Why Healthcare Documentation is So Bad

Care Venn Diagram CropHeath care documentation is done for three reasons.

1) Health care delivery (that’s the obvious one)

2) Regulatory compliance (checking all the boxes our government and payers think are important)

3) Malpractice avoidance (no one wants to get sued)

These three categories actually apply to every task we do in healthcare, but let’s confine this discussion to documentation.

Note in the accompanying figure, our three basic healthcare work requirements fit logically into a venn diagram. Much of what we do serves only one or two of the three driving purposes. In an ideal world, we work in the center of the diagram where all three converge. Unfortunately that “sweet spot” is pretty small, especially when it comes to documentation.

If all clinicians needed to do with our documentation was practice medicine (#1 above, blue in the attached Venn diagram), our notes would be more logical and much less bloated. Laundry lists of irrelevant and inaccurate diagnoses would not populate into every note. Copy and paste would occur a lot less often, and likely could be limited to appropriate uses such as carrying over past medical history (which should always be copy and pasted after verification to reduce errors). Only relevant physical exam findings would be reported, so these would not be lost in a sea of normals. Useful information that is not valued externally, such as personal touches – i.e. patient’s wedding anniversaries, achievements of their children, would have it’s own optimized workflow.

Regulatory compliance and malpractice protection, the #2 and #3 health care documentation purposes above, are responsible for the large majority of the drivel that shows up in our notes. Believe me, we doctors would all love to confine our work to health care delivery, but external forces box us into this uncomfortable place, and this creates junk documentation.

The result of trying to serve all of these missions results in the mess we have today. Healthcare IT expert Fred Trotter says that working with EHR is “like having a conversation with a habitual liar who has a speech impediment.”Care Venn Diagram EHR Crop

As I’ve diagrammed here, EHR serves all three basic functions, but not to equal degrees. EHR is designed for and sold to hospital administrators. Their first priority is business related – i.e. making sure the system runs efficiently and within the law. They work in the peach (Regulatory Compliance) circle.  After the Federal Government stepped in with EHR incentives, Meaningful Use requirements created a set of requirements for the EHR companies that are about 90% peach-colored as well.

After satisfying the needs of administrators and the government, EHR vendors allot remaining resources to serving working clinicians seeing patients, as well as the patients themselves. This results in the lesser segment of EHR devoted to care delivery represented in blue.

Malpractice protection, the green circle, is a critical area of alignment for both the administrators and clinicians. EHR systems provide some degree of protection via completeness and automation, but also introduce new risks.

Since working clinicians don’t make purchasing decisions, what is an EHR vendor’s motivation to optimize the systems for care delivery? Note, also, that the enormous cost of each system coupled with a lack of easy data portability effectively locks in a healthcare system to their EHR. Nowadays, most physicians are employees of their hospitals and lack sufficient leverage to effect an expensive change, even if such a clinician-friendly EHR system were available.

EHR activities fundamentally service the task of Regulatory Compliance (the peach circle) as their primary mission. This satisfies both the hospital administrators and the government. Because all parties have limited resources, the contribution to the Health Care Delivery circle suffers. Both hospitals and clinicians are interested in Malpractice Protection, so the green circle is served at of mutual self interest, although EHR workflow only tangentially addresses this need.

Clinicians need mechanisms to streamline documentation so they can spend time with patients instead of in front of computer screens. Ironically, many of the efficiencies built into EHR to give clinician more time with their patients have become targets of disapproval for our regulators and critics. I find it frustrating when I hear pundits and government officials rally against copy/paste and templates (such as normal physical exam findings). Most of these critics have no perspective on running a busy clinic or inpatient service. It would be impossible to do our jobs without some degree of automation. Do you think the legal profession would consider eliminating templates and copy/paste? Do you think contracts and wills are written freehand each time? Ridiculous.

Good clinicians need to fight external forces to protect their ability to care for their patients. That means we need to devote the large bulk of our time and thoughts to working in the blue circle of healthcare delivery. That’s where our mission is served. The other two circles? We should click/copy/paste/dictate/template only what is necessary to prevent us from being sued, sanctioned, denied payment, or accused of poor quality. If we can do that efficiently, we can get back to taking care of our patients. One casualty of this appropriate triage is ugly documentation.

Folks need to stop confusing healthcare documentation with health care delivery. Those who grade and pay us give far too much weight to the former. Those actually taking care of patients know where to set their priorities.

Edward J. Schloss MD

Adapted from my comments on EMR & EHR Forum post EHRs Don’t Make Errors, People Do.

Addendum 8/16/15: In response to a comment from Michael Katz MD @MGKatz036 discussing role of EHR in upcoding and other greed and fraud issues, I issued a lengthy comment/reply. Because it extends well my arguments above, I’ll include these as an addendum to the original post for better accessibility.

Mike, I’ve heard the concern that EHR causes fraud and increased cost charge many times. So much to say, but I’ll try to be brief

– E&M billing is already stacked against us. Leaving one irrelevant bullet point off the ROS list or physical exam can cause dramatic devaluation of an encounter. This is a playground for RAC audits and doctors live under that threat continuously. The system is illogical and need for attention to silly details draws up away from our primary mission. The EHR levels the playing field here. As I’ve said before, the dishonest MDs knew how to upcode dishonestly before EHR. Automation and reminders from EHR demystify the rules and lets honest doctors be fairly compensated. Do you have all the E&M rules memorized? Could your billing withstand an audit without the help of an EHR? If you were like many doctors, you’d just code level 3 and not take any chances. Ethical billing consultants (yes they exist) in the pre-EHR days found many doctors to be systematically undercoding because they didn’t want or know how to play the E&M game. If office charges go up after EHR, that may be entirely appropriate.

– How much free care is delivered now BECAUSE we have an EHR? I just spent 30 min on the phone doing two very complex patient evaluations involving EHR and remote pacemaker review. I did this at no charge. Without an EHR, this quality of care would be impossible without the paper chart. That means it won’t get done until tomorrow at the earliest, or I’d have to make do without the chart. In many cases we can prevent office and ER visits with this data access. Patient and system benefits, MD makes less money. It’s the right thing to do, so we do it.

– EHR charting is so painful, I often avoid the encounters altogether just so I don’t have to go through the misery of clicking through the documentation. The care gets delivered, I just don’t get paid. Lots of ways to do this, all ethical and appropriate. None violate our contracts. In the paper days, many of these would have been billed.

I decided not to include a circle on the venn diagram for unethical or inappropriate behavior. I have absolutely no doubt this exists and is a big problem. Nothing I say here denies this fact. This has been reported well and extensively by others.