Another Clinical-history Piece…

…although, to be fair, this time I’m not railing against careless referring clinicians who can’t be bothered to jot down some pertinent details when ordering an imaging study. Not much, in any event.

Take a little stroll with me down memory lane. We’re not going far; fewer than 20 years. Around the span of time during which I was doing clinical clerkships in med school, and then internship, residency, fellowship.

At least in the facilities where I worked, those ordering imaging did so by good old fashioned paper and pen. The imaging studies were protocoled and read out according to whatever written words had been provided. If those words were insufficient, more might be requested. Whoever was actually doing the imaging (technologists, or even the radiologist, if present, such as during hands-on ultrasound) might add to those words by communication with the patient and/or family of same.

In the report, however, the “Clinical History” or “Reason for Exam” section was no more and no less than what the radiologist spoke during the dictation. However (ir)relevant it may have seemed to the rad; s/he could hardly invent stuff out of thin air if all that was provided was “R/O path.”

There were rads who found the paucity of clinical info intellectually dissatisfying. Other rads were less motivated, and so were coaxed to improve upon the clinical detail, in the name of getting properly reimbursed for the work they were doing. Government agencies and insurance companies, it was explained during orientation meetings and other mandatory conferences, would happily withhold payment if certain magical words and phrases weren’t included in the clinical histories.

So, some rads made the extra effort, and I’m sure that others did not. Especially those who were in employed positions, who might see no direct negative consequences from unsuccessful billing in their names.

Meanwhile, the regulators and payors kept on adding new wrinkles to enable themselves to withhold reimbursement for professional services which had been rendered in good faith, and even the reimbursements which got paid out were diminishing by the year as health care (and especially radiology) became tougher places to survive, let alone thrive.

Now, I’m not privy to the inner workings of the computerized order-entry or radiology-dictation software industry. But, as a rad who’s made to use their products whether I like it or not, I’ve gotten the distinct impression that the Powers That Be made a decision: We rads and the referring clinicians, folks who were actually delivering the health care, could no longer be trusted to jump through the hoops to say whatever needed saying in the Clinical History section of our reports.[[{"type":"media","view_mode":"media_crop","fid":"55358","attributes":{"alt":"Radiology report","class":"media-image media-image-right","id":"media_crop_566906932437","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6928","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 170px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

So, these industries summarily took the matter out of our hands. Docs ordering exams no longer had quite as free a hand in writing down why they were ordering this imaging study, because the computer wouldn’t let them…or made it such a chore to do so that clinicians just took the easy route of clicking on “pain” or whatever appeased the machine.

And we rads, slowly but surely, were required to use software that would automatically populate the Clinical History section of our reports with whatever had been entered by the referring clinicians. Or, rather, what their computers had transmogrified the referrers’ input into. Sure, we rads could take the extra effort to click around in our reports and tidy up the gobbledygook in the History section…but to do that 100, 200 times per day for each and every study we read? Not quite the path of least resistance, that.

I fondly remember the days when my reports’ Clinical Histories would be nice, tidy, straightforward statements like “Right lower quadrant pain and leukocytosis; question appendicitis.” Or “Status post fall, now with snuffbox tenderness on the right; scaphoid fracture?” Instead, now the History is just a jumble of words, often redundant and sometimes contradictory.

I might see the history state “pain” in one phrase, and “abdominal pain” in another. I might see that there was “surgery <1 month,” but I’ll have no idea whether it was 29 days ago or this morning. I’ll see the word “fracture,” but not know whether that means a fracture is being questioned, has been diagnosed on clinical grounds, or was sustained a month ago and now I’m just checking up on healing.

And if we’re confused about this mess that has been made in our reports, what must outsiders reading them think?

Does anyone think this has resulted in an improvement? Seems to me, all we’re doing is appeasing middlemen and regulators, and by willingly knuckling under, allowing the medical record (and thus patient care) to suffer.