Ruth Armstrong: On the record

A RESEARCH paper published last month in the MJA and reported in MJA InSight, made quite a splash in the medical and lay media.

Based on a large study of computerised general practice records, the researchers found that only 22.2% of patients had their body mass index documented, and just 4.3% had a record of their waist circumference. The imputation was that GPs are not monitoring patients for overweight and obesity, and are therefore failing to manage these health risks.

As a former GP, I bristle a bit at these kinds of studies. I know that failure to document something does not always mean failure to consider it; that recording basic parameters might be a low priority in some consultations, and that measuring something does not equate to managing it.

In an article in The Conversation last week, two Melbourne-based academics went further in questioning the importance of documenting measures of overweight and obesity, arguing that GPs would be better off spending their time listening to their patients to discover the reasons why they may be above their most healthy weight, than weighing and measuring them.

While the article left me feeling like I’d been presented with the old “if a tree falls in a forest” conundrum, it touched on an important issue in medicine that is also raised by two very different MJA InSight articles this week. What is the value of measurement and documentation, and what are the risks?

An MJA study published online and reported in our first news story, has found almost half of all Australian adults with asthma have poor symptom control, much of which is avoidable with appropriate management.

Commenting on the study, respiratory physician Hubertus Jersmann told MJA InSight one barrier to effective management was that doctors were simply not aware of their patients’ symptoms, and suggested that that GP surgeries use routine patient questionnaires to document asthma status.

“The more questions we ask a patient, the more we can control their asthma”, he said, making the reasonable assumption that the first step to managing something is knowing about and documenting it.

Another of our news stories reports on a US study that found stroke patients treated in hospitals with electronic health records (EHRs) were no more likely than those at other hospitals to receive high-quality care, and had similar outcomes.

Speaking to MJA InSight, Dr Steve Hambleton, chair of the National E-Health Transition Authority, observed that the function of EHRs needed to move beyond documentation, which, after all, might just be providing an accurate account of substandard care.

“If you mechanise medical records by creating an EHR, there will be no change. But if you re-engineer what you do with that information, that’s when we should get some leverage”, he said.

Failure to act on documented problems is not a new phenomenon, nor is it confined to any one aspect of practice. Studies that show deteriorating clinical signs in hospitalised patients were often documented yet not acted upon before critical events underpinned the development of medical emergency teams (or rapid response systems) almost two decades ago.

What are the risks of measurement and documentation?

The authors of the article on obesity in The Conversation say weighing and measuring can be off-putting to patients and might distract doctors from the main game of getting alongside their patients and looking at the root causes of weight problems.

Failure to recognise that documentation is not an end point is a real risk, but surely it is better, if possible, to sensitively obtain the data, record it and use it to objectively monitor the outcomes of management.

Documenting something doesn’t lead to change — but before you do make a change you probably should document it.
 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight