Death By Handwriting

By Glabman, Maureen

Interpreting physicians’ orders can be as confusing as deciphering hieroglyphics-with the potential for serious patient iniury or death.

Saints Memorial Medical Center nurses attended to hundreds of details, preparing to dazzle a team from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). When the team arrived for a January inspection at the Lowell, Mass., hospital, the nurses had checked fire procedures, conducted mock patient tracers and scrutinized charts for forbidden abbreviations.

Saints’ Web site boasts “an exceptional 95 percent” on its last examination in 2002, and administrators fully expected a similar assessment. But after surveyors left, stunned executives learned Saints was cited twice for a pervasive problem rarely addressed a decade ago in the nation’s hospitals-illegible physician penmanship. The hospital was given 90 days to correct the deficiency.

“I was surprised,” says Peter Connolly, M.D., Saints’ medical director. Connolly urged a review of all doctors’ charts who regularly wrote rather than dictated their notes. Of 100 physicians, 90 were found to have illegible or marginally readable writing. “We realized it was a problem that extended beyond those two black sheep for whom we were cited,” he explains.

Most Americans don’t receive any formal handwriting instruction beyond the third grade, so how we learned to write then is more or less what we are stuck with for the rest of our lives. It’s a worn joke that when someone writes poorly, we tell him he could be a doctor. But a medical error due to misinterpretation of illegible writing is no laughing matter-and for physicians it is a major threat to patient safety.

The Joint Commission does not know precisely how often hospitals are reproached for handwriting deficiencies, but the problem is believed to be substantial. “The Joint Commission almost always finds instances where handwriting is of poor quality,” says Peter Angood, M.D., JCAHO vice president and chief patient safety officer. The standard that encompasses handwriting legibility also includes stipulations that medical records be dated, that patients be identified and that diagnoses are supported, among other requirements, so it is difficult to sort out individual deficiencies.

In the last five years, the JCAHO has placed special emphasis on illegibility, or clinician “cacography,” particularly after the release of the 1999 Institute of Medicine report on preventable medical mistakes, To Err is Human. In a highly publicized case that same year, Texas cardiologist Ramachandra Kolluru, M.D., received a medical malpractice judgment when a pharmacist trying to read his writing dispensed the blood pressure drug Plendil instead of what Kolluru scribbled-the angina pain drug, Isordil (see illustration). Kolluru’s patient died. It was the first instance where a U.S. physician was found negligent solely on the basis of poor handwriting, according to the Chicago-based American Medical Association.

Poor penmanship is responsible for an estimated 6 percent of all hospital medication errors, according to the Agency for Healthcare Research and Quality. Taken as a whole, adverse drug events in hospitals, including those caused by handwriting errors, missed dosages, duplicate therapy, drug-drug interactions and more, cost up to $5.6 million per hospital due to prolonged hospitalizations, according to the Agency for Healthcare Research and Quality’s March 2001 report, “Reducing and Preventing Adverse Drug Events to Decrease Hospital Costs.”

Cacography (i.e., bad handwriting) can be illegal, too. Since 2000, at least six states-Delaware, Florida, Washington, Montana, Tennessee and Maryland-have enacted laws requiring physicians to write legible prescriptions. Montana fines doctors $500 for each illegible prescription. That could get expensive when you consider a single doctor may write 100 prescriptions daily. Florida exercises the right to deny a license or to discipline a physician who fails to keep legible medical records. In the age of computers, only an estimated 18 percent of prescriptions are electronic, according to the Pennsylvania-based Institute for Safe Medical Practices (ISMP). The great majority of the more than three billion prescriptions dispensed annually are written by hand.

Besides medical errors and litigation liability, poor penmanship causes efficiency problems and delays in care when hospital staff have to track down doctors to explain what they wrote. Some hospitals have strict rules-if there’s a doubt, call the doctor. That’s not so easy when signatures can be a flourish without any formed letters.

About 78 percent of signatures on patient charts at Presbyterian Hospital in Dallas were illegible, or “legible with effort” as reported in one study published in the March/April 1997 Heart and Lung Journal.

And, according to a 2000 report from the ISMP, “A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years,”"Indecipherable or unclear prescriptions result in more than 150 million calls from pharmacists to physicians asking for clarification, a process that could cost the health care system billions of dollars a year in wasted time.”

Written communication problems are further exacerbated when consulting doctors called in to manage part of a case try to figure out from the chart what was previously done for the patient. Additionally, medical coders cannot file accurate insurance claims or charge patient accounts appropriately if they can’t read charts.

