Getting Everything in One Place

— Electronic health records aren't delivering on their promise of fewer paper forms

A photo of a male physician holding a piece of paper and looking at a laptop in his office.
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    Fred Pelzman is an associate professor of medicine at Weill Cornell, and has been a practicing internist for nearly 30 years. He is medical director of Weill Cornell Internal Medicine Associates.

The scattered minutia of our lives only adds to the chaos.

The other day, I got a message in our electronic health record from one of the front desk staff, about a form that had been faxed in to our office, they had then scanned it into the chart, put the paper copy in my mailbox, and advised me to call the patient's homecare nurse after it had been completed and faxed back.

Simultaneously, I got an email from a separate portal created by that same visiting nurse service with an electronic version of the same form, requesting that I sign that one. And later that day, one of the residents brought in an identical copy of the same form, that had been placed in their mailbox -- since they were the primary care provider for this particular patient -- that I needed to sign as the supervising attending.


This never-ending barrage of stuff that comes at us, that often has very little to do with patient care and everything to do with bureaucracy, seems to have increased exponentially, and is probably contributing to providers' frustrations, short tempers, lack of focus, and burnout. And I can only imagine that this hardly leads to a sense of inspiration among the trainees who are looking to see if primary care outpatient medicine is the right career choice for them.

We take care of an incredibly complicated group of patients with high needs. These patients often require intensive collaboration with multiple specialists, and also frequently involve extensive forms and bureaucratic tasks that need to be attended to. Working in a resource-challenged environment, there is usually very little support, and much of this work ends up falling to the doctors.

That includes home care forms that need to be filled out immediately, prior authorizations (PAs) for medical supplies and durable medical equipment, and the need to change medications based on changing formularies from insurers, all overlaid with a sense of urgency and pressure. Something as simple as prescribing medications leads to chaos, as each instance of doing this can have so many complications, from pharmacies not having medications in stock, insurers deciding which medications our patients can have and changing this month to month, and us having to prove that our patients deserve medications we think are medically indicated.

One of my hospitalist friends told me that one of the jokes on the inpatient wards as residents head off to their outpatient clinic rotation is that they want to get them T-shirts that say: "WCIMA, PA required". (WCIMA refers to our practice, Weill Cornell Internal Medicine Associates.)

The other day, I got a message from the staff that a patient had dropped off a form, and for me to call them when it was ready for pickup. The form was a 25-page document that the patient required from New York State for transition from one level of care to another. It necessitated an enormous amount of detail on their past medical and surgical history, literally everything that had happened to them medically through their lives, along with an updated physical exam, and a huge battery of testing.

I'm hoping that someday we will get to a point where I never need to hand copy someone's medication list from my electronic health record onto a paper form. There have got to be ways that we can synchronize and smooth this stuff out.

So much of this is already represented electronically within our patients' records, in this EHR we are paying so much to use. When a vendor calls to request incontinence supplies, shouldn't there be a way for them already to know that the patient is incontinent and has been using these things forever?

When we switched over to our current electronic health record, many of our surgical colleagues still requested that we hand-write onto their preoperative medical clearance forms all of a patient's past medical, surgical, and other health history, along with their medications, allergies, physical exam, preoperative testing results, and our medical evaluation recommendations. But it's right there in the same chart they are using -- just saying.

We refused to fill out the paper forms, and eventually we were finally able to convince them that our own freestanding electronic notes would suffice. Pretty much everything we need to be able to provide these ancillary services necessary to take care of people is already right there -- it's just a question of using the right technology to transmit it from one place to another.

My hope is that smart people are working on smart systems that will be able to identify what is needed for a form to be completed, and will then be able to extract that information from the medical record, and fill it in, in all the right places. Right now, our electronic faxing system doesn't even allow us to complete forms within the PDF that is created, but requires us to print out the scanned fax, fill it out by hand, sign it, then scan it back to the chart after manually faxing it back to the requested location. Sort of defeats the purpose of electronic faxing into the EHR, don't you think?

This doesn't seem to be asking too much, that the information somebody wants that is already there gets put into the right place. Then I can click some buttons and add my electronic signature, and send it on its way.

No PA required.