Why hospital care costs so much--the expansion of medical records

It's always been the business of doctors, nurses and health care givers of all kinds in hospitals, nursing homes, doctors offices, clinics and the like to keep close and detailed patient records. Depending on the circumstances these range from a folder your doctor keeps that contain his handwritten notes about your complaints and condition, test results, his analysis or assessment, treatment recommendations and prescriptions ordered. If you're hospitalized you might have a more detailed health history taken, plus data sheets and charts, progress notes of those taking care of you, results of lab tests and the analysis and diagnoses of various practitioners who have had a whack at you. That's my guess. It's simply taken as truth that the doctors and clinics and other health care practitioners who take responsibility for your care will review these records and rely on them when they next evaluate you. And they will plan for your continued care and what role others might play, on the basis of what is written down in your records.

As sensible and eternal as this system has been for everybody serving in an office or clinic or hospital, modern corporate medicine has made big changes in medical record keeping in the last decade. The changeover to electronic records is still going on, with ever more complex and extensive kinds of data gathering and analysis required. This creates an amazing burden on nurses (as well as the Ellis mental health clinicians downtown) who are the primary record keepers. I've recently witnessed the fact that nurses spend more than half of their time on the orthopedic floor at Ellis at their computer workstations in the patient's room and out in the hall. They're not talking to the patient, or observing or doing treatments or giving out medicine, which are the things that nurses do.

They take vital signs (blood pressure, pulse and temperature) at your bedside in seconds, then retreat to their consoles to record everything that the computer program calls for including such inanities, I'm told, as whether the bed rails are up or down. And I suppose, they assess whether you look bright this morning, if you're eating and sleeping and have had a proper bowel movement. And they will do this type reporting over and over, filling in boxes on the computer screen using different codes and shorthand that some computer whiz has designed for them.
It's enough to make nurses turn away from the profession. The student nurses I had at my bedside during my recent recovery from hip surgery at Ellis in April said they spent several hours a day at their computer. One said they had to assess what my condition meant, not just the physical signs. That means using their imagination. It's done so that supervisors can see what they've done, every shift, every day.

Do they want to do this? Not at all. They told me they disliked it, it kept them away from direct patient care and their reason for becoming a nurse. They were asked to put down far more detail than needed. My professional home-care physical therapist said when she went into nursing 27 years ago she did it to be close to patients, to make a difference in their recovery. Now she works on a laptop in my house for part of her time with me and spends more time on it at night—all to satisfy federal rules for her position.

Why do they do it? The nurse said it's required by federal Medicare regulations. That governs Medicaid and private insurance companies as well. The hospital has to do it to be reimbursed. They also do it because the hospital wants to be protected in the event of lawsuits over the treatment someone has received or a medical malpractice claim, for instance. That's why we knuckle under to these outrageous claims on the time and energy of our doctors and nurses.

While electronic records are touted as cost-saving, critics say this is not demonstratedly so. Instead, the price tag to switch over to these systems has cost hospitals and the public millions of dollars. There's an extreme concern in the hospital about sharing and safeguarding the extensive system of electronic records, which adds to cost. They must protect both patient and physician confidentiality under federal and state laws. So the sharing and access is likely missing. The visiting nurse's computer record on me cant be shared with my surgeon, who ordered her care, nor the hospital, both of which have systems incompatible with hers. And time spent at the computer console is certainly a consideration. Nurses can't be assigned more patients than now, just as the Ellis mental health clinicians can't take on more patients, leading to the backlog in appointments the past few years.

While computerized records are all the rage, and have clear benefits for storage and versatility of use over the handwritten ones, hospitals and clinics and doctors offices still must rely on longhand notes for many applications. For one thing, it's simpler to write down what the patient says when face to face. These are the customary progress notes and charting that nurses are trained to do. Why should they recapitulate the record on a computer screen? For whom are the records kept, after all, if not the immediate patient? Instead, the computer records seem destined for data banks that serve the institutional purposes of regulators and insurance companies and research entities. I don't think my hospital records have much value to anyone else, except for somebody's studies and we shouldn't have to pay for that.

By the way, NY State is about to implement a multi-million dollar computer network to store and manage our medical records, called eHealth. It's like a data bank for each of us so doctors and other care providers can access information about us when we need them to. The information would come from hospitals, physicians, pharmacies, clinical labs, health insurers, and the Medicaid program. It can pave the way for safer, more convenient health care,say the people touting eHealth. It will tell others if we've changed doctors, seen a specialist, visited a clinic, or checked into a hospital and much more. I call it invasive and super-expensive, not needed or wanted. The state will receive federal surplus money through ARRA, the Recovery and Reinvestment Act to pay for it. It's also called SHIN-NY and you'll be hearing about it soon, as
hospital costs keep rising, and you wonder why. (Roy Neville)