Treat the Chart, Not the Patient

How doctors became checklist monkeys.

Posted Nov 02, 2017

pixabay at pexels
Source: pixabay at pexels

Killing Care Softly

It’s official: doctors treat charts, not people. Harvard researcher Russell Phillips reckons physicians of many stripes are now "data entry technicians." My preferred term is “checklist monkeys.” The results for your health care?

Not good. 

How much time and energy are really wasted? Recent reports show ER physicians spending 44 percent of their time on data entry and charting. A recent study of physician practices found 37 percent of face spent with patients engaged doing charts and administrative chores. That’s not counting time spent once doctors leave you, full of questions, fuming in the examining room. It does not count the mental time doctors put in fulfilling increasing documentation requirements.

Nor the real results. Control what people spend their time on and what they think about, and you'll control what they do. That’s the real effect of documentation mania on health care workers.

Consider other professions. What would it be like if your plumber spent 40 percent of her time writing down the exact minute she arrived, how many minutes were spent cleaning a joint as opposed to greasing it, noting why she greased and did not lubricate, all the other possible cleaning/repair options and why they were discarded?

Or a farmer told he must spend several hours each night documenting each acre of land, the overall level and percentage of growth that day, total number of insects for each acre, and then is told by his grain wholesaler tracking that information that because he sprayed Roundup only 19 rather than 20 days in the last month, 10 percent of his payments would be forfeited?

Sound ridiculous? It’s happening in health care. To find out what's going on, do what the pharmaceutical advertisements tell you when describing the many side effects of their drugs: ask your doctor.

Why do we presently treat charts before people? Consider the gainers and losers:

1. Insurance company “clawbacks” and “savings.” If you don’t fulfill all of the checklist items, they don't have to pay you. One gastroenterologist I know was surprised to see some of his insurance payments refused because “data was missing.”

Except the data was all there. A very detail oriented, disciplined man, he knew all the information requested was already in his charts. He spent future weekends and much of his office manager’s time combing through the audited charts and finding all the “absent” material.

The result? A letter saying, “Thank you for the new information. Please send 20 additional charts for audit.”

He did not contest the next time around.

2. Killing physician time. Insurers and payers of all stripes consider that killing enough physician time with documentation means less time to see patients – and less payments to doctors. The actual result, as is usual in the cost shifting games of medical care, is more complex.

A physician who is given by her large group practice manager 15 minutes to see a patient, of which at least six will be spent in documentation, will do what can be done quickly: drugs, drugs, devices and procedures. Time to discuss diet? How and when to walk to get healthier? Work changes and family stresses? Quickly issues of physical, mental and social wellbeing go out the window – along with public health. What can be done quickly rises to the top of the agenda? And ultimately, costs a lot.

3. More data mining. Lots of documentation may well create fake data. Many patients tell me of five-minute encounters with physicians while I’m looking at the 16-page report that visit created but it’s still data. And data, as the IT industry knows well, is power and money. Information Technology, Big Pharma, Pharmacy Benefit Companies and Health Insurers can use that data for marketing and selling. And sell it on. 

4. Rolling up physicians into corporate or hospital owned large practices. To get around documentation issues, you need more firepower and larger IT systems. That is much easier for large physician groups, which are easier for insurers and others to contract with – why deal with fifty solo practices when you push them all into one? Recent documentation requirements are also mandating certain electronic health records be used, a huge cost to physicians (and you) in time and money. That these records have been hacked by the hundreds of millions; that they don’t talk to each other and use transferring records as a profit center; that Britain scrapped a 15 billion dollar EHR system as unusable; that physicians have struck hospitals with ineffective and wasteful EHR systems – that you don’t see in the media.

5. Killing the doctor as drug. A large part of medical effectiveness is the placebo effect. It depends on the patient feeling someone is with them, cares about them, wants to make them well. That happens a lot less when “medical assistants” and “scribes” at very considerable cost are employed to get all the newly demanded documentation information, and the physician rushes in for a tense 90-second conversation. Turning doctors into technicians who don’t talk to you has many noxious effects on your care. Often, placebo results are close to that of “standard” treatments – look at anti-depressants. Do you really want to get rid of 30 to 40 percent of medical effectiveness through making documentation king?

What To Do

Today we have a system where doctors are angry and frustrated, with at least half claiming near or future burnout. As Bob Brody points out, that makes them less effective doctors. Patients get less time with doctors, feel fobbed off, and grow increasingly disenchanted with all aspects of medical care. The end result is a sicker, irritated, unhappy population. Other health care workers are equally affected. The reason you can’t find the nurse to see your ailing mother is often because he’s “charting.”

Mayo Clinic researchers estimate 85 percent of what appears in medical records is unnecessary information. It’s time for “evidence-based medicine” to do what it should have done long ago: conduct clinical trials looking at what sorts of documentation aid effective care, and perform those trials before yet more useless documentation is required of health care workers.

It shouldn’t be hard. You can look at the chart practices of countries where health care is much cheaper and people live considerably longer than the U.S., like Sweden, Switzerland, and the Netherlands. And then get a national administration which claims to want rapidly rid us of unnecessary regulation. 

But that might offend some of their biggest donors.

Just remember who loses under a system where charts have physical and mental preference over people, you do.