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Monday Jan 13, 2020

Beware Virulent Deer and Confounding EHR Notes

Editor's note: We asked our new physician bloggers about the worst EHR notes they have seen. Here is what they shared.

[oops key on keyboard]

How Not to Train Your Dragon

This just in: "How Not to Train Your Dragon" is an electrifying comedy coming soon to an EHR near you! Maybe you have already experienced it. If so, you may recall that the dialogue in this performance is a bit grammatically incorrect, full of sentence fragments and peppered with surprise words that seem out of place and turn simple phrases into complete nonsense.

I am referring, of course, to the wonderful but often clumsily used dictation tool that most of us have interacted with in one form or another: Dragon software. Whether you have been on the voice-to-text side of this application or you have reviewed the notes of clinicians who were, you know what I am getting at. You often have to pause and ponder what the dictating clinician's original intent was before you can get the full meaning of a sentence that has been spoiled by a challenge to this software's speech-recognition ability. This could be due to anything from a program glitch, a momentary lapse in internet connectivity, poor pronunciation or a failure of the user to adequately train their Dragon program to recognize the nuances of their accent and diction.

Don't get me wrong -- this is an amazingly helpful and time-saving utility that makes my life easier every day. But I have to chuckle when I recall many of the amusing errors I have seen in patient charts. For example, I recently read a pain management clinician's note in which the specialist had to postpone a steroid injection because the patient was "working on eating (getting) his medical insurance." In another instance, a patient was being treated with the diuretic "Spinal Lactone" (spironolactone). I read one note in which erythromycin ophthalmic ointment was to be placed "inside of flow or (lower) eyelid." One of my favorites is from when I was rounding on a patient in the hospital who had just had a hip replacement. The note from the orthopedist stated, "I will be prescribing Zero (Xarelto) for anticoagulation."

And while writing this post, I dictated the phrase "colonoscopy is up to date" into my Dragon mic, and it morphed into "Skippy is up to date."

Dictation bloopers are often funny and innocuous, but they can sometimes be deadly serious. Keeping that in mind, I hope we can all get better at training our Dragons and using this and similar dictation utilities more effectively and accurately. In doing so, we will improve our efficiency and the clarity of our communication. We may also avoid giving our colleagues the chance to snicker and chuckle as they read through our otherwise professional visit notes.

Kurt Bravata, M.D., Buffalo, Mo.

Alphabet Soup

On inpatient services during my residency training, my team spent an hour racking our brains trying to figure out the meaning of the abbreviation "K.W." at the bottom of a surgical consult note on a post-op patient. It wasn't an anatomical position or body part, it wasn't any procedure or treatment we were familiar with, and it didn't seem like any medical condition the patient had. We went through every orthopedic abbreviation we could think of and still had no idea. We finally asked the surgical intern what he meant by the last line in the consult. The intern sheepishly told us those were the attending surgeon's initials.

Abbreviations are incredibly common in medicine, and clinicians are the biggest culprits in perpetuating this situation. We have mastered the art of turning complex medical terms into abbreviations. But many groups have recognized the inherent danger in medical abbreviations. If John is being treated for GBS, is he getting antibiotics for group B Strep or is he getting IVIG (intravenous immunoglobulin) for Guillain-Barré syndrome? If Jenny's CT scan showed PE, does she need blood thinners for a pulmonary embolism or diuresis for pulmonary edema? Most of the time we can figure this out by context, but it can be frustrating and time-consuming and -- in the worst cases -- can lead to dangerous medical errors for patients.

Medical errors are the third-leading cause of death in the United States(www.npr.org) (ahead of strokes and diabetes), so abbreviations matter. Most of the data about abbreviations and medical errors is related to prescriptions and medications. The National Medication Errors Reporting Program represents one attempt to track medication errors. From 2004 to 2006, more than 600 institutions reported 643,151 medication errors. Of those, 4.7% (29,974) were attributed to abbreviations.(www.ncbi.nlm.nih.gov) In 2004, The Joint Commission came out with its "Do Not Use" list(www.jointcommission.org) of abbreviations that should be avoided in medicine because of the high rate of potentially dangerous errors they're associated with. This is why most medical students get a crash course in which abbreviations aren't safe to use.

