The Cost of Documentation in the American Healthcare System

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One of my colleagues today over lunch suggested that if we only had body cameras like the police, we could see more patients. We wouldn’t have to spend all of the time we do creating documentation of visits.

Of course that wouldn’t work, because documentation of visits serves a number of purposes:

1. Reference for other care providers on the health care team
2. Reference for me (I can’t possibly remember details on all of the patients I’ve seen in 19+ years of practice)
3. Documentation of the visit supporting insurance claims
4. Documentation of my practice style for peer review
5. A legal document of the visit for future lawsuits (either against me, an employer or someone who caused an injury, or even for a class action suit against a pharmaceutical company or medical device company)
6. Documentation for quality improvement efforts
7. Possible documentation supporting retrospective research (patients typically sign a document initially allowing or disallowing this use when they first join a practice, and can revoke it in the future at any point)

Because of all of these uses, it is critical that my documentation accurately reflect the visit. Unfortunately, a complex visit often has complex documentation. In my practice, because of the complexity of patients I work with, I am afforded the luxury of 60 or 90 minute appointments. 6 follow-up patients at 60 minutes a piece, though, is 6 hours out of my day. Add in a noon meeting, prescription refills, telephone follow-up and a few emails, and it’s a long day already. Adolescent medicine is a uniquely feeling field – as an introvert by nature, I’ve found that spending the day intuiting implied responses and sensing the unsaid leaves me quite tired. It’s difficult to force myself to revisit each of those visits to complete the documentation (I’ve described it to some colleagues as PTSD inducing to relive each visit) that same day.

One of my colleagues recently resigned her position because of difficulty keeping up with documentation. A number of my other colleagues have asked for a medical scribe to assist with the documentation chore. The police camera idea is what we all wish it could be (but not really, of course). Many primary care colleagues describe taking work home to complete after the kids have gone to bed, or regularly staying for 3-4 hours after clinic has closed. I had one, somewhat misguided, medical director tell the providers (in a past practice) that full-time was expected to be, be definition, 60 hours a week.

What is the answer? Electronic health record vendors would like us to believe that their software will improve our life and increase productivity. Unfortunately, the only ones that seem to deliver on that promise are ones that fail the above purposes. I have seen templates that are blown in to a visit that introduce so many errors, that the record is unusable (which gives a savvy lawyer grist to question all of our documentation). All it takes is one medical student to document that my patient with cerebral palsy instead has spina bifida. Suddenly, all the consultants are auto-populating an incorrect problem list, and it looks like my patient suddenly developed a hole in their back. A recent enteroscope through an ileostomy described entering through the rectum and advancing to the proximal jejunum. Now that would take a skilled gastroenterologist! Especially since this patient did not have a connection between their rectum and their small bowel.

Perhaps, then, the interim answer really is scribes. At least until technology catches up with the needs of the profession. I’ve always said that medicine was 10 years behind business in utilizing computer technology – not in all areas (radiation oncology, for example, is quite advanced, as are parts of radiology) – but in most. When was the last time you had to think about losing your document if the computer crashed? I still do.

Scribes are not inexpensive, however. In most settings where they are used their cost can be justified by increased productivity. Medicine, however, is largely built on scientific enquiry, and there is little published on the cost effectiveness. Certainly in high pressure or high volume circumstances, the ROI is fairly easy. Unfortunately, my 60 or 90 minute visits don’t even cover the overhead. We stay in the black because my services prevent negative outcomes and result in referrals to other more lucrative services. It’s a difficult ask.

For more discussion on medical scribes, see a nice article by blogger, Kevin Pho, MD who blogs under the twitter handle of @kevinmd: “The disturbing confessions of a medical scribe”