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<div class="">November 22, 2012</div>
<h1>A Shortcut to Wasted Time</h1>
<h6 class="">By
<span><span>LEORA HORWITZ</span></span></h6>
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<p>
New Haven </p>
<p>
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. </p>
<p>
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. </p>
<p>
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 <a href="http://health.nytimes.com/health/guides/symptoms/nasal-congestion/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Nasal congestion." class="">nasal congestion</a> to <a href="http://health.nytimes.com/health/guides/symptoms/constipation/overview.html?inline=nyt-classifier" title="In-depth reference and news articles about Constipation." class="">constipation</a>. </p>
<p>
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. </p>
<p>
Hospitals received $1 billion more from <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier" title="Recent and archival health news about Medicare." class="">Medicare</a>
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. </p>
<p>
And then there are the evil <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/twins/index.html?inline=nyt-classifier" title="Recent and archival health news about twins." class="">twins</a>, copy and paste. I’ve seen “patient is on day two of <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/antibiotics/index.html?inline=nyt-classifier" title="Recent and archival health news about antibiotics." class="">antibiotics</a>”
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. </p>
<p>
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. </p>
<p>
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. </p>
<p>
Last week, I spent 40 minutes with a patient who had just placed her mother into <a href="http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/hospice_care/index.html?inline=nyt-classifier" title="Recent and archival health news about hospice care." class="">hospice care</a>.
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.
</p>
<p>
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? </p>
<p>
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. </p>
<p>
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. </p>
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<p> <a href="http://www.yalemedicalgroup.org/YMG/directory/public/profile.asp?pictID=66337">Leora Horwitz,</a> a primary care internist, is an assistant professor at the Yale School of Medicine. </p> </div>
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