A few years ago, we doctors kept handwritten charts about patients. Back then, it sometimes seemed like we spent half our time walking around looking for misplaced charts, and the other half trying to decipher the handwriting when we found them. The upside was that if I did have the chart in front of me, and I saw that someone had taken the trouble to write something down, I believed it.
Unfortunately, this is no longer the case. The advent of electronic medical records has been a boon to patient safety and physician efficiency in many ways. But it has also brought with it a slew of "timesaving" tricks that have had unintended consequences. These tricks make it so easy for doctors to document the results of standard exams and conversations with patients that it appears more are being documented without ever having happened in the first place.
For instance, doctors used to have to fill out a checklist for each step in a physical exam. Now, they can click one button that automatically places a comprehensive normal physical exam in the record. Another click brings up a normal review of systems — the series of questions we ask patients about anything from nasal congestion to constipation.
Of course, you shouldn't click those buttons unless you have done the work. And I have many compulsively honest colleagues who wouldn't dream of doing so. But physicians are not saints.
Hospitals received $1 billion more from Medicare in 2010 than in 2005. They say this is largely because electronic medical records have made it easier for doctors to document work and be reimbursed. That's probably true to an extent. But I bet a lot of doctors have succumbed to the temptation of the click. Medicare thinks so, too. This fall, the attorney general and secretary of health and human services warned the five major hospital associations that this kind of abuse would not be tolerated.
Then there are the evil twins, copy and paste. I've seen "patient is on day two of antibiotics" appear for five days in a row on one chart. Worse, I've seen my own assessments of a patient's health appear in another doctor's notes. A 2009 study found that 90 percent of physicians reported copying and pasting when writing daily notes.
Reading the electronic chart has become a game of looking for a small needle of new information in a haystack of falsely comprehensive documentation and outdated, copied text. Why do we doctors do this to ourselves? Largely, it turns out, for the same reason most people do most things: money.
Doctors are paid not by how much time they spend with patients, how well they listen or how hard they think about what could be wrong, but by how much they write down. And the rules for what we have to write are Byzantine: Medicare's explanation takes 87 pages. To receive the highest level of payment for an office visit, I have to document several aspects of the main problem, screening questions about at least 10 organ systems, something about the patient's family and/or social history, and/or a lengthy physical exam. In addition, I have to demonstrate that my medical decision making was very complicated, considering the number of possible diagnoses and treatments, the complexity of the data and/or the patient's risk of serious complications. That type of visit is supposed to take about 40 minutes.
I recently spent 40 minutes with a patient who had just placed her mother into hospice. My patient was distraught, not sleeping. I gave her advice, but mostly I just listened. By the end of our visit, she was feeling much better. But I wouldn't be able to bill much for that visit: I didn't review her medical or family history, conduct a review of organ systems or perform a physical exam. The payment system tells me to cut her off after 10 minutes, listen to her heart and give her a sleeping pill. Which doctor visit would you prefer?
Of course, I would never go back to the bad old days of lost charts, illegible writing, manual prescription refills and forgotten information. Electronic medical records help us avoid dangerous drug interactions and medical ordering errors, remind us to provide preventive care and allow us to view data as trends over time. Even copy and paste have legitimate uses.
But physicians need to be better stewards of our records so they remain useful, regardless of skewed incentives and new technology. And as a nation, we should question whether paying physicians by documentation — instead of by time spent on quality patient care — is such a great idea after all.
Leora Horwitz, a primary care internist, is an assistant professor at the Yale School of Medicine. This piece originally ran in the New York Times.