[Vision2020] A Shortcut to Wasted Time

[Art Deco]

  [image: The New York Times] <http://www.nytimes.com/>

------------------------------
November 22, 2012
A Shortcut to Wasted Time By LEORA HORWITZ

New Haven

A FEW years ago, we doctors kept handwritten charts about patients. Back
then, it sometimes seemed like we spent half our time walking around
looking for misplaced charts, and the other half trying to decipher the
handwriting when we found them. The upside was that if I did have the chart
in front of me, and I saw that someone had taken the trouble to write
something down, I believed it.

Unfortunately, this is no longer the case. The advent of electronic medical
records has been a boon to patient safety and physician efficiency in many
ways. But it has also brought with it a slew of “timesaving” tricks that
have had some unintended consequences. These tricks make it so easy for
doctors to document the results of standard exams and conversations with
patients that it appears more and more of them are being documented without
ever having happened in the first place.

For instance, doctors used to have to fill out a checklist for every step
in a physical exam. Now, they can click one button that automatically
places a comprehensive normal physical exam in the record. Another click
brings up a normal review of systems — the series of screening questions we
ask patients about anything from nasal
congestion<http://health.nytimes.com/health/guides/symptoms/nasal-congestion/overview.html?inline=nyt-classifier>to
constipation<http://health.nytimes.com/health/guides/symptoms/constipation/overview.html?inline=nyt-classifier>.


Of course, you shouldn’t click those buttons unless you have done the work.
And I have many compulsively honest colleagues who wouldn’t dream of doing
so. But physicians are not saints.

Hospitals received $1 billion more from
Medicare<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier>in
2010 than they did in 2005. They say this is largely because
electronic
medical records have made it easier for doctors to document and be
reimbursed for the real work that they do. That’s probably true to an
extent. But I bet a lot of doctors have succumbed to the temptation of the
click. Medicare thinks so too. This fall, the attorney general and
secretary of health and human services warned the five major hospital
associations that this kind of abuse would not be tolerated.

And then there are the evil
twins<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/twins/index.html?inline=nyt-classifier>,
copy and paste. I’ve seen “patient is on day two of
antibiotics<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/antibiotics/index.html?inline=nyt-classifier>”
appear for five days in a row on one chart. Worse, I’ve seen my own
assessments of a patient’s health appear in another doctor’s notes. A 2009
study found that 90 percent of physicians reported copying and pasting when
writing daily notes.

In short, reading the electronic chart has become a game of looking for a
small needle of new information in a haystack of falsely comprehensive
documentation and outdated, copied text. Why do we doctors do this to
ourselves? Largely, it turns out, for the same reason most people do most
things: money.

Doctors are paid not by how much time they spend with patients, how well
they listen or how hard they think about what could be wrong, but by how
much they write down. And the rules for what we have to write are
Byzantine: Medicare’s explanation takes 87 pages. To receive the highest
level of payment for an office visit, I have to document several aspects of
the main problem, screening questions about at least 10 organ systems,
something about the patient’s family and/or social history, and/or a
lengthy physical exam. In addition, I have to demonstrate that my medical
decision making was very complicated, considering the number of possible
diagnoses and treatments, the complexity of the data and/or the patient’s
risk of serious complications. That type of visit is supposed to take about
40 minutes.

Last week, I spent 40 minutes with a patient who had just placed her mother
into hospice care<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/hospice_care/index.html?inline=nyt-classifier>.
My patient was distraught, not sleeping, not eating. I gave her some
advice, but mostly I just listened. By the end of our visit, she was
feeling much better. But I wouldn’t be able to bill much for that visit
based on my documentation: I didn’t review her medical or family history,
conduct a review of organ systems or perform a physical exam.

What the payment system tells me to do is to cut her off after 10 minutes,
listen to her heart and lungs and give her a sleeping pill. Which doctor
visit would you prefer?

Of course, I would never go back to the bad old days of lost charts,
illegible writing, manual prescription refills and forgotten information.
Electronic medical records help us avoid dangerous drug interactions and
medical ordering errors, remind us to provide preventive care and allow us
to view data as trends over time. Even copy and paste have legitimate uses.

But physicians need to be better stewards of our records so they remain
useful, regardless of skewed incentives and new technology. And as a
nation, we should question whether paying physicians by documentation —
instead of by time spent on quality patient care — is such a great idea
after all.

Leora Horwitz,<http://www.yalemedicalgroup.org/YMG/directory/public/profile.asp?pictID=66337>a
primary care internist, is an assistant professor at the Yale School
of
Medicine.

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-- 
Art Deco (Wayne A. Fox)
art.deco.studios at gmail.com
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