Wednesday, June 17, 2009

Drowning in Paperwork

First what I mean by paperwork is documentation. This can be through an electronic record, dictation, or good old-fashioned tree pulp derived paper.

Think your doctor doesn't spend enough time with you? Think it is because they are greedy and trying to see too much in too short a time? How about this as a reason - It is because physicians are drowning in required paperwork and have to jump through pre-authorization hoops by insurers. As an ER doc, I thankfully don't have to do the latter, but I spend about 2 hours of my 12 hour shift dictating. Until my throat is sore - especially when you see 30 patients and have to dictate on all of them.

First, check out this article "Physicians Spend 3 Weeks per Year on Insurer Paperwork." What was even more shocking was that Nursing staff spent more than 23 weeks per physician per year, and clerical staff spent 44 weeks per physician per year, interacting with health plans. There are 52 weeks in a year, and while I understand clerical staff doing administrative work, nurses spend HALF of their time doing non-nursing work. Wow.

And this costs 31 billion dollars each year. I'll say this again, non-medical-care administrative time costs 31 billion dollars a year. In health care insurance-speak, that means 8 million more people could have had good health insurance (at $5K/year).

If I did not have to dictate, I could see six more patients per shift, or spend more time with the ones I have. Conversely, I recognize the need for good documentation for the benefit of the patient; not to mention for medicolegal reasons.

I remember I did an administrative month in my medical training, where I sat in on a meeting where they were discussing "How to increase nurse satisfaction" as morale was low. They put boxes around the ER asking for suggestions. In the same breath they talked about how they needed something tracked and said the nurses should do it and would now make the nurses fill out ANOTHER form as part of the discharge process. I raised my hand and suggested that if they want to increase morale, tell the nurses they have to fill out one less form; not give them one more. Needless to say, nobody "got it" and continued with their plans.

Healthcare providers went into the profession (for the most part) to deliver healthcare. But increasingly, we do so much that has nothing to do with providing healthcare. Which is why many physicians are going to all-cash practices - without insurance plans (includes Medicare/Medicaid) hassles to deal with, they can spend more time with more patients at a lower cost to patients.

Some suggestions include single-payer systems, as one payer means less bureaucracies to maneuver through. Whatever the system, politicians need to acknowledge that if they want higher quality care, they need to pay physicians for providing care, and minimize administrative duties for them and their staff (less staff would cost less too).

Regarding documentation, computerization has offered a solution that has pros and cons. I have used a few history/physical and order entry systems and have found, for me - a computer literate 75wpm typer - it saves time and is more legible. Many systems are overly complex and take too long for simple documentation i.e. it should not take 10 minutes to document an ankle fracture. I like these systems where I take a laptop in the room and document while in the room, order tests in the room, and before I leave, the nurses/techs are already there initiating my orders. I have to document and order stuff, why not do it in front of the patient where they can get more face-time and it doesn't interfere with the flow of the physician-patient interaction?

However, there are a number of problems: 1) Laptops used everyday have degradation of battery life and don't last more than a few hours, to say nothing of a whole shift. 2) Physicians who are not as computer literate will find the process frustrating as it takes longer for them to document. 3) Templates do not have good medicolegal documentation and make a poor narrative. 4) Free-form typing takes a long time, even with macro use. 5) Actually uses more paper than a paper system. 6) Major issues when computers are "down."

We have a number of hurdles to getting higher quality, higher efficiency, lower cost health care. Administrative costs are one of them.

1 comment :

  1. I use smartnotes in the ER. It takes me about a minute per patient, max.