Problem in medicine: too much paperwork

[Frogger27]

http://www.forbes.com/sites/brucele...s-of-their-time-doing-paperwork/#608d6b386e5d

Any ideas on how to solve this problem?? Do we invest enough money into clinic QC?? Do people see this being improved on in the future??

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[FindersFee5]

I think well-trained, well-trusted scribes can help with this a lot. Not somebody who just is your personal voice-to-text machine, but somebody who intimately understands the annoying but necessary parts of the note.

I also think seeing less patients could result in better patient care/clerical work balance. A lot of the paperwork is busywork that is the same for every patient, and spending more time with a patient doesn't create commensurately more paperwork. If you have to spend 5 minutes filling out a note for every patient as baseline, and then an additional 10minutes for every 2o minutes you spend with the patient, seeing 2 patients in an hour and seeing 10 patients in an hour results in very different amounts of paper work vs. medical decision making.

 

[Cotterpin]

More scribes might help.

 

[Frogger27]

Is there an answer besides more scribes/administrative assistants? Would there be some sort of way to outsource this work if it is so mundane?

 

[Cotterpin]

Like.... outsource to an independent contractor? Outsource to child laborers in some third world country? What do you mean? The doctor "outsources" his or her paperwork to a scribe or administrative assistant.

 

[Frogger27]

Like.... outsource to an independent contractor? Outsource to child laborers in some third world country? What do you mean? The doctor "outsources" his or her paperwork to a scribe or administrative assistant.

Hahah yeah I was not talking about child labor, just some other third party besides scribe/administrative assistant...

 

[Cotterpin]

Hahah yeah I was not talking about child labor, just some other third party besides scribe/administrative assistant...

I don't think that's any different from a scribe company that is a third party. What other kind of third party could that be? A government agency tasked with doing all of the nation's medical paperwork? Tack it on to Obamacare?

 

[SSSMDt]

Scribes can only do so much. What about prior-auths, home health orders and paperwork, nursing home orders and paperwork etc.? Our nurses do prior-auths so the physician does not have to, but the physician is constantly reviewing these others and signing off his/herself. I assume this is what OP might be talking about when asking to mitigate these? In which case I don't see much hope in the immediate future.

 

[RogueBanana]

Outsourcing invites more problems into the mix though, security issues, quality control, lost notes/paperwork.
Maybe a new electronic system that allows docs to take their notes on a tablet, which then gleans the necessary information from the note and fills the forms automatically? Then the doc would just have to review it for correctness and sign off on it.

 

[Cotterpin]

Maybe we could train doctors to specialize in paperwork. It would be a very short residency.

 

[RogueBanana]

Maybe we could train doctors to specialize in paperwork. It would be a very short residency.

"SIR, You need to help my son! He was hit by a car on his bicycle!"
"Of course ma'am. Ill have his forms filled out right away!"

 

[NotYou20]

Burning the insurance companies and government to the ground should do it

 

[CyrilFiggis]

Any ideas on how to solve this problem??

Asking people other than pre-meds?

 

[Frogger27]

Asking people other than pre-meds?

There are other people on this forum besides pre-med. And I was just looking for ideas/discussion on the article

 

[efle]

I think well-trained, well-trusted scribes can help with this a lot. Not somebody who just is your personal voice-to-text machine, but somebody who intimately understands the annoying but necessary parts of the note.

But to do that, they might have to start paying scribes more than $9/hr

 

[eteshoe]

Robots?

 

[Sardinia]

.

 

[CyrilFiggis]

There are other people on this forum besides pre-med. And I was just looking for ideas/discussion on the article

Maybe post this is someplace other than the pre-med forum, like here - http://forums.studentdoctor.net/forums/topics-in-healthcare.147/

 

[Lost in Translation]

I also think seeing less patients could result in better patient care/clerical work balance.

You're right. Unfortunately, we currently live in a pay-for-service system. Lots of things are being done to try and change this, such as more doctors becoming hospitalists and taking salaries, but those are not in the majority.

 

[benjamin94559]

Is there an answer besides more scribes/administrative assistants? Would there be some sort of way to outsource this work if it is so mundane?

some people argue that a single payer system would solve this problem by eliminating. whether the cure is worse than the disease is another arguement we need not get into.

 

[Mr Terrific]

Why is this paperwork not computerized? Is it against policy to write a program to expedite the process? It's 2016, no reason for anyone to have to spend so much time on paperwork especially when we have the resources.

