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I attended medical school in the 1960s, when Dr. Lawrence Weed reinvented the medical record to organize and leverage the physician’s patient evaluation for clarity and quality of care—what he dubbed “the problem-oriented medical record.”1,2 My internal medicine house officer training at Massachusetts General placed a high value on efficient, effective medical records and communication of patient information among colleagues and staff. As a young faculty member in San Antonio, I designed and taught a course in clinical skills that emphasized the critical role of effective, problem-oriented medical records in patient evaluation and management. This prepared students better than traditional approaches for their clerkships and careers in patient care.3
As a practicing rheumatologist for 35 years, I have been well served by these skills in my own care of patients. In coordinating the Rheumatoid Arthritis Practice Performance (RAPP) Project recently, I found the same to be true for the highly capable clinician rheumatologists who participated.4
It alarms me that today’s medical records have been hijacked by payers and practice administrations from their previous purpose of supporting effective patient care to their current purpose of documenting physician work for reimbursement; the incompatibility of these two purposes has degraded the value of care. I fear physicians are becoming more adept at clicking, copying and pasting than using their medical records to provide and communicate effective care. By linking medical records to volume-based payments and physician compensation, payers and administrators have created an irresistible motivation for physicians to align their record keeping with these financial interests.
Too often, payers and administrators simply don’t understand the logic and process of patient evaluation and management, or its importance to effective delivery of care. Why should they? They’ve been trained to run businesses and earn money, not to enable high-value healthcare or assess the logic or quality of the physician’s work product. They focus instead on the components and volume of work: health insurers to rationalize costs, and health system administrators to maximize revenues and avoid payer audits and rejections.
Of greater concern, in the face of this fundamental change, payers and administrators have taken physicians’ ability to maintain high-value care for granted, but mounting evidence shows this is a fool’s bet. Increasing documentation and other administrative work at the expense of patient evaluation and management degrades physicians’ performance both during individual patient encounters and by reducing how many patients they can successfully manage. Wasteful care, omissions and errors increase. Don’t believe me? Ask any consultant who reviews prior medical records or those physicians who review records for lawsuits involving physician errors.
The business of healthcare in the U.S. is doing just great, as indicated by the high and rising percentage of our gross domestic product it consumes annually, while the value of care delivered lags behind other developed countries and too often provides less than what patients require.5,6 Meanwhile, an increasing percentage of revenues earned from physicians’ work is being diverted to administrative expenses.
A Fundamental Change
The shift from value to volume has fundamentally changed the content and usefulness of medical records. High-value care back in the day involved reporting the critical positive and negative clinical information that supported our identifying the patient’s problems, creating management plans for each of them, prompting re-assessments at timely intervals and communicating this essential information to others. They supported an iterative process. The components of a comprehensive history and physical examination were performed only when necessary; other evaluations were focused according to the patient’s needs and the individual physician’s role.
In contrast, current high-volume record keeping involves reporting more work components in more detail to maximize reimbursement, independent of, even contrary to, its value in supporting high clinical performance and effective communication. Nowadays, a physician gets paid less for a focused evaluation, even if it takes longer and requires higher skill, unless lots of irrelevant information is added.
Immediately after new evaluation and management visit requirements were released in the 1980s, I attended an ACR Clinical Council meeting at which the discussion revolved around, “What makes a visit a Level 4 instead of a Level 3, and how can we make it a Level 5?” Game over!
The assessment of physician performance should be returned to structured peer review … rather than the current monitoring by administrators & payer clerks.
Different Specialties, Different Impacts
It is clear to everyone that physicians who evaluate and manage complex patients over long cycles of care are the big losers—primary physicians, geriatricians, infectious disease specialists, neurologists, endocrinologists, psychiatrists and rheumatologists, as Dr. Atul Gawande recently observed.7 Their work often requires review of voluminous prior records, detailed examinations, complex analysis and record keeping, and coordination of care across health systems over long time spans. What the Level 5 billing code pays cannot begin to cover the time and resources appropriately consumed by this work, no matter how much documentation the physician provides. The result, according to Gawande, is that these practices are starved for resources, and physicians are compelled to do work that others could perform better, and at a lower cost.
Physician trainees get this. Fewer now choose specialties that used to attract some of the best and brightest graduates. Those who do pursue these medical specialties either choose practices that pay a fixed salary, or they make mid-career changes to better meet their financial needs. Other medical specialists who also perform procedures, such as cardiologists, neurologists and gastroenterologists, often choose to emphasize their procedural services rather than care for complex, long-term patients. These workforce distortions then translate into access problems that affect patients with complex chronic diseases disproportionately.
Electronic medical records (EMRs) did not cause this shift from value to volume record keeping, but they have enabled it. Physicians initially wrestled with volume requirements using paper records, either handwritten or dictated. EMRs were first sold to medical practices to save storage space and facilitate more rapid electronic communication of essential information among providers and payers. And through no accident, it was also linked to electronic scheduling and billing software to simplify documentation. Then it evolved further, from documentation that mirrored the logic and formatting of previous records to auto-filled standard templates and checklists.
