Charting a course toward legible medical records: Perfect paperwork can mean financial savings, better patient care. (Medical Records).

THE PRIZE: A SUMPTUOUS lunch at the Four Seasons restaurant in Los Angeles, hosted by Cedars-Sinai Medical Center chief of staff Paul Hackmeyer, MD.

The challenge: Decipher a sampling of prescriptions, care instructions and clinical notes routinely penned by a group of Hackmeyer's ham-handed staff physicians.

The winner: Charity. The prize had to be raffled off. None of the contestants managed to penetrate the hieroglyphic mysteries of these crucial medical communications.

Amusing? Not really.

With patient deaths and injuries in the national spotlight and health care executives scrambling to improve quality, it's a sad reality that many of the problems can be traced to garbled transmission of vital information.

A seminal 1995 study at Brigham & Women's Hospital in Boston, for instance, found that 5.3 errors occurred for every 100 medication orders; snafus in paperwork lay at the root of 60 percent of the "adverse drug events" that resulted. (1)

Sampled over a seven-day period in 1997, more than one in 10 physician orders at Scott & White Memorial Hospital and Clinic in Temple, Texas, were illegible or dashed off in felt-tip pen, which does not produce clear copies. Fifteen percent of the new prescriptions submitted to the hospital-owned pharmacy were unreadable and 10 percent were incomplete. (2)

Experienced nurses were unable to decode one in five medication orders written by the 36 physicians attending patients in three care units at Presbyterian Hospital of Dallas in 1997, and almost one in four was incomplete. Fully 78 percent of the signatures affixed to these orders were unrecognizable. (3)

"Medicine is one of the only data-intensive businesses left that relies on a paper record," says M. Michael Shabot, MD, director of surgical intensive care units at Cedars-Sinai and medical director of enterprise information services. "It's very odd. We're like a cottage industry -- and yet information is so important to everything we do."

A tough storyline

Chalmers Nunn, MD, squirmed nervously. On the phone was the CEO, twitting him for failing to correct a major problem identified by the board of directors in a set of minutes the CEO had just reviewed.

The board had complained that physicians were not completing their patient charts "in a timely fashion."

Nunn, MMM, CPE, FACPE, and senior vice president and chief medical officer of Centra Health, in Lynchburg, Va., wasn't sure how to respond.

Then he relaxed when the CEO acknowledged with a laugh that the minutes were from a meeting -- in 1924.

""Messy medical records? That's a tough storyline. It's been a pandemic problem in health care," says Marty Rosenberg, CEO of Miller Orthopedic Clinic in Charlotte, NC. William Costenbader, MD, CPE, FACPE, an Asheville, NC, physician practice management consultant and a surveyor for the Joint Commission on Accreditation of Healthcare Organizations, agrees that good record-keeping is a perennial area of concern in hospitals, clinics and doctors' offices.

And he too cites history: "When the American College of Surgeons did its first survey, in 1917," he notes, "one of the primary issues was documentation."

Back in the old days

The problems involve more than penmanship and punctuality.

"In the old days," recalls Costenbader, referring to the early 1970s, "the big problem was trying to get physicians to put something into progress notes. 'Ahh, I can remember it all,' they'd insist. And a lot of times that argument did kind of hold water, because they were the sole physician treating a single patient.

"But now a lot of physicians treat every patient. So you've absolutely got to leave some note so that the next doctor or nurse who comes along will understand what you've done and what you were thinking."

"It's extremely important to improve the accuracy, completeness, timeliness and legibility of medical records," says Frederic Jones, MD, CPE, FACPE, a Sapphire, NC, accreditation consultant.

There are dozens of rules laying out the whats and whens of proper medical documentation -- state law, Medicare and Medicaid regulations, and hospital staff and group practice bylaws. All of them establish basic requirements and specify penalties for failure to keep abreast of paperwork demands. Often, however, enforcement is lax.

As a result, medical information management is a priority for the JCAHO.

"For example," Jones says, "it's a standard that every physician after the third visit with a patient has to have a complete, updated problem list in the chart, along with a complete medication record.

"Thirty days after a patient has been discharged from the hospital, the record has to be complete. Before a patient can leave the operating room and go to recovery, there has to be a handwritten note in the chart that is substantive and signed by the surgeon. The JCAHO is enforcing these requirements very stringently in its review process this year."

