problems are much more understanding and sympathetic to you.
ReplyDelete