Various studies of physician penmanship over the last 25 years generally report that physicians write no worse than the general public, but the stakes are higher. One researcher employed by the Pilot Pen Company of Trumbull, Conn., used a computer to examine the handwriting of 130,000 physicians attending specialty society meetings in the past five years. Sheila Kurtz, Pilot’s chief graphologist, discovered 10 percent of doctors have handwriting so illegible it often resembles irregular EKG tracings.

Safety initiatives by the JCAHO, among others, are forcing hospitals to pay close attention to how physicians write. “Looking for ways to get rid of illegible [which it defines as the inability of two out of three individuals not being able to read a chart entry] handwriting is a high priority,” says JCAHO’s Angood.

Health care systems have gone to different lengths to address the issue. Saints’ medical director Connolly devised a remediation plan, announced it to the board and got its approval. The first thing he did was to alert the medical staff of the JCAHO requirement for improvement. “Just exposing the problem had an impact on physician behavior,” he says. At the very next medical staff meeting, he ceremonially dispensed two handfuls of $20 pens to physicians whose handwriting had been consistently legible. “That sparked envy among some doctors who thought they should have received a pen,” he says.

Connolly was not satisfied that the problem was solved, however. He hired Kate Gladstone, a New York handwriting specialist who, along with the Oregon team of Inga Dubay and Barbara Getty, routinely visit hospitals to conduct three-hour seminars on handwriting improvement. He sent invitations for seminar attendance to the worst offenders, noting the JCAHO recommendation for improvement, and extended an open invitation to other physicians. The classes, which enticed doctors with dinner, were surprisingly well-attended. Two months later, Connolly surveyed the handwriting in charts.

“People who were bad began to write fairly legibly and people who were fairly legible became quite readable,” he says. Connolly rewarded another 10 physicians who had most improved with pens, a gesture he intends to continue. He may also hold more classes.

Some hospitals that have not been cited for faulty penmanship have still put early warning systems in place. Starting in January 2005, the Medical Executive Committee at Baptist Hospital of Miami created the following policy it shared with JCA-HO representatives, according to Mark Hauser, M.D., vice president of medical affairs:

1. Charts will be screened for illegible notes or orders.

2. Potentially illegible charts will be brought to the medical records committee where physicians and others are permitted to comment. If there is agreement among committee members that the documentation is inadequate because of legibility, the physician at issue will receive a letter requesting improvement. Further, the physician is advised that his or her notes will be monitored for the next 30 days.

3. If there is no improvement, an intervention is required, such as a handwriting course, or asking the doctor to find someone to write or type his or her notes.

4. As a last resort, the doctor could be suspended until he or she comes up with an action plan for improving legibility.

In addition to this protocol, Baptist has dispensed gadget pens in fancy cases to staff physicians in order to bring attention to legibility. It appears to be a normal pen, but when it is turned upside down, a little rubber stamp falls out with the doctor’s name, staff number and telephone number for signing off on hospital records. Sales staff from Trodat, the Austrian company that makes the pens, which cost between $15 and $40 each, sayorders from hospitals and medical schools have increased dramatically in recent years.

Hauser, Connolly and others concede that the ultimate answer to the problem of legibility, as well as many other types of medical errors, is computerized physician order entry (CPOE) and electronic health records (EHR).

CPOE is a process in which physicians write orders for hospital patients using a clinical software application, sometimes with decision support. A 1998 study by members of Harvard University’s medical school, school of public health and others published in the Journal of the American Medical Association found CPOE reduced the rate of serious medication errors by more than half. More recent articles report that CPOE has reduced medication errors by as much as 81 percent. “Though there’s still the potential for problems with typing, such as that [information] can be transcribed inaccurately, EHR and CPOE will get rid of a lot of the problems with handwriting,” says JCA-HO’s Angood.

Only an estimated 3 percent to 8 percent of the nation’s hospitals have CPOE systems, according to various experts and studies conducted for the American Hospital Association. Additional studies published between February 2003 and January 2005 report that 29 percent to 40 percent of hospitals have some component of electronic health records, from simple word processing to more sophisticated systems. The reasons for low adoption rates are well- documented: hardware and software incompatibility, disagreement on clinical terminology, expensive training required, older physician reluctance, and most importantly, expense. It costs $8 million for the initial investment plus $1.35 million annually to install and operate a CPOE system. An EHR together with CPOE could cost tens, if not hundreds of millions of dollars depending on the size of hospital, says AHA Senior Associate Director for Policy Chantai Worzala.