Money matters

Cleaning up the medical charting mess is a quality of care issue. It also has major financial ramifications for health care providers.

Aside from the unnecessary distress and inconvenience suffered by the 60 patients who experienced preventable adverse drug effects at Brigham & Women's Hospital during the course of another 1997 study, the expense of their treatment -- almost five days added to their stays in the hospital -- was inflated by close to $6,000 each. (4)

As it stands, the authors calculated, a 700-bed teaching hospital can expect to spend nearly $3 million a year coping with drug prescription and administration mistakes.

Although no one knows how many errors of all kinds arise from communication lapses among medical caregivers, adverse drug effects are highly visible and economically quantifiable.

Another dramatic indicator is wrong-sided surgery.

It's not as rare as one might assume. These blunders -- a healthy foot amputated instead of the diseased one, a normal lobe of the thyroid excised instead of its cancerous twin -- represent one in 155 of the closed claims in the files of the Physician Insurers Association of America.

To prevent such horrors, the JCAHO urges hospitals to develop a verification checklist that includes all documents for the operation, including:

* The medical record

* X-rays and other imaging studies and their reports

* The informed consent document

* Operating room record

* Anesthesia record 

* Observation of the marked operative site on the patient

If the JCAHO procedure is followed, the limb or side of the body to be invaded surgically will bear its own prominent pre-operative "medical record."

The patient is encouraged to ink "Yes" and "No" or "Right" and "Wrong" on the sites that might be confused before going under anesthesia. Unbelievably, even then, there have been cases when stubborn surgeons override the label.

Nothing to shake a stick at

The malpractice consequences of such medical misadventures are obvious.

"Everybody is aware of the legal issue," Costenbader says. "But they think they're not going to get trapped by it -- until it happens. That's why timeliness is so serious. If you don't put a note on the chart when you do something and anything bad happens to the patient -- even if you've gone back and completed the record properly in the meantime -- when you get on the witness stand most lawyers will say, 'Well, doctor, you just wrote that to protect yourself!"

In 1999, the latest year for which data are available, the average jury award in a medical malpractice case was $3.49 million, according to Jury Verdict Research of Horsham, PA. (5) Even staying out of court is costly. The median malpractice settlement in 1999 was $650,000. (6)

Finally, there's the simple day-to-day drain on the organization's financial health exerted by sloppy or belated medical records.

"We quantified the costs to our group [of about 40 physicians] of not getting in their charts in a timely fashion," says Rosenberg, "and we figured it represents a lost cash-flow opportunity of $400,000."

In other words, if procrastination -- like saving up all the surgeries and submitting the charges at the end of the month -- could be curbed and all charges for services submitted within 48 hours, Rosenberg thinks his clinic would reap close to $500,000 in additional income.

"That's nothing to shake a stick at," he concludes. "And our group has seriously considered the stick rather than the carrot. A lot of practices have penalties -- like withholding quarterly bonuses, or 1 percent of the actual charge -- when doctors don't turn their charts in when they're due. But penalties are very hard to enforce. The devil's in the mechanics. If the doctor says he didn't get the hospital note back in time, for instance, what can we do?

"Anyway," he sighs, "I'd rather they did the chart completely and accurately than necessarily in the precise time you want it in."

Unlooping the loops

Medical organizations address derelict documentation in a variety of ways.

At Cedars-Sinai, for example, Hackmeyer turned to a pair of Portland, Ore., calligraphers, Barbara Getty and Inga Dubay, whose workshops on handwriting improvement -- and book, Write Now: A Complete Self-Teaching Program for Better Handwriting, (Continuing Education Press, Portland State University, 1999) -- he read about in The Wall Street Journal.

Hackmeyer invited Getty and Dubay to conduct a three-hour penmanship seminar for his staff physicians. Attendance by the most flagrant legibility offenders (identified by nurses) was strongly encouraged. Sixty-two showed up.

"Some of them come in kind of grumpy," Getty says, "but by the end of the first hour we get really positive feedback." She's since repeated the program for doctors at 24 health care organizations nationwide.

Handwriting has one advantage over a computer, Getty adds. It's "virus-free." But when it's unreadable, "it's like mumbling. The loops are what make it break down."

Getty and Dubay teach doctors to scrap what they learned in elementary school and switch to "basic italic, which is like joined printing. There are no loops. And you can write it fast when you master it."

Which doesn't take long, she claims.

