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The New York Times

Medical Record Abuse

By Brian L. Grant, MD

The timely New York Times article, “A Shortcut to Wasted Time,” describes problems arising from improper use of record keeping.

It is important that those involved in medical care and treatment review, including those requesting these services understand the capacity of electronic systems to be misused.

There is nothing wrong with such systems and they are not going away. But as with most information tools, the quality of what is generated is only as good as the input, in this case the clinician doing the work.

Electronic systems can be abused and misused in many ways. And one does not need an expensive record system to misbehave. Microsoft Word will do. In the course of reviewing records, I have seen a number of abuses.

Here are a couple of ways to identify the misuse of medical record systems:

  • Boilerplate used where unique data is required: A psychotherapist working with a patient over time reports the exact same mental status findings from week to week, in the same words. People change and emotions are not static. The clinician demonstrated laziness and questionable competence when each note read substantially the same, courtesy of cut and paste or template.
  • Normal findings reading exactly the same: Physical and mental status findings have many variations. This includes normal findings. When an orthopedist reports the same range of motion on multiple patients, where the normal range can and does vary, a reader can conclude that the measurements are likely inaccurate, and the overall credibility of the examination is in doubt, including whether the measurement was actually taken.

In the old days of handwritten or dictated notes, each entry was unique and required that the clinician take specific action to report a given finding. Now with a click of a mouse, one is capable of filling a page or more with content. Just because one can, does not mean one should.

If you create records, demonstrate thoughtfulness and do not use boilerplate for findings. A template can be useful as a guide to what content should be included for a particular assessment or complaint. And typed records are legible unlike most handwritten notes.

If you read records and see findings reported in such a way to suggest that they were computer and not clinician generated, it should raise red or yellow flags about the overall quality and credibility of the treatment records and the clinician describing the treatment.

The abuse of record systems is a significant unintended but entirely predictable consequence of the technology. I invite readers to comment on their own findings and observations from working with or reviewing the work product of such systems.

Read More…

The Costly Marketing Budget for Antipsychotic Drugs

By Brian L. Grant, MD

At the American Psychological Association Conference, the pharmaceutical industry has a large marketing presence.

The New York Times article, “A Call for Caution in the Use of Antipsychotic Drugs,” was alarming but not surprising to me as a psychiatrist. The numbers are staggering though. The advertising budget alone, at 2.4 billion dollars for the new antipsychotic drugs equates to about $57,000 per US psychiatrist (about 42,000 total)!

This marketing budget total alone just approximates the entire market for non-Federal IME’s and medical reviews. If spread across the U.S. population evenly, each of us would have consumed about 58 dollars worth of antipsychotic drugs in the past year! The use of such medications is clearly concentrated to a small portion of the population and are prescribed in large amounts by a small portion of psychiatrists and other licensed practitioners.

Anyone who has been to a major psychiatric conference would not be surprised at the massive booths from the drug purveyors manned by sharp men and women hawking the wares, with various enticements to visit their booths. The incentives to over-prescribe is clear, given the money involved.

The fact that a number of medical lightweights fail to understand how they are being used as gatekeepers to these drugs is sad and costly, not only for payers, but for patients who are often given these costly drugs with very real side effects, when less costly alternatives with equal or better outcomes exist. To deny the positive impact of these medications in select patients is wrong. But common sense combined with available science should lead to the obvious conclusion that this is not right.

Label creep, where a good drug is advocated for the wrong reasons, is not unique to psychiatry. Articles like this by Dr. Friedman does little to bring pride to my profession. Similar scrutiny is warranted for so-called ADHD (attention deficit hyperactivity disorder) in adults, fibromyalgia and any other malady that is largely associated with profitable, or abused drugs and often direct to consumer advertising to create a wider market.

The Premie Challenge

By Brian L. Grant MD

Rafi, now age 3, was born premature at 28 weeks unable to maintain body temperature, breath or feed unassisted. He spent a month in the Neonatal Intensive Care Unit and is alive now because of a multidisciplinary team, medicine and technology.

The photo of the boy holding the flustered chick is my three-year-old grandson Rafi. He is perfect in every way. But his life is a triumph of medicine and technology. Rafi was born at 28 weeks of age, after an unexpected premature labor. His mother was rushed to deliver at the University of Washington. When born, he looked similar to the photo below. The delivery of such a small baby was easy. But what followed was not. A large team took over in the Neonatal Intensive Care Unit (NICU) and for the next four weeks, Rafi was watched and cared for. He was unable to maintain body temperature, feed or fully breathe unassisted – so others helped. After a month in that unit, he spent another month in a less intensive unit in Seattle before discharge at what would have been about 36 week’s gestation.

Absent the care he received, he would have died at birth. He had no apparent abnormalities beyond prematurity, and being kept alive while being allowed to mature took care of the issue. His situation is hardly unique, as the article, “In Premies, Better Care Also Means Hard Choice,” from the New York Times describes. The article focuses on the decision(s) to resuscitate premies.

In Rafi’s case, there was no discussion, just action. Perhaps had there been severe problems or anomalies there might have been, but it appeared to be a given by the system that he would be given all resources available. I can’t imagine the challenge his parents would have faced had they been asked to make a life or death decision at that trying time. And they and we are very appreciative of the incredible care Rafi received by a skilled multidisciplinary team. The actual cost is not known to me, but I assume it was well into the six figures – covered by his parent’s insurance without challenge. Such tertiary care resources are expensive. But Rafi shared the unit with babies from less fortunate backgrounds, who received the same level of attention. While payment for and cost of care is a big issue for all of us, the source or availability of payment played absolutely no role once a baby was admitted.

When I was a medical student on the late 70’s, one of my first clinical rotations was in a NICU. My first exposure to babies was of the two-pound variety, such that when I finally worked with full-term babies, I could not believe how big they were! The technology and skills to sustain these kids and avoid long-term problems continue to evolve and even then, I concluded that this is one area of medicine that truly has an impact – lives are saved that would have ended and many or most go on to lead normal lives. But challenges remain, especially in earlier gestation births. The ethical questions and values that the choices that were not available until recently are many. And each baby, family and set of resources creates a different set of opportunities as well as challenges. Read More…