EHR Rules Compete With Medicine's Grassroots Nature

Rules and regulations are important. Society could not function without them. Consider sports. The very essence of a game is that it has a set of rules. The rules define the game - different rules, different game - no rules, chaos.

In the philosophy of Aristotle, the golden mean is the desirable middle between two extremes, one of excess and the other of deficiency. There is no clearer application of the golden mean than the rules intended to regulate EHR - too little regulation, apparent chaos - too much regulation, dictatorship, and stagnation. Finding that golden mean is, and has always been, the challenge.

Some people are drawn to organizing groups, making rules, and enforcing them either for love of power or from feelings of powerlessness. Others simply want to be let alone. Since nature abhors a vacuum, the rule-makers have a natural advantage over those who want to be left alone. There is, it seems, always some problem for which the "obvious" solution is to make another rule. It takes great wisdom and restraint to know when enough is enough - when the golden mean has been achieved.

At the moment, the country is caught in the grip of a rule-making frenzy - a situation that results when a number of "sharks" (organizers) fight over the same "prey" (perceived problem). Physicians and the natural evolution of EHR have fallen victim to this rule-making frenzy.

There is a defense. For all its "industrialization" and "corporatization," healthcare is still a grassroots activity. The individual clinician has control over what they say and do during an encounter with a patient. They likewise have control over what they document and order, and what they leave undocumented and unordered.

There are several important implications. First and foremost, the quality and ultimate utility of the information in the medical chart is only as good as the clinician chooses to make it. If you write a complete, thoughtful note it will have lasting value. If you abbreviate, skimp, cut-and-paste, or are less than complete, the information available in the future will be of low quality and it may adversely affect the patient if someone acts on it.

Second, the rules (and there are a lot of them) actually encourage thoroughness but they do not reward it. Each clinician must make a choice to do all that is required and expected, both to practice good medicine and to comply with the rules, or to do a slop-up job in order to "keep the numbers up." If clinicians do right by each patient, their "productivity" may suffer but their quality and patient satisfaction will not. If they succumb to the stress the rules elicit in most physicians, then quality will suffer.

The defense against exuberant rule-making is to follow them to the letter and let those who made the rules, rather than the patients, experience the adverse effects. This has been called "work-to-rule" - when labor engages in an industrial action in which employees follow safety and other regulation precisely, understanding that the result may be a slowdown in production.

In the clinical context, work-to-rule can hardly be faulted. Presumably the rules were meant to be followed. It is always appropriate to take a full and complete history, do a complete examination, document everything in detail, and make sure that the patient understands their condition and the proposed treatment. If following the rules creates unintended consequences, those should impact the rule-makers, not the patients. It also means not staying in the office for two to four uncompensated hours every night to finish complying with the rules. You should finish each patient before going on to the next. If you don't, your memory will falter, your documentation will suffer and, in the long run, so will the patient. If the regulations don't seem to allow that, well - the rule-makers should have considered that before acting.

Quality care starts and ends right there during the encounter. Encounters that are cut short and documentation that is sloppy and incomplete because you feel time pressures will add up to poor performance of the entire healthcare system. Each clinician must decide whether to comply with the spirit, or merely the letter, of the rules. That is a grassroots decision that is each clinician's to make.