 

[alpinism]

Easy:

1. single payer system
2. comprehensive tort reform

The problem is that neither one of these things is happening soon. Too much money stay stake.

 

[libertyyne]

Simple Answer.
APPs.

Advanced practice providers -
and
iphone apps that make it easier?

 

[alpinism]

More scribes might help.

That doesn't solve the underlying problem, it just off loads some of the paperwork onto another person.

Why is this paperwork not computerized? Is it against policy to write a program to expedite the process? It's 2016, no reason for anyone to have to spend so much time on paperwork especially when we have the resources.

Almost all US hospitals have EMRs nowadays. Most of the time they just make things slower not faster. Remember, EMRs were designed to help with billing and collections, not to make doctor's lives easier and certainly not to improve patient care.

For example:

(A) In order to write a simple order for tylenol using a computer chart:

1. log onto the computer
2. log onto the EMR
3. open the patient's chart
4. open the orders tab
5. search for tylenol
6. find the correct type of tylenol
7. select the correct type of tylenol
8. enter in the dosage
9. enter in the route
10. enter in the timing
11. acknowledge multiple alerts
12. sign the order

(B) In order to write a simple order for tylenol using a paper chart:

1. write tylenol 650mg PO one time only at 350pm 9/8 signed xyz

 

[Cotterpin]

That doesn't solve the underlying problem, it just off loads some of the paperwork onto another person.

Is paperwork itself actually a negative thing, though? Do we want to have detailed, accurate medical records or not?

 

[libertyyne]

That doesn't solve the underlying problem, it just off loads some of the paperwork onto another person.



Almost all US hospitals have EMRs nowadays. Most of the time they just make things slower not faster. Remember, EMRs were designed to help with billing and collections, not to make doctor's lives easier and certainly not to improve patient care.

For example:

(A) In order to write a simple order for tylenol using a computer chart:

1. log onto the computer
2. log onto the EMR
3. open the patient's chart
4. open the orders tab
5. search for tylenol
6. find the correct type of tylenol
7. select the correct type of tylenol
8. enter in the dosage
9. enter in the route
10. enter in the timing
11. acknowledge multiple alerts
12. sign the order

(B) In order to write a simple order for tylenol using a paper chart:

1. write tylenol 650mg PO one time only at 350pm 9/8 signed xyz

The problem with that is no one can read your handwriting and misinterpret tylenol 650 for enema 6 X q1H.

 

[Lucca]

@alpinism actually makes a very good point that actually gets at the heart of the problem.

The first question to ask ourselves is this: why is this a problem to begin with?

Let's use the basic business framework. From a common sense perspective, it doesn't make any sense that you have your 200-800k employees spending a significant amount of time doing work that a 50k employee could do (basic data entry). This is why 300k managers/engineers/professionals have assistants, why paralegals are a thing, etc. because you want your very expensive labor doing as much of the very profitable work you hired them for as is physically possible.

So why is medicine this way? Is it because all hospital admins are idiots? No, in fact if you just accept uncontroversial business principles the current arrangement is exactly what you expect. Namely, as a business you want to maximize profit centers and minimize cost centers. What is a hospital's profit center? Billing. What is a hospital's cost center? Lawsuits and patient care. So what do you do? You minimize patient care and lawsuits and maximize billing. So, you get exactly the system we have. In an ideal world under this framework, there would be no patients, not even any doctors, just machines in empty rooms billing insurance providers. Your billing / documenting system needs to be built around profitability and protecting against lawsuits, it does not actually need to be useful for the physician who once upon a time might have kept patient notes to write useful information pertinent to patient care. Under the system we have, the current arrangements and trends make absolute sense. So change the system fundamentally, or nothing happens.

 

[Cotterpin]

In an ideal world under this framework, there would be no patients, not even any doctors, just machines in empty rooms billing insurance providers.

This is so dystopian.

 

[libertyyne]

@alpinism actually makes a very good point that actually gets at the heart of the problem.

The first question to ask ourselves is this: why is this a problem to begin with?

Let's use the basic business framework. From a common sense perspective, it doesn't make any sense that you have your 200-800k employees spending a significant amount of time doing work that a 50k employee could do (basic data entry). This is why 300k managers/engineers/professionals have assistants, why paralegals are a thing, etc. because you want your very expensive labor doing as much of the very profitable work you hired them for.

