Paperwork prevents doctors from spending time with patients

Just how bad is paperwork for doctors?

In a recent New York Times piece, surgeon Pauline Chen gives us some stark numbers.

Paperwork takes up “as much as a third of a physician’s workday.” That’s a lot, and is coming at the expense of face to face time with patients.

Worse, look how it’s affecting medical residents.

Researchers at the Mayo Clinic found that most residents spent as much as 6 hours per day documenting, with only a fraction of that time spent with patients. Furthermore, administrative time also eats away at their educational activities, such as lectures and didactic sessions.

For those who hope that electronic medical records to be a solution, there’s bad news on that front as well. Dr. Chen notes a worrisome trend as doctors simply use these systems to cut and paste notes:

Residents may rely on notes written by other doctors instead of talking to the patients themselves. These other notes may have also been pieced together from previous notes rather than from actual interactions with the patient. As a list, a paragraph or whole sections get pasted into progressively more documents, important information, like a reaction to a certain treatment, can be lost in the transfer. Clinicians who rely mostly on computer notes for their information are at risk of inadvertently choosing the wrong therapeutic course of action for a patient.

The answer is to outsource some of the paperwork requirements away from doctors, to support staff. For instance, completing discharge paperwork and scheduling follow-up appointments should be arranged by administrative staff. Medications can be reconciled by nurses, under the supervision of doctors. Even notetaking can be streamlined — perhaps by the use of scribes who can more efficiently enter data into the computer.

This takes money, of course, and that’s not something most financially pressured hospitals are willing to spend on. But they should, so doctors can spend more time with their patients, instead of in front of a computer.

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  • Dr Geek

    The real issue is WHY this volume of paperwork exists. There is entirely too much focus on “paper for paper’s sake.” Litigation, defensive medicine, government beauracracy, all creating literal tons of paper that serve no medical purpose. It’s absurd. And while I think reform is good, and all people should have access to basic public health services, paperwork only inceases with government involvement.

  • Family Medicine Doctor

    Agree w/ comments above. Current EMR systems are designed with billing and minimizing legal risk as top priorities.

    There will need to be cost shifting to patients for these administrative tasks. Right now, physicians are eating the costs of onerous paperwork. More doctors offices are requiring an “administrative fee”. I lump concierge and retainer practices into this group. I’ve seen $150/ month, down to $5 /month. Whatever they are, these fees are essential. They’re required to keep independent, non-hospital affiliated primary care practices open in the future.

  • http://pagingdoctorgeek.blogspot.com Dr. Geek

    I can handlenpaperwork that makes me better or passes information to the incoming doc/team, just as a point of clarification.

  • http://nostrums.blogspot.com Doc D

    I agree with the comment. Why does the electronic record have to record every negative symptom or sign known to medicine. My software prints out a 6 page report for a sore throat–most of it is relevant only to lawyers. And when I see a patient it takes me 15 minutes to get through the mountain of useless documentation from previous visits. Providers know what they need to know, electronic records don’t.

  • rezmed09

    IMO, the solution will be computerized dictation of what really happens – not just paragraph after paragraph of template puke (useless info). But it is much easier to bill for templates than to have a coder figure how much a note is worth. The bottom line is that we will document more useless info as long as we get paid more for documenting useless info.

    Some day in the future, we will look at our present E H R’s the way we now look at ERT or radiating tonsils – backward and dangerous. For the present – no one seems to care about the bottom line – seeing patients efficiently and effectively.

  • Primary Care Internist

    rezmed you are exactly right. And insurers’/ medicare’s increasing tendency to ask for medical records to justify billing & medical necessity, which is happening across the board in every specialty, will only increase the useless over-documentation and further decrease face-to-face time with patients.

    After all, a patient encounter includes an actual history & physical exam (however brief), discussion with ancillary staff/nurses/consultants, entering orders in a computer, looking up ICD codes to justify labs, perhaps researching some signs/symptoms, reviewing recent lab/xray/ct results, hunting down those old reports, discussing the case with family members of the patient, writing prescriptions, getting preauthorization for meds & radiology, and finally writing or typing a note. Then billing out the visit is another story, and most docs have realized that this part should be outsourced.

    The ONLY components of those listed above that can be trimmed down (ie. sacrifice quality for time) are the face-to-face encounter, and the note. Get a couple of record requests from insurance companies or medicare, and the note takes priority over the face-to-face, and ultimately the patient suffers.

    At least the HIT crowd will get rich off the process, encouraging more cut-and-paste, selling their defective products to doctors who are forced to buy in to stay in practice, courtesy of King Obama

  • Observer

    A single-payer system as in other countries would solve this paperwork problem and increase efficiency and effectiveness (e.g., in a recent documentary, they compared the billing depts. in a Canadian hospital against that of a U.S. hospital – 6 employees in the Cdn. vs. > 250 employees in the U.S. hospital). I would expect that the Cdn. doctors also spend much less time on paperwork.

    Too bad the American doctors & businesses will not lobby for such a system with such a marked difference.

  • Primary Care Internist

    “Too bad the American doctors & businesses will not lobby for such a system with such a marked difference”

    while the current multi-insurer system in the US is far from perfect, and while there ARE definitely groups of organized doctors pushing for single-payer (e.g. PNHP), putting too much power in the hands of gov’t has problems that I think an intelligent thinking person could easily foresee.

    If medicare suddenly decides to sacrifice geriatrics for cataract surgery, or even for useless “telehealth monitoring” from visiting nurse services, then in a single-payer system docs have no recourse. That is essentially what already happens with geriatrics today – with a patient population that is entirely medicare (whether rich, poor, or in between) the doctor is completely subject to the whim of medicare. If they decide to change or deny the payment for a particular service, there is NOTHING the doctor can do.

    Doctors, and everyone else, have very good reason to fear unilateral government power, in medicine just as well as in any other industry.

  • hawk

    observer

    The problem is that most single-payer systems also pay nothing for services to practitioners. Most physicians, myself included, would much rather have a little hassle and be rewarded for our hard work, training, etc.

    If you compare avg salaries, you will see that most canadian docs make about 100k a year, where in the US, especially for specialists, that figure is much higher, sometimes triple to quintuple for the basic care specialists.

    right or wrong, the fact si that in the US, getting a medical education takes money and sacrifice, most people who hav gone through it would like to be rewarded. I know this is becoming a foreign concept under obama’s america, but I am old enough to remember when the mantra was work hard, get rewarded.

  • http://TooManyClicks.com Jeff Belden MD

    Agree with all ideas above. I have two very broad EMR functionality goals to aim for: 1. documentation as a by-product of physician workflow. 2. A layered EMR which allows a particular viewer to see only the level of detail/complexity desired. See my post at http://bit.ly/4layeremr.

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