Once more with feeling: Don’t let patient care interfere with documentation!
I’m being sarcastic, of course, but that’s often how it feels some days. And, since I posted on this subject a few years ago, not much has changed. If anything it’s worse, with more and more clicks needed on the screen to find what I want to find. Those are days when I’ve been busy at patients’ bedsides all day and then struggle to get my documentation done later, typically many hours later. I jot notes to myself as I go along, but it can be hard to recall at 5 PM just what I did and why at 8 AM. This is a particular problem in critical care because some of our billing codes are time-based and we’re supposed to remember exactly, to the minute, how much time we spend on each patient.
It used to be very different, and that wasn’t always a good thing either. Years ago I spent months going through patient charts from the era of 1920-1950. They were all paper, of course, and the hospital charts were remarkably thin, even for complicated patients. I recall one chart in particular. It was for a young child who was clearly deathly ill. The physician progress notes for her already prolonged stay in the hospital consisted of maybe 2 sheets of paper. Most of the daily notes were a single line. I could tell from the graphs of the child’s vital signs — temperature, pulse, breathing rates, and blood pressure — that one night in particular was nearly fatal. The note the next morning was written by a very famous and distinguished physician. I knew him in his retirement and he was a very loquacious man in person. His note after the child’s bad night was this: “mustard plaster did not work.” If I were caring for a patient like that today there would be just for that day and night multiple entries probably totaling several pages on the computer screen.
Patient charts are burdened with several purposes that don’t always work together. The modern medical record as we know it was invented by Dr. Henry Plummer of the Mayo Clinic in the first decade of the twentieth century. Up until that time each physician kept his (only rarely her) case notes really as notes to themselves. When the multi-specialty group appeared, and Mayo was among the first, the notion of each physician having separate records for the same patient made no sense; it was far more logical to have a single record that traveled from physician to physician with the patient. That concept meant the medical record was a means for one physician to communicate with another. So progress notes were sort of letters to your colleagues. You needed to explain what you were thinking and why. Even today’s electronic medical records are intended to do this, although they do it less and less well.
Now, however, the record is also the principal way physicians document what they did so they can get paid for it. Patient care is not at all part of that consideration. The record is also the main source for defending what you did, say in court, if you are challenged or sued. The result is that documentation, doctors entering things in the record, has eaten more and more of our time. Patients and families know this well and the chorus of complaints over it is rising. Doctors may only rarely make eye contact these days as they stare at a computer screen and type or click boxes. But we don’t have much choice if we are to get the crucial documentation done. That’s how we (and our hospitals) are paid and payers are demanding more and more complex and arcane documentation. I don’t know what the answer is, but I do think we are approaching a breaking point. We are supposed to see as many patients as we can. But the rate-limiting step is documentation.
To some extent we brought this on ourselves. In our fee-for-service system physicians once more or less said to payers: “We did this — trust us, we did it — now pay us for it.” I can’t think of a formula more guaranteed to cause over-utilization or even rare cases of outright fraud. But there is only so much time in the day. In my world an ever smaller proportion of it is spent actually with the patient.
The demand for ever more detailed documentation is not the fault of the electronic medical record. One thing that helps in pediatric critical care is the notion of bundled care. This applies for all children up to age 5 — there are categories for 0-29 days of age, 29 days to 2 years, and 2 years to 5 years. The patient is charged a flat rate for the initial day of care, then a flat rate for each subsequent day of critical care. For anyone older than 5 you are supposed to keep track of the specific minutes you spend on them. My colleagues in hospital medicine bill according to the complexity of care, called evaluation and management or E&M codes, which on the face of things seems reasonable. What can become unreasonable is that there are all manner of odd and picky criteria, constantly changing, requiring the use of special magic language, to fulfill the requirements of the several different categories. For pediatric critical care (for those under 5) one only really needs to document how the child is critically ill and what you did about it. After that the daily global charge kicks in.
For myself, I only ask for a system in which the time we spend with patients is more than the time we spend with their medical record. Surely such a thing is possible?