"There was one neurosurgeon who told us he was accused by the nurses the day after he attended our seminar of having someone else do his charting for him," she says. "Another physician told us his handwriting had been so bad it had been banned by his medical center. When we came back for another workshop, he proudly showed us a letter from the hospital giving him permission to use his handwriting again."

Getty acknowledges her class is a stop-gap measure. Computer print-outs will eventually supplant penned prescriptions, instructions and notes altogether.

"It's my belief that handwriting is a very poor way to convey technical information," Nunn says. "And I'm skeptical about those classes. I wonder how long the effect lasts. I'd like to see some data on that."

Hackmeyer can provide it for the short-term, anyway. Calls to physicians to clarify orders fell by two-thirds following the penmanship workshops at Cedars-Sinai, he says. Improvements in legibility for the physicians who attended were noted on 13 of 19 units three months later.

But the real payoff, he says, was the heightened awareness among Cedars-Sinai's 2,000 physicians of their own responsibilities in contributing to patient safety.

"We've put several recalcitrant doctors on probationary status. One even threatened legal action under the Americans with Disabilities Act. Our legal department informed him his claim wouldn't fly unless he had a diagnosable condition. Just being unable to write clearly is not a disability."

A better way

Many physicians dismiss concern about documentation as merely a financial issue for the hospital, Nunn says. "We emphasize that it's a care issue too.

He's a fatalist, though. "What you're struggling against is history and individuality," he says. "So... we shame 'em, we talk to 'em, we say we're going to take their names to the executive committee... but it almost doesn't matter what you do and how you approach it. Whatever system you come up with, they're going to game it."

In the short-run, Nunn says, the best antidote to messy medical records is to establish a culture of expectation. For the future, all the physician executives interviewed pin their hopes on technology.

Electronic medical records are used in varying degrees by each of their organizations. Computerized physician order entry systems are coming soon.

Digitization of medical information exchange is costly, they say. But to speed the flow and accuracy of communications to and from bedside, office, pharmacy, laboratory, imaging, nursing station -- even the patient's home -- is worth the expense, they say.

"The world's not going to change tomorrow," concedes Charles "Ray" Fernandez, MD, CPE, FACPE, who's the CEO and CMO of the Piedmont Clinic in Atlanta. "But every doctor from personal experience can think of something that happened -- a horror story -- that could have been prevented if the system had provided a check."

Which is why his clinic's parent organization, Promina Health, is spending $40 million to eliminate misreadings and slips that can arise from handwritten prescriptions and chart entries. In three years, all orders by Promina physicians will be entered on computers.

So far, only a tiny percentage of U.S. health systems possess such a capability. But their numbers are growing rapidly.

David O. Weber is principal of The Kila Springs Group, an editorial organization specializing in science and health care based in Mendocino, Calif.

References

(1.) Bates, DW. "Relationship between Medication Errors and Adverse Drug Events." Journal of General Internal Medicine, 1995 Apr; l0(4):199-205.

(2.) Meyer, TA. "Improving the Quality of the Order-writing Process for Inpatient Orders and Outpatient Prescriptions." American Journal of Health-system Pharmacy, 2000 Dec 17; 57 Suppl 4:S18-22.

(3.) Winslow, EH. "Legibility and completeness of Physicians' Handwritten Medication Orders." Heart & Lung, 1997 Mar-Apr; 26(2):158-64. Erratum in Heart & Lung 1997 May-Jun; 26(3):203.

(4.) Bates, DW. "The costs of Adverse Drug Events in Hospitalized Patients. Adverse Drug Events Prevention Study Group." JAMA 1997 Jan 22-29; 277(4): 307-11.

(5.) Treaster, JB. "Malpractice Rates Are Rising Sharply; Health costs Follow." New York Times, September 10, 2001.

(6.) "current Award Trends in Personal Injury, 2000 Edition," Jury verdict Research, Horsham, PA. cited in Albert, T. "Malpractice Awards Pushing Insurance Premiums Higher." American Medical News, March 5, 2001.

RELATED ARTICLE: IN THIS ARTICLE...

Short of going fully electronic, there are various ways to clean up your medical record system to make it more efficient and less time-consuming. Check out how some experienced physician executives are dealing with this perennial problem.