This is when the train flew off the tracks. Such boilerplate records may have saved time and transcription costs, but they also enabled including more information, relevant or not, while obscuring critical thinking and clarity. And the healthcare businesses can’t play the volume game without them.
More recently, more and more physicians copy and paste text from their own and others’ prior records into current visit notes. Any other physician reviewing this work product knows the amount of information copied and pasted could not possibly have been reviewed or collected during the current encounter, as is represented, and that its purpose is volume. This practice is a red flag for billing fraud, and payers are increasingly disallowing it. Predictably, however, physicians will devise other work-arounds to maximize volume as long as this is what they get paid to do. The promise of EMRs improving communication across providers at the system level also remains unrealized because of sheer volume, let alone impossibly low signal-to-noise ratio.
The professional and personal impacts of volume-based documentation on physicians are profound. The shift to volume-based record keeping in EMRs not only adds 1.5 hours of work per day for today’s physicians, it has fundamentally changed how they spend this time. Only 30% is spent providing care, while 45% is spent documenting it, and 25% is spent on other administrative activities, such as coding reviews and specialty recertification requirements.8
The pajama practice is another recent addition to physician’s work day; this is the time they spend logged into their EMR system from home to clean up unfinished documentation before retiring. For today’s physicians, time pressures and loss of professional control are the two top contributors to their escalating stress and burnout, not to mention the erosion of time available for family and personal activities.9
What May Help
It is a given that the U.S. needs an effective, highly motivated physician workforce. Any hope of achieving this requires the policymakers, payers and administrators to support physicians’ refocusing their time and attention on high-value care. This will require implementing and funding more efficient and effective delivery teams and processes at the points of service, including a return to value-based medical record keeping and financial incentives that promote value rather than volume. Also, the assessment of physician performance should be returned to structured peer review, as in the past, rather than the current monitoring by administrators and payer clerks.
This practice redesign must begin with shifting work from physicians to others whenever possible, or omitting it entirely, because few have the time now to even consider how they might make things better. Revenues must be used to support increased practice staffing and resources rather than increased administration. Billing must be based once again on the time, effort and complexity of services provided, as estimated by the physician, rather than on the volume of documentation. Administrative review should be restricted to outliers rather than being imposed on all physicians by growing bureaucracies.
Most importantly, physicians must regain control of how they spent their time in their patients’ best interests, and they must be rewarded for maximizing their practices’ efficiency and effectiveness. In the end, team care actually pays for itself by increasing the number of patients managed per physician and decreasing the costs of care per patient.
The American Medical Association, the National Academy of Medicine, the medical licensing boards, the alphabet soup of professional organizations and the large-practice administrations all appear to have accepted high-volume medical records, growing administrative and regulatory burdens, and low-value care as immutable realities. They are embarking on multiyear studies to better understand physician burnout when the root causes—time pressures and loss of control—are in plain sight, as are the solutions.10
It is way too easy for health system stakeholders to protect their advantages by continuing to add widgets to physicians’ workloads and expand their EMRs in the name of improvement. They must instead recognize and address time compression and loss of control as the root causes of degraded physician performance and well-being.
The challenge for physicians? To re-engage and collaborate in well-conceived point-of-service practice redesigns and meaningful quality improvement initiatives instead of responding to these initiatives with, “I’m too busy,” “I’m burned out” or “I quit.”
Timothy Harrington, MD, is retired from rheumatology practice and a professorship of medicine at the University of Wisconsin School of Medicine and Public Health in Madison, Wisc. He has served the ACR/ARHP on the Committee on Rheumatologic Care, the Communications and Marketing Committee, the Osteoporosis Task Force and the Quality Measures Subcommittee, and as an editor of ACR news. He is an ACR Master and Paulding Phelps awardee. He is now a consultant in clinical practice performance.
Disclaimer: This article expresses the views of the author and not necessarily those of the ACR and The Rheumatologist.
References
- Weed LL. Medical records that guide and teach. New Engl J Med. 1968 Mar 14;278(11):593–600.
- Weed LL. Medical records that guide and teach. New Engl J Med. 1968 Mar 21;278(12):652–657.
- Littlefield JH, Harrington JT, Anthracite NE, et al. A description and four-year analysis of a clinical clerkship evaluation system. J Med Educ. 1981 Apr;56(4):334–340.
- Harrington T, Arnold E, Arnold W, et al. Help wanted: The rheumatology workforce shortage revisited. The Rheumatologist. 2016;10(5).
- Centers for Medicare & Medicaid Services. (2018, April 17). National Health Expenditure Data.
- Squires D. (2015, October 8). U.S. Healthcare from a Global Perspective: Spending, Use of Services, Prices and Health in 13 Countries.
- Gawande A. (2017, January 23). The Heroism of Incremental Care.
- Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med. 2016 Dec 6;165(11):753–760.
- Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012 Oct 8;172(18):1377–1385.
- National Academy of Medicine. Action Collaborative on Clinician Well-Being and Resilience.