I don't know why medicine has evolved to utilize abbreviations so heavily, but I would hazard a guess that it is to save time. How long does it take to write out (type out) the following patient assessment? "This is an 18-year-old male presenting for acute onset sinus congestion, cough and rhinorrhea most consistent with viral upper respiratory tract infection without any evidence of group B strep, pneumonia or acute bacterial rhinosinusitis."

It didn't take long, but it's more likely that a note conveying similar information might read, "18 yo M p/w acute onset sinus cgxn, cx, rhinorrhea, most c/w URI w/o e/o GBS, PNA or ABRS."

With my slow typing skills, abbreviating the assessment saved me 25 seconds. (I timed myself.) That was one sentence. If I extrapolate that out to the HPI (history of present illness), FHx (family history) and all the other sections of a note in which I might type, this can actually save me a lot of time. And that's just on one note. Multiple that by 20 patient visits (or more) a day.

Perhaps with the continued evolution of EHRs (electronic health records), voice-to-text software, and AI (artificial intelligence), we will improve as a profession and move away from so many costly abbreviations and errors. Then again, if we didn't have to cram patient visits, orders and documentation into 15- or 20-minute visits, then maybe we wouldn't need to use abbreviations in the first place.

Kyle Leggott, M.D., Aurora, Colo.

You Attached What?

EHRs have so much potential, and perhaps that's why I channel so much of my anger toward them. We have the technological capabilities to put satellites into orbit, land rovers on other planets and surveil the minutiae of anyone's day-to-day behaviors, yet my EHR can't talk to another health system's EHR. I have to guess about things like how my patients are taking their medicines if they followed up on a referral I sent out and how that visit went with the outside cardiologist. It's insane.

What's equally insane: When I actually do get my patient's outside records (in unsearchable PDFs, mind you), I have to comb through 10 pages per encounter of computer-generated hogwash to find the two or three sentences that actually tell me what happened to my patient. It's a consequence of the bizarre policies and regulations from those for whom we work -- insurers, really -- so I deal with it and chalk it up to the system being the system.

So, when I'm searching for those two or three sentences of clinical information, it's even more infuriating when the computer and technology we rely on screw up that little, valuable pearl buried in the mess. Once, I was reading a clearly dictated note that said, "... the Hoover Vacuum was attached without leak at the wound."

Reading it, I laughed out loud, imagining that poor, poor patient with an entire household vacuum stuck to them. Of course, dictation software had misheard "wound vac" as "Hoover Vacuum." No human would ever accidentally write that in a handwritten note, and no human transcriber would write that, either. The resident should have caught it. But alas, it is what it is.

I have a huge personal problem with getting angry at technology and inanimate things. I want them to be perfect, darn it!

Allison Edwards, M.D., Kansas City, Kan.

Always Spell Check

My favorite EHR mistakes are the ones that make it past spell check. I work with a scribe now, which is amazing and life-changing. I literally cannot imagine going back, but it makes it obvious when I don't use the scribe. I am a reasonably good typist, but when I'm trying to listen and type and attend, it gets pretty crowded in my brain.

On those rare occasions when I am on my own, I spell check. Still, some things just have a way of sneaking past that helpful-but-flawed tool.

The most common mistake I make is hitting the space bar too early or too late. When my fingers are flying, "hips hit" becomes "hip shit" too easily.

"As smart" becomes "ass mart," and "as small" becomes "ass mall." (These are either places to studiously avoid or my first million-dollar idea. Time will tell.)

Perhaps my most common hurdle is the word "does."

"Does hit" becomes "doe shit."

"Does not" becomes "doe snot."

"Does have" becomes "doe shave."

I catch many of them, but as often as I type "does not" in my HPIs and ROSs, I imagine that my charts are replete with virulent deer that have escaped into chart lore. Hopefully it never sounds like a zoologic infection.

Stewart Decker, M.D., Klamath Falls, Ore.

Posted at 01:42PM Jan 13, 2020 by Kurt Bravata, M.D.

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