Thursday, September 2, 2010

Electronic Outpatient Records

This week I completed my formal training on how to enter data on Endocrine outpatients at Mercy Catholic Medical Center where they are implementing an electronic record, to begin on my second day on the job.  Over the years I have become something of a medical craftsman, not quite an artist who takes creative liberty, but somebody very proficient who can discern one person's situation from the next.  It came as a shock to encounter a computer program that can be clicked in minutes and generate a relatively nonspecific narrative about diabetes.  It reminded me a lot of my residency time of despair when assigned to the coronary unit.  I quipped in the 1970's about templating everyone's history with substernal chest pain of x hours duration that radiated somewhere, as where usually didn't matter much unless straight through to the back where thoracic aortic dissections go.  You enter the age and the response to nitro if any and you could save yourself a good deal of writing.  These histories didn't matter much since everybody got templated in their care with cardiac enzymes and an ekg.  The differences in the ekg's mattered as did evidence of congestive failure but for the most part a jaded resident like myself could safely conclude that most angina follows a pattern that leads to uniform lab testing and a small variation in decisions with little nuances of history not all that essential to decisions.

That is not the case for diabetes where the difference between me taking care of it and the primary physicians or non-physicians taking care of it are the nuances of history.  There are responses to individual medications, as virtually everybody who comes for consultation arrives already unsuccessfully treated.  There are end organ symptoms that belong in the HPI, not the ROS.  It is extremely hard to template that but people try.

No comments: