When the Doctor Must Choose Between Her Patients and Her Notes
commonhealth.wbur.org
commonhealth.wbur.org
While some of that is true, it is far from the whole explanation.
I am a Norwegian we have what you guys call socialised health care. I've been treated in the US and Norway so I can compare. In the US there is a lot more paperwork related to disclaimers, suing, billing, insurance companies etc which we don't have to deal with.
However when it it comes to the medical side of things, doctors here also sit and type at their computer while seeing their patient. They are also stressed out trying to make it all add up. Just because there isn't a profit motive doesn't mean there isn't a push to be more efficient from above.
There is lots of political pressure from above to save money on health care. The core problem here isn't profit or not. I think the problem in common both in the US and Norway is the measurement and feedback based management. New Public Management or whatever you call it. Both in public sector and private those at the top want to be able to control and improve what is going on below and so they insist on massive amounts of feedback, so they can measure everything about how things are run. Of course they never consider the massiv cost of all this documentation.
It is the same in schools here in Norway. Teachers have ended up spending a shitload of time documenting and measuring over the last decades. The paperwork load keeps adding up even though every successive government says they are all about cutting paperwork.
IMO opinion the solution to this isn't to go public or private but to change our ideas about how things are managed and run.
What has the overall effect of these paperwork changes been on healthcare outcomes?
I.e. you are getting more "cold hands" (administrators, controlllants, bureaucrats) than "warm hands" (doctors, nurses, caregivers)
This at least has been one of the main issues in Denmark. Can't speak for Norway but my guess is the issue is the same.
Denmark has fallen far down the list of the places with most effective care. It is however (mostly) "free".
There is a real groundbreaking business hiding there. How to ensure control of whats going on without burdening the wrong people.
That's a good political talking point, but it just begs the question. How much good do those two groups do in terms of ultimate outcomes?
Of course there needs to be a control system but the problem with NPM is that it puts optimization over outcome and because getting the data is the only way they know how to optimize it basically ends up being the goal justifying the means.
This has created layer upon layer of highly paid middle managers and is basically right now crippling the Danish healthcare system.
It used to be one of the best in the world but have slipped down to 36 now.
But, is that a bad thing? If the notes are relevant/useful and can only be entered by a doctor, then I'd say that's just part of practicing medicine.
How much of that 50% is purely red-tape? And, if it is red-tape, can that work be off-loaded to a less valuable employee?
I am in complete agreement that it would be great to get more data but it should never be on the expense of time that a doctor can use to do what they are most needed for.
If the increase in data is so valuable then it should be no problem hiring "professional" notators who can do the job for the doctor.
In the end this is a problem of not having found a practical solution to a political problem which then in turn is being solved with a political solution (NPM).
The complaint above was about "making notes". In a hospital setting, those notes would be used when shifts change. Or, when patients come back for follow-up. That would be part of "practicing medicine" and not something we can remove completely (though we can make it more efficient).
I have no idea how much of that type of note-taking has to be done by the MD (or nurse). Or, how much of it is simply red-tape.
My father's secretary has done it for 20 years. Now she does less, liability has decreased slightly, my father works longer hours and sleeps less while seeing the same amount of patients. All in all, a big win for everyone except the doctors and patients.
What I don't think people are realizing is that the data DOES exist. It just isn't entered into a central electronic database. They already took notes. Now they have to write them twice. It's not a bad thing that they are centrally located, but from watching my father's life change since this happened, I struggle to see how it benefits patients.
From my side, I have epilepsy. When I was younger, I went to see a different doctor, and the physical MRI was sent between hospitals. The images and accompanying notes were misread, and they thought I had a brand new brain tumor. Not exactly awesome to hear at the ripe old age of 14. Had EMR existed, that mistake would be much less likely to have happened. It obviously CAN be beneficial. On the flip side, since this legislation, I don't see my neurologist anymore. I go every 6 months to get a "checkup". Which really means visiting the nurse practitioner to re-up my prescriptions. Since my epilepsy is stable (and I've known him 20 years), it's a time saver for both of us to just fake the appointment. I can't complain too much as it's a time saver for me as well, but the legislation doesn't seem to be in my medical best interests in that my doctor is willing to take that shortcut. I used to have to fight to see him less frequently (taking days off work to strap electrodes to my head or sit in a tube can be draining on the vacation/sick days).
The issue is as you say New Public Management.
So literally her only option is to document while also treating.
she comes home and tells me that a patient asked for water and that creates a dilemma for her: go get water and lose productivity while treating your patient like a human OR reject their request and keep productivity high and avoid being scolded.
The problem is, obviously, good care is therapy AND getting water for your patient. They're humans not numbers. We're forcing medical professionals to only work within the scope of "billable" activities and that ultimately hurts the patient.
Standardization has benefits in the existing system.
My gut tells me that standardization of what is and isn't billable solves a bigger problem than described in the above comment. My whole being tells me that changing the definition of billable time won't fix crappy workplaces run by bean counters.
And if I had to guess, classifying documentation as treatment is unlikely to improve patient care and outcomes.
Anyway, my gut tells me that sometimes getting water for a patient is good therapy and sometimes it is bad therapy. The same for documenting during a session. Depends on the person and their situation. Sometimes what people describe as their is the problem, sometimes the describing things as problems itself is more the problem. Good workplaces have a leadership culture that can and does distinguish between them.
Anyway, I don't expect to stop hearing variations on that theme any time soon.
They don't care if she gets overtime (so long as she meets productivity), so that's nice, but I really can't understand why they don't just go to salary or work with insurance companies to incorporate documentation into billable time. I can't imagine the patient experience would be hurt too much by shifting from 1 hour sessions to 45 minute sessions with 15 minutes of paid documentation. If anything, insurance companies should get better documentation and that should help them combat fraud while also improving care. Granted, I think the clinic my wife works at is almost entirely built around Medicaid reimbursement and Medicaid doesn't have many real incentives to reduce costs or improve quality of care.
The new Accountable Care Organization (ACO) model has the potential to reduce the documentation requirement. Under that model the insurer shifts the risk to a provider organization which is receives a flat fee per year to care for the patient. So the providers no longer need to submit detailed insurance claims.
The secondary reason for requiring detailed clinical documentation is coordinating between all members of a patient's care team. Obviously your primary care physician would like to know what your psychiatrist did and why.
Doctors are extremely valuable workers/members of society, I'm surprised that they don't feel more in-control of the situation (if you want shorter notes, push for it?)...
Also, this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either... If my doctor takes notes while I speak to him/her (and it was made clear at least once that I have their attention), that impresses on me that they're doing their job, which is far more important to me than the feeling of being treated like a human for an hour.
Also, why not just take micro breaks during billable time to do notes? bill for the 45 minutes, notes for 15 mins, take notes right in front of the person, and let them know what is happening?
Maybe this just seems easy to fix to me because I'm an outsider
And then the hospital starts making less money (losing money), research funding dries up, and we start using mercury to treat syphilis again. I'm only half-kidding. I say hospital because all the laws that have changed in healthcare have driven most doctors out of private practice into hospital positions. since 2004, hospital-employed doctors have gone from 11% to over 60%[1]. One major reason being that with the wave of medical reform, the overhead of running a practice has skyrocketed. "Comfortable and enjoyable" are rarely applicable when you only start paying off your $1m schooling debt at 30.
> I'm surprised that they don't feel more in-control of the situation
I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes.
> this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either...
I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer.
>Also, why not just take micro breaks during billable time to do notes?
My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill.
[1] http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/P...
Sorry, I meant suggest taking less patients, in addition to charging enough to match what you were making before. Not just doctors/hospitals making less money across the board. This will encourage more people to be doctors/open hospitals in the long run to fill the demand (then bringing down the price again, until we're at a nice equilibrium), which will bring down prices, and ensure that doctors take as many patients as is comfortable.
> I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes.
Is there no doctor's lobby? If the law is wrong/naive, there are measures you can take to make sure it's changed.
> I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer.
Yes, that would be a very insensitive way to convey such information, but that's also not the routine case, right? Also, I noted that it seems serviceable for the doctor to cut up the time (in a world where they could set their own billable hours, which could exist).
> My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill.
I didn't call into question how much current doctors work to catch up on notes -- from what the article said, and your personal experience that is a crazy amount of paperwork. If hospital employees don't get to choose the amount they bill, then maybe someone should change the hospitals? Or come up with some other structure for serving patients.
My main point condensed: The amount of paperwork doctors are buried under is insane, that much is clear. Doctors are some powerless group of victims -- surely there are some actions they can take to alleviate the problems, especially if what's best for patients is what the care about.
I did not know about these problems so reading this article was informational for me, but I found it lacking in the "what we're going to do about it" department.
How? They can't negotiate with public insurers (Medicare and Medicaid), who together control over 40% of the payer market.
They can't charge self-paying (uninsured) patients any more, because those patients can't really afford it so they don't actually pay.
And they already overcharge private insurers (to account for the below-cost reimbursement rates of public insurers), so there really isn't room to charge them any more.
