I think the record has several uses in it's current form
Legally we are not merely the custodians of the record - we own it , can
buy and sell it , and up till recently have ben able to prevent the
patient having access. This changing, and probably for the better.
The conventional use of the record is to aid patient care, and this
doesnt need much detail - indeed only a problem list, significant past
history and medications are required.
As an "episode" of illness is evolving and the diagnosis is not yet
clear, there may be a need for detail on history and examination etc,
but once this is past the detail is irrelevant to the patient's management.
The "secondary" uses of the record are legal and audit/review (and maybe
a few others)
In this case the requirements are entirely different. Even exhaustive
detail will not be enough to satisfy a lawyer looking for a weakness. I
reckon we should really start to explicitly separate these two roles for
the record and design systems accordingly
I agree on the fixity of belief - doctors as a whole are used to coming
to a conclusion and selling that to the patient. It is not acceptable to
conclude "I dont know" and do nothing. We have to at least stick a fancy
label on the patient and offer them a solution. To do this we have to
confident and assured. There is plenty of certainty on this list!
R
David de Bhál wrote:
We are merely the custodians of the record - we hold the record in trust for
the person to whom it is most relevant.
If you practice proper medicine and you do what is right and document the
history and the examination and show how you came to the conclusion that you
did, as required by law, then you have little to fear.
I have never met anybody nor heard of anybody who was told "indemnity
insurer tells him his arse isn't sufficiently covered". My understanding is
not documentation, per se, but the lack of it that is the problem.
What we have now is very poor documentation often secondary to very poor
medicine. Better no medicine than bad medicine.
Most mistakes are made not by not knowing but by not looking. If people are
afraid of the system, then they are better off out of it.
What I would implore is the ability to leverage the knowledge in and the
power of a patient-centric record and preferably with access from the
patient.
A good example is that of Andy Gore of Intel quoted in Fortune Dec 2005 when
he reports on having prostate cancer. He was told that surgery was the best
option and that was pretty much all there was to it. Was it though? It took
very little to discover that there was much, much more to it. There were
alternatives to surgery. No surgeon advised him to take them seriously. But
the expert opinions were just that - opinions, based on little if any hard
data. Data did exist. What he found most shocking is that no one had done
the hard work of pulling it together. Plainly, Grove would have to do it
himself.
What he "found most appalling, in the end, was the utter fixity of belief
among doctors who failed to separate knowledge from conventional wisdom.
Even the doctor who carried out the procedure was captive to it". Grove had
prostate cancer in 1995 and researched it himself and came up with the idea
(then) that brachytherapy was the best therapy. It is interesting that the
patient can now often have as much information as the doctor. What he often
lacks is experience.
I was amazed when in the US in the 1970s that the students often had more
knowledge on a particular subject than the consultants and they
(consultants) often had to defend their position. Grove apparently fostered
a culture at Intel in which "knowledge power" would trump "position power".
If you talk to patients (who are not your patients) is that they are amazed
at the inability of the brightest and most powerful group in the community
to embrace the power of information technology for their( the patients')
benefit.
David de Bhál
www.v-practice.com
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