A Little Bit of Offers Hope for Poor Record-keeping

Disorganized, fragmentary or prolix case notes are equally time-honored hallmarks of poor medical charting. In the 1960s, Lawrence Weed, MD, addressed this issue by developing what he called the "problem-oriented medical record." Weed counseled doctors to follow a logical, scientific structure described as SOAP.

Under SOAP, a patient record should contain:

* Subjective data about the condition as described by the patient

* Objective data derived from physical examination of the patient and test results

* The physician's own Assessment of the problem in pathophysiological terms

* A management Plan for further investigations to pinpoint a diagnosis, treat the condition and educate the patient.

Many health care organizations and consultants urge physicians to follow this format.

"There are some people who seem to think they're writing the great American novel," says William Costenbader, MD, CPE, FACPE. "We tell them 'No, no, no.' It isn't necessary for everyone to enter weight and vital signs. On the other hand, it's not enough to just put down 'fractured right hip' if it's an 86-year-old woman. You've got to have her other medical history as well, because there can be significant factors that play to overall care."

To hammer home the malpractice liabilities inherent in messy records, Costenbader also recommends that young physicians volunteer to review medical records as expert witnesses for a local lawyer.

"You can learn a lot about the way those guys think," he explains, "and about what can happen... so it doesn't happen to you."

To avoid leaving money on the table from incomplete or delinquent charts, many health care organizations deploy teams of physicians or nurses to coach and advise doctors on proper documentation.

"For a number of years we've trained a few doctors as 'coding experts,"' says John Babka, MD, FACHE, FACP, CPE, FACPE, vice president of medical affairs at Morton Plant Mease Health Care in Clearwater, Fla. "Physicians at our three hospitals have begun to understand that complete and accurate coding may be important to them under managed care."

In addition, he says, a trio of clinical resource coordinators -- RNs or licensed social workers -- not only review and pre-code charts, they affix evidence-based care reminders as appropriate.

"They're the arms and the legs of quality improvement at our organization," Babka says.

David Weber

Treating DDD (documentation deficiency disease)

Here are some ways to fix sloppy medical records:

Legibility

* Host handwriting workshops for physicians and nurses, especially those with identified problems in penmanship

* Require physicians who are habitually unable to write clearly to enter all medication and care orders on a computer or a handheld electronic device

* Establish rules that any uncertainty about a written order must be resolved by checking directly with the source

"We have asked our pharmacists and nurses not to 'vote' on what an order says," reports John Babka, MD, of Morton Plant Mease Health Care.

* Employ dictation and transcription services

"(These are) probably the most cost-effective alternatives to resolving messy medical charts right now," according to Miller Orthopedic Clinic CEO Marty Rosenberg. His 40-doctor practice spends $400,000 a year transcribing 3.7 million lines of dictation. But, he points out, "you can never write as fast or as much as you can think or speak, so you're liable to leave out a lot of detail. And if you haven't recorded it, you haven't done it."

Relevance

* Adhere to formats that reduce disorganized, rambling, fragmentary or unfocussed case notes, such as the scientific SOAP structure (see sidebar)

* Develop templates for documenting standard physician-patient encounters such as routine physical examinations, generating case-notes and drafting letters

Accuracy and completeness

* Deploy consultants or teams of physicians and registered nurses with documentation expertise to review records and coach clinicians on coding and evidence based care guidelines

"Sometimes physicians in the parsimony of their writing don't put all the complicating and comorbid conditions in the record," explains Babka. "There are ways things have to be worded and coding rules that may not make much sense medically but are very important for reimbursement and denials under managed care."

* Adopt medical group policies encouraging young physicians to serve as paid or unpaid expert witnesses reviewing patient records for a malpractice attorney to provide an education in the hows and whys of adequate charting.

Timeliness

* Withhold paychecks of physicians whose records are delinquent

* Deny bonuses to physicians whose documentation is belated or consistently problematic

* Deduct a percentage of the charge from the physician's reimbursement when the record is submitted late

* Shut down the office or refuse to schedule elective procedures for physicians whose records are not completed on time

* Place physicians on probation

* Suspend staff privileges when inadequacies in record-keeping are flagrant and habitual

Draconian disciplinary measures are a last resort, however, cautions Centra Health senior vice president Chal Nunn, MD. "Who are you hurting." he asks, "if you tell a doctor at 5 p.m. on a Friday that his privileges have been revoked when he has an 80-year-old patient in his office who needs admission to the hospital?"

David Weber