So why is medicine this way? Is it because all hospital admins are idiots? No, in fact if you just accept uncontroversial business principles the current arrangement is exactly what you expect. Namely, as a business you want to maximize profit centers and minimize cost centers. What is a hospital's profit center? Billing. What is a hospital's cost center? Lawsuits and patient care. So what do you do? You minimize patient care and lawsuits and maximize billing. So, you get exactly the system we have. In an ideal world under this framework, there would be no patients, not even any doctors, just machines in empty rooms billing insurance providers. Your billing / documenting system needs to be built around profitability and protecting against lawsuits, it does not actually need to be useful for the physician who once upon a time might have kept patient notes to write useful information pertinent to patient care. Under the system we have, the current arrangements and trends make absolute sense. So change the system fundamentally, or nothing happens.

Look throw all of that out. It is safer for the patients. Hospitals do not exisit to make it convenient for physicans or the people that work there contrary to what healthcare professionals may believe. CPOE reduces the liklihood of communication errors in order entry. Everything else is just a side effect.

 

[Lucca]

This is so dystopian.

If you replace insurance providers with other machines purchasing and selling against other machines you just get a description of the stock exchange. The only human labor is behind the scenes

 

[libertyyne]

If you replace insurance providers with other machines purchasing and selling against other machines you just get a description of the stock exchange. The only human labor is behind the scenes

This is pretty accurate and amazing to the point of people moving servers closer to the exchange servers to reduce the fiber run to cut 1/100000000th of a second off the transaction time. Crazy, crazy HFT!

 

[Lucca]

Look throw all of that out. It is safer for the patients. Hospitals do not exisit to make it convenient for physicans or the people that work there contrary to what healthcare professionals may believe. CPOE reduces the liklihood of communication errors in order entry. Everything else is just a side effect.

It's not a question of whether EMR decreases communication errors. That's good. The question is: is our current system of documentation the best possible arrangement for improving patient care? I don't think it is, at all. People not misreading physician notes is great and all but it doesn't prevent communication errors from happening absolutely and it isn't the reason that documentation systems are arranged the way they are.

If you add in the structural barrier imposed by the fact that the information actually created by the system is treated as proprietary information, the problem just becomes exponential because it means talk between providers or care systems is either redundant or incomplete almost all of the time, which could lead to useless or repetitive care that costs everyone money and helps no one. On this last point, by the way, the institute of medicine has been writing FOR YEARS that patient information should not be proprietary for a million reasons besides those discussed in this thread.

Essentially what I'm saying is this: the question is not "Is paperwork good or bad?", the question is "what should the paperwork be for?" Once you have an answer for that you can just look at a system's structure and conclude whether or not the system is actually doing the best it can on those terms or not. If not, change the structure.

 

[DrBowtie]

Is paperwork itself actually a negative thing, though? Do we want to have detailed, accurate medical records or not?

The problem with all of the auto fill garbage is that a note becomes 3 pages long with about 3 useful sentences for anyone trying to read it.

 

[Cotterpin]

The problem with all of the auto fill garbage is that a note becomes 3 pages long with about 3 useful sentences for anyone trying to read it.

I didn't say anything about "auto fill garbage." Just that paperwork and records in and of themselves are not inherently bad. There are more effective and less effective ways to use them.

 

[URHere]

Things I wish I had access to that would cut my paperwork/charting burden by 90%:

1) Really reliable intake providers who can do all of the time-consuming things on newly admitted patients: a real medication reconciliation (including calling PCPs/pharmacies for the >50% of patients who have no idea what they are taking), a thorough review of systems, a real (and appropriate) code status discussion, obtaining names/contact info for PCPs and specialists, obtaining outside records when they require written authorization and/or faxing, etc.

2) Fewer inane requirements for what notes need to include in order to be billable. I really wish that instead of writing a brand new note on a patient every day, I could just addend my H&P/admit note with updates. If I could just write, "Patient febrile, new LLQ abdominal tenderness, exam otherwise unchanged, CT showed X, antibiotics started" I could save so much time and it would be so much easier to figure out what on earth happened to patients who were admitted for 30 days when they inevitably get handed over to me on day 31 ready for discharge without any hospital course or discharge summary written down.

That's pretty much it. I don't mind paperwork and documentation when it's needed for patient care.