
When the Doctor Must Choose Between Her Patients and Her Notes - xenophonf
http://commonhealth.wbur.org/2016/01/opinion-doctor-patients-notes
======
jernfrost
I see people here explain all this documentation requirements as a function of
it paying private health care.

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.

~~~
lmm
This has to be answered empirically. No doubt there is value in giving doctors
or teachers the freedom to do what they think best - especially the best ones.
But there is also a lot of value in standardization, accountability, and
ensuring we know what went on. A patient may think they care more about how
kind the doctor was, but if better notes make the difference in spotting a
rare condition or simply catching a mistake - or, more subtly, enable data
analytics that let us spot new correlations and develop improved treatments -
then (with a limited amount of doctor's time available) that's a lot more
important.

What has the overall effect of these paperwork changes been on healthcare
outcomes?

~~~
ThomPete
One of the outcomes is that doctors spend up to 50% of their time making notes
instead of seeing patients. Another issue is that by making these overly
controlled environments you are basically being forced to higher more control
people.

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.

~~~
alistairSH
_One of the outcomes is that doctors spend up to 50% of their time making
notes instead of seeing patients._

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?

~~~
lloyd-christmas
> If the notes are relevant/useful and can only be entered by a doctor

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).

~~~
ThomPete
Exactly.

------
iambateman
My wife is a therapist. Her supervisors expect 80% efficiency (billable time)
and her treatment to paperwork load is close to 1:1.

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.

~~~
asift
My wife is a therapist as well. She has to clock out and do documentation on
the evenings or weekends to meet productivity (documenting while treating
isn't an option given her need to be hands on with patients). They also
require her to overbook (i.e., book >100% productivity) so that she stays
above 80% in the case of no shows. I get the logic behind it, but it really
sucks for her when she doesn't get no shows.

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.

~~~
mattmanser
These sorts of universal employee abuse problems are what unions are supposed
to solve.

------
nradov
The requirement for high levels of documentation is largely an attempt by
payers (insurers) to prevent fraud, waste, and abuse. In the US most
healthcare providers are still paid on a fee for service basis so the more
patients they treat in a day the more money they make. There have been many
incidents of providers submitting claims for patients who didn't need
treatment, or with the wrong billing codes. (Obviously the vast majority of
doctors don't do anything unethical or illegal, but still fraud is fairly
common.) So payers want to see the notes in order to verify that treatment
actually occurred, was medically necessary, and consistent with the terms of
the patient's insurance policy.

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.

~~~
Aleman360
There is still a requirement for highly structured data entry that is
unavoidable. Even if you reduced the other documentation requirements, the
"computerized physician order entry" systems (healthcare lingo) still require
quite a lot of provider time. You need to be very explicit when entering
things like chemotherapy regimens.

~~~
nradov
Right that's also a factor. Some medical practices have hired scribes to
shadow physicians during patient encounters and do the data entry in real
time. This is expensive but can end up being cost effective if it allows a
highly-paid physician to see more patients per day.

------
hardwaresofton
Uh... Isn't the fix to just stop taking more patients than you can handle
comfortably and enjoyably? Maybe that, paired with encouraging more of the
younger generation to become doctors (to cover for the patients you feel like
you might be abandoning?)?

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

~~~
lloyd-christmas
> Isn't the fix to just stop taking more patients than you can handle
> comfortably and enjoyably?

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...](http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf)

~~~
hardwaresofton
> 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.

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.

~~~
chimeracoder
> Sorry, I meant suggest taking less patients, in addition to charging enough
> to match what you were making before.

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.

~~~
hardwaresofton
Thanks for the information/sharing the challenges that are present.

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?

~~~
chimeracoder
> 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.)

~~~
hardwaresofton
OK got it - so there is some law that prevents/makes it prohibitively
expensive for hospitals to not serve medicare/medicaid patients?

~~~
lloyd-christmas
Not specifically law, but the number of patients on Medicare. You're
essentially eliminating at least 15% of potential patients(and growing as the
population ages) That doesn't even factor in the age of patients. Only 15% of
that 15% are under the age of 65. That leaves you with 40m+ people on medicare
who are over 65. Who tends to go to the doctor more frequently, a 25 year old
or a 70 year old? Dependent upon specialty, you could have 90% of your
patients on medicare. If I dropped 90% of my clients, I don't think
"comfortable" would be an accurate description of my workload.

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.