> Is there no doctor's lobby?
Not really. The last 40 years have been a massive power shift from doctors to hospitals, and from hospitals to insurance companies. The ACA was probably the single biggest sign of that, but it was as much a symptom as it was a cause.
Contrary to popular belief, doctors have less power today than they did 20 or 40 years ago, and they have very little leverage with which to secure any additional power. Almost all the industry power rests in the hands of the insurers. (And the private insurers are themselves beholden to Medicare).
The entire narrative is around expanding coverage and reducing costs, which invariably means paying doctors less, not more, for the same work.
Don't forget Big Pharma who pay for all of their research and sponsor their conferences. Speaking out against them means your research funding disappears. Doctors have a lot of industries surrounding them that are pulling strings. It's arguably the most regulated industry in the world. If you puff your chest out in any direction, it's the Alamo.
Forgive my naive thought - but what if doctors just stop... negotiating with public insurers? is there some legislation I don't know about that prevents that?
Doctors aren't negotiating at all with public insurers. Medicare doesn't negotiate, for any meaningful definition of 'negotiate'. They set the rates they are willing to pay, and you can either accept it or.... accept it. As a provider, it's very, very difficult to refuse to treat Medicare/Medicaid patients in practice, for all sorts of legal reasons.
(Also, it's usually the hospital that's in this position now, not doctors. Private practice is a dying breed; most doctors in the US are now salaried.)
It's a tough position to be in. Many doctors ARE dropping medicare due to the large amount of paperwork, costs of auditing, deep price discounts, etc. This means that the doctors who DO accept medicare end up getting swamped with patients which increases the patient wait times. So, as a medicare recipient, you either end up paying more out of pocket to see the doctors who dropped medicare or you wait longer to see your doctor. As a doctor, you either lose your patients or gain an unmanageable amount of patients along with drastically more paperwork. Lose-lose.
All that being said, it's clearly a lot easier to criticize than contribute meaningful suggestions. The only thing I could suggest is to put much more effort into preventative medicine. Preventing disease is drastically cheaper than managing symptoms. While it comes up a lot, it doesn't seem to be a focal point.
Or creating new technology. I wonder just how much spending has been headed off by pneumonia vaccines. Not that a single treatment like that will make a noticeable dent in demand, but at least it usually comes with a good improvement in outcomes.
Scribes are a good solution. Her brother-in-law is an ED physician and doesn't really have to worry about notes because he has good scribes.
Is there something inherent in medical notes that typing them should take longer than hand writing them? Or, is the software just awful? (I assume the second, which makes me wonder why nobody is disrupting this area)
It's not being "disrupted" because it's extremely capital intensive to enter this market. The requirements seem intractable:
- Structured data with very high level of granularity.
- Patients often don't fit the mold exactly. It's hard to classify something that is going on with a patient; there are 68,000 ICD-10 codes.
- Data needs to be interoperable with existing and competing systems.
- Every hospital has their processes and documentation practices. As a result, most electronic record software is highly customizable, and a company representative is usually on call or on site to continuously customize it.
- Software needs extreme backwards compatibility. You need to be able to read records that are tens of years old.
- Need to be able to print everything.
- Need to meet regulatory requirements and security audits. Regulatory requirements vary by state and country.
- Healthcare institutions are inherently conservative with their technology, and for likely good reason. Plus they don't upgrade equipment very often. If they just spent $1 billion upgrading their entire IT infrastructure, they're not going to consider your startup's solutions for awhile.
- Patients don't like it when their provider is focused on a computer or taking notes instead of on them.
- Different UI for each provider (e.g., primary care physician vs. pharmacist vs. radiologist)
- Need to communicate with a wide variety of medical hardware that doesn't have good standard protocols, and much of which is very old.
And on and on...
People say that EMRs are awful (And I used to think that). But the truth is that they're just not built for doctors, they're built for the hospital. And they're doing a great job at increasing billing, to the detriment of doctors productivity.
As an analogy, imagine a tenant / landlord relationship with a sink problem. The tenant asks the plumber to change the whole sink whereas the landlord asks the plumber to find the cheapest hack to fix it. The plumber has no choice but to listen to the landlord. The tenant and their friends blame the plumber for doing a shit job. But hey, soon after, a startup knocks at the door of the tenant and offer to change their sink for the best-of-the-market.. but the tenant would have to pay himself so he politely declines and stick to his old shitty sink.
