If we can’t remember what we were doing, and others can't see what we were doing either, then. . .

Who’s going to care for the patient (and how)?

November 18, 2014 by David

A woefully misunderstood and clearly under appreciated medical record concept is the treatment plan. It is often subsumed under the heading of “disposition” on in electronic record systems where clinicians themselves seem to have tacked it on to a contact note as an apparent a few words of after-thought.

For a moment, let’s use the CMS Guidelines for Documentation of Evaluation and Management (E & M) Services to summarize (for now) what a medical record consists of.

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The Guidelines central purpose served different ends from a clinician’s record of medical care. They were in the end analogous (dare I say complementary?). The motivation for the guidelines had entirely different philosophies and goals. It is extremely important to bear this in mind whenever assessing an implementation of an electronic medical or health record (EMP/EHR).  In their design, the guidelines served as a principle part of the analysis of requirements.

The problem oriented medical record (POMR) as developed, and evolved, provides an extensible record of care and a database of the patient’s medical state. It is a data repository and medical decision tool. The documentation of E & M services is a minimum requirement of documentation for payer auditors (specifically federal government Medicare auditors, and their agents) showing that billed care meets the requirement for payment as actual services rendered. Thus I state that, not-withstanding claims otherwise, it is primarily a government auditing document. Although, usurped in many cases by private sector payers for the same purposes. Further many others have adapted it for use as a documentation guideline, in lieu of a medically standardized expectation of data content and organization for information storage and communication.

It remains to be seen whether the E & M Documentation guideline is up to the task of medical recording database standard, arbiter of medical communication content or even a suitable substitute for the a current incarnation of the POMR. My sense is that it does not address the needs brought to light by the Institute of Medicine (IOM). This is particularly true concerning treatment planning that moves through “patient time”. There was originally no intention for the Guidelines to serve that role. Any effect it has had on record quality in general is coincidental to the economic need to ensure (under threat of federal punishment ¹ that one “gets what one has paid for”.

I never tire of referring to the IOM Report “To Err is Human”. I feel it is one of the most far reaching and significant reports on the state of medicine since perhaps the Flexner report. The main observation is that communication problems are the single most important threat to a successful patient outcome – certainly while in hospital. I submit that an economically motivated document (such as “The Guidelines”) has never in history had this potential effect for the human condition.

The field of healthcare in general continues to be rife with opportunities for patient care to fall through cracks in the system. A major implication of the report is that neither medical skill, competence, nor the availability of modern technology is irrelevant to the communication deficit involved.  Improved communication alone can seal most of the leaks in health care quality; communication everywhere the patient is or will be, among whomever the patient must meet, as often and consistently as possible. In particular the movement of the patient between episodes of care in the outpatient setting must be recognized as a weakness.  I believe a high yield solution for this weakness is the complete, comprehensive, frequently revised and revisited, and widely available treatment plan. It may very well be more important than a diagnosis alone!

Diagnoses can be incomplete, in process, or outright wrong and the patient can still receive good care ². Litigators take note! A well developed, frequently revisited and revised treatment plan (which does include of course a working diagnosis) is actually the story about what is being done and why at any instant. Such a 3 point plan as: continue meds, get test and return next week (or more often, “if not better”) does grave disservice to our patients. A foremost omission is “what will we be focusing on, or doing, next visit”. Recall from a previous Blog, my frequent encounter with the patient complaint “they didn’t even know why I was there”. Certainly this clinician embarrassment must, if nothing else does, justify a properly written Treatment Plan”.  (This would be so even if the note was only for your use – which it is not!).

So, what view of the patient’s treatment should be constructed and maintained?

1. >A general statement of the clinician’s thinking is helpful to all involved in care – not a sign of indecision for litigators to jump on in court.
2. A statement of anticipation of the course of the condition disease or disorder is also helpful in both establishing a baseline and a measure of response expected to interventions.
3. A summary of interventions taken (started) and planned at that current phase of the therapeutic process. These include therapies, tests, and goal of any intervening period of observation (or benign neglect) and including criteria to make deviations from these interventions.

4. A statement summarizing for the patient in their own (layman’s) language the information contained in ii and iii above. (A detailed patient education update).

5. A summary of tasks and activities to be completed by the time of the next meeting.
6. A date and time for the next meeting and criteria of how and why to alter follow-up arrangements.
7. A list of other persons booked (appointments being arranged etc.) or known to be involved in care directly (and indirectly, e.g. Patient disclosed alternative therapists) at that current time.
8. Who is back-up for the period of the pending next visit if you are not available.

Many of these will be default entries such as back-up but are included explicitly for others consulting the current the version of the plan. Other entries may be selected from lists. Many entries such as thought processes are best entered in an ad hoc fashion.

The intention of the patient visit and educational summary is to anticipate and answer things that occur to the patient after the end of the meeting. However, we must recognize that the patient has a fundamental right of access to the full contents of their clinical record. There is a proviso, however, that the rare (usually psychiatrically motivated) concern for harm to a patient or others by such full disclosure can override such a right. With that in mind,+ a non-clinical addendum (Warning to the Patient requesting such details) should always be present explaining the speculative nature, pending further information or the fullness of time, of some of the content of the Therapeutic Plan. This is not intended as a legal disclaimer at all but a service to the patient; but indeed does also serve a disclaimer role if ever needed.

All that remains for me is to consider templates and other tools to assist in this model of a therapeutic plan. I am developing these, as part of my projects, to be a logical part of a generic, care directed, and clinical record. Such a clinical data source is also the precursor of the database available for data analysis that we want to carry out. This clinical data should be compatible with all the business management, the third party accounting and payment, and economic and health policy needs. Thus clinical care coexists with these needs with-in an informatics instrument and primarily addresses clinical, biomedical, and direct patient care needs. This demonstrates the many stakeholders in such a system.

More to come.

Another blog post

to be announced

is coming in December 2014 - David