Though adoption of these systems is progressing, Worzala estimates it may be 30 years before all U.S. hospitals have both CPOE and electronic records. Until then, hospital staff must continue to decode physician penmanship, some of which appears to be “like mumbling on paper,” says Oregon handwriting instructor Dubay.

Handwriting experts Gladstone, Dubay and Getty attribute physician handwriting illegibility to stress, long hours, impatience, thinking faster than they write, physical ailments, or growing up thinking it was acceptable to write illegibly if you had an “M.D.” after your name. Some penmanship problems can be traced to non-native English speaking physicians who “write English with a foreign accent,” adds Gladstone.

Handwriting experts say they are often called in before or during a JCAHO inspection to prove that hospitals are working on the issue, or after a recommendation for improvement, to demonstrate that the institution is making corrections. In three-hour seminars, which cost from $500 to $3,000, they speak a language of their own, of “joins” and “strokes” and how to hold a pen and position a paper. They teach doctors to “slow down to speed up” by printing or using a combination of print and cursive with semiconnected letters. Physicians are advised to put a sharp angle on a quotation mark (“) so it doesn’t look like a 2, to close their a’s and b’s and lose the superfluous loops that foster illegibility. Following Gladstone’s techniques allows physicians to write more quickly.

“Like a suturing class, if doctors apply the [right] techniques, they will work,” Gladstone says. Requests for her classes mushroomed five years ago because of the Joint Commission. “Conceivably, I am helping to save lives,” she says.

The Dubay/Getty team has given more than 130 handwriting seminars at health care institutions. At Jewish Hospital in Louisville, Ky., board chair Julian Shapero, eager to show support for legibility, was the first to sign up for the class.

However, not everyone supports penmanship seminars. The Institute for Safe Medical Practices believes handwriting courses “achieve only marginal improvement at first and even less sustained improvement over time.”

Moreover, even orders written by physicians who have good penmanship can easily be misinterpreted, especially if a drug prescribed resembles another drug, such as Celexa (for depression) and Celebrex (for arthritis), or Lamicel (for cervical dilation) and Lamisil (an antifungal agent). “A course in penmanship should not give the … hospital governing body … a false sense of security. It must not forestall establishing … computerized methods for prescribing that have been proven to reduce errors,” states the ISMP.

Handwriting classes are often voluntary, so the worst writers may not attend. “Classes don’t get at the cause, they only treat the symptoms,” says Pilot Pen’s Kurtz, who says that “personality determines legibility.” The best way to correct bad handwriting is to work one-on-one, using behavior modification, she explains.

By contrast, Getty says she gets results in the classroom setting. Following a class at Cedars-Sinai Medical Center in Los Angeles, former chief of staff, Paul Hackmeyer, M.D., acknowledged that for the 63 physicians in attendance, calls from staff to translate their scribbles went down 50 percent within three months. “Even having a class builds awareness,” Dubay says.

While CPOE and EHR may eventually replace handwritten charts and prescriptions, doctors will always need to write and have their writing understood by others, even if it is just a Post-it Note. For example, at Southeast Alabama Medical Center in Dothan, Ala., legibility is a criterion for staff appointment. Unreadable applications from community physicians and allied health professionals are returned marked “incomplete.” Handwriting is always with physicians-computers cannot always be.

WHAT CAN BOARDS DO TO PROMOTE LEGIBLE PHYSICIAN HANDWRITING?

Through their CEOs, boards should encourage management to take the following actions:

1. Investigate computerized physician order entry (CPOE) and electronic health record technology.

2. Enforce legibility policies through medical executive committees.

3. Insist on monitors of legibility and the completeness of medical orders.

4. Implement other supports until CPOE is deployed, such as inaugurating a special facility to have notes typed. Examples include eScribe or other types of transcription methods.

5. Distribute name stamps to identify signatures.

6. Consider a structured/formatted medication order sheet with boxes to mark the drug route, frequency and indications. This has also been beneficial in other settings.

7. Restrict nurses and pharmacists from trying to decipher hard- to-read orders-insist they contact physicians for clarification.

8. Require physicians to print their last names and telephone numbers near their signatures.

9. Hold educational programs focusing on legibility.

10. Start a program to publicly commend physicians with good penmanship.

Sources: These suggestions were culled from various experts quoted throughout “Death by Handwriting.”

MAUREEN GLABMAN is a writer based in Miami, Fla.

Copyright Health Forum Inc. Oct 2005