In regards to the second question, that's what I do. If you've ever worked in any corporate setting that has industry-specific software, convincing the company to change it is near impossible. "Time saving" is incredibly difficult to demonstrate and "cost saving" can take 2 years to show anything meaningful. Software for a complicated field ends up being complicated no matter how hard you try to not be the java-megastructure catch-all application, which means it will always take some amount of training. This means you have to convince someone who just lost 2 hours of their day to spend more time learning a new application. Welcome to the shit-show of corporate software.
As my father loves to counsel: "It's hard to get the nine-to-fivers to listen to the five-to-niners".
How did it end up becoming this broken in the first place?
You might be right that there is a breaking point, but there is a ton changing right now so I don't see that point any time soon.
I know the bigger systems get more negotiating power so in the short term this should probably help but if the local competition isn't there than that money just stays in the hospital pockets.
Regarding the content, this doctor provides compelling arguments that the documentation doctors have to require takes a large toll on the doctors themselves and their patients, but I'm curious if we can look at data to corroborate that. For example, maybe the copious note taking improves patient care because more information is available to more people, and is not trapped in the head of one doctor. Note I am not saying that is necessarily true, but we've been presented with arguments and anecdotes - very compelling ones, which I am inclined to agree with. But it is probably not wise to change healthcare policy without looking at what data we can.
Yes. The authors cite data showing that physicians in Canada spend far less time on administration than do U.S. doctors, http://www.eurekalert.org/pub_releases/2014-10/pfan-pco10231... Administrative work consumes one-sixth of U.S. physicians' working hours Note, this is non patient related Administrative work.
Now what? IMO, the simplest solution is for doctors to bill based on administrative requirements.
It would be reasonable for patient-related notes to be correlated with other administrative work, but it's not necessarily so.
A seasoned supervisor told me that, when he was a resident working in the psychiatric emergency room, he used to see more than three times as many patients as we residents see now.
“How?” I asked him, with an incredulous lilt in my voice that could barely be masked.
“Our notes could be shorter back then,” was his reply. (Insurance, regulations and electronic health records weren’t issues back then.)
However, ~50% increase in healthcare costs would need to have a huge impact on patent outcomes or drastic fraud reduction to be worth it.
1) A speech-to-text transcripting intelligent system that could automatically make some guesses at the notes the doctor would want to write. Could save them quite a bit of time if it can be tuned for utility 2) (the cheaper short-term solution) An assistant who can focus on taking notes while the doctor focuses on the patient.
Unfortunately, (1) is a technologically challenging AI problem and I bet the current medical rules and patient's expectations of being able to 1:1 with their doctor without a third-party listening in probably scuttle (2).
But... we already have much more advanced technology than we had 30, 20, or even 15 years ago. And the problem has only gotten worse.
> “Our notes could be shorter back then,” was his reply. (Insurance, regulations and electronic health records weren’t issues back then.)
This quote in passing just assumes everyone is familiar with the fact that "electronic health records" are something that makes things harder. That doesn't make sense, does it? Shouldn't electronic records make things easier? They should. But they don't, due to adverse incentives in the medical system, and in the political organizations which constitute it.
My point is, the pressing need is not for more advanced technology. We have the technology, we have had it for years. We just need to somehow reduce the crazyness. Medical software is like enterprise software but worse - it's the crappiest, most expensive software you've ever seen in your life. There are all sorts of reasons for this. It's not chosen by the people who use it, checkbox feature lists are more important than what works, regulations, political deals, "high touch" sales, etc. The result is often "I have to sign in three times, then wait 5 minutes for it to load the patient, and hope it doesn't crash in the middle". It has to be seen to be believed.
Admittedly, doing so isn't as easy as it sounds, but this isn't all that much different than developers being told to push back on schedules that don't leave time for (testing, documentation, technical debt payoff, etc)
From what I've seen, even with newer EHR systems (Epic, Athena), medical technology is about 15 years behind current technology.
Now, to make data more standardized, it's a wall of clicks and checkboxes, which require domain expertise. So doctors canned the transcriptionists, replaced them with enterprise IT and hire PAs and NPs to try to bridge the gap.
I shake my head every time I go to my doctor. He's a brilliant guy and really good physician, but easily 50% of his time is dedicated to click-monkey bullshit.
Through training it is possible to become efficient in doing two tasks seemingly simultaneously, in this case, anamnesis and note-taking. Nevertheless true multitasking is not proven, and switching occurs instead, the trained person simply responds quicker to certain stimuli.
Multitasking might also be the source of frustration and contributing factor to the reported depression.
Of course the documentation work can be rationalized and tools can be developed to help this, but there is also room for improvement on the work of the doctors, revealed by the lack of standardization reported in the article.