------
Aleman360
Girlfriend is an oncology PA. Writing notes are the absolute most dreaded part
of her job. She has to spend about 8 hours every weekend catching up on them.
The switch to electronic records vastly increased the amount of time to
complete notes.

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.

~~~
alistairSH
_The switch to electronic records vastly increased the amount of time to
complete notes._

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)

~~~
Aleman360
Both. It's extraordinarily complex. The data entry is highly structured. All
the electronic record software I've seen has probably ~100 pages worth of
forms, a big subset of which usually need to be filled out for each patient
visit.

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...

------
danieltillett
Whenever I look at the USA medical system I wonder how much longer it can go
on for. Ever rising costs combined with an ageing population and a political
system that finds it hard to make decisions must end at some point, but when?
What percentage of GDP does the healthcare budget have to reach before it
breaks?

~~~
scott_s
I'm not sure that's relevant to the article - it sounds like a general lament
about the US healthcare system that could have been attached to any article on
US healthcare. Have we established that doctors in the US have to deal with
more documentation than doctors in other industrialized healthcare systems? I
think establishing that is required to turn this discussion into one about the
problems of the US healthcare system versus others.

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.

~~~
Retric
> Have we established that doctors in the US have to deal with more
> documentation than doctors in other industrialized healthcare systems?

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...](http://www.eurekalert.org/pub_releases/2014-10/pfan-
pco102314.php) _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.

~~~
scott_s
Yes, very interesting. But it is non-patient administrative work, so I'm not
sure if it applies to the submitted article. That does, however, support the
argument that in general, the US system requires more administrative work, yet
(I believe), the US and Canadian systems achieve about the same health
outcomes. And I also believe the Canadian system is cheaper. It's then
reasonable to conclude that the many layers of the US healthcare system are
the cause.

It would be reasonable for patient-related notes to be correlated with other
administrative work, but it's not necessarily so.

~~~
Retric
The article points out that most of these notes are not related to patent
care.

 _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.)_

~~~
scott_s
Correct, and I understood that, so I was not clear. My question was on whether
or not patient notes are also associated with more-bureaucracy-for-the-same-
health-outcome. At higher cost. Maybe more patient notes actually lead to
better health outcomes, even though they're an annoyance for doctors and cause
them to see less patients.

~~~
Retric
Got it, it's a good point and worth looking at. Doctors taking lot's of notes
while in with a patent could also lead to worse outcomes as they are
distracted.

However, ~50% increase in healthcare costs would need to have a huge impact on
patent outcomes or drastic fraud reduction to be worth it.

------
betenoire
The article doesn't mention transcribers. I remember in the 80s and 90s, a few
of my relatives typed up medical transcriptions as a part-time from home job.
Has this fallen out of style? Or is this a result of some legislation perhaps?

------
gherkin0
When I saw a dermatologist about a year ago, and he had an assistant in the
room whose job seemed to be to update the notes while he was interacting with
me. I can see that helping with a lot of specialties, but maybe not
psychiatry.

------
fixermark
I can't help but think there could be two solutions to this problem.

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).

~~~
djb_hackernews
My SO is a family medicine MD and works at an inner city clinic. When we first
started dating she'd mention the need to spend time during the evenings to
write notes. As someone that a) wanted more of her time b) wrote software for
a living, it surprised me that such a system doesn't already exist. It seems
like it could aid in catching errors and also being a helpful assistant of
sorts to ensure good notes are being captured and all possibilities are being
addressed.

From what I've seen, even with newer EHR systems (Epic, Athena), medical
technology is about 15 years behind current technology.

~~~
Spooky23
It's worse than 15 years behind -- it is a step backwards. In ye olden days,
they recorded notes on a $50 voice recorder, and had a transcriptionist
transcribe notes into a written form that went into records.

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.

------
Xyik
Maybe doctors should hire someone to help with the paperwork? This seems like
a case where scaling horizontally works better than scaling vertically. Like
how some tech companies make use of QA departments while others do their own
QAs, perhaps some doctors having an assistant on hand could make things more
efficient.

------
gabriel34
Multitasking has the effect of increasing perceived workload whilst decreasing
work throughput and increasing the error rate.

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.

------
ALee
This article just makes me think of supporting more startups like Augmedix and
the future of Augmented Reality will truly be a revolution in healthcare.

------
Skeletor
If this Doctor was using drchrono she wouldn't have this problem.

