Letter: It's not your doctor's fault

Posted
Editor of the Reformer,

Many people complain that their doctors spend too much time facing their computers and not facing their patient, and perhaps not even listening to their patient. Indeed, studies have shown that in the exam room doctors devoted about half of their time doing electronic tasks. Family physicians in one study spent 2 hours doing computer work for every one hour spent face-to-face with a patient. Computer tasks spill over after hours and eat into the doctor's free time. A tool that was supposed to make us more efficient has become our master.

The root of this problem began in the early 1990s when Medicare developed the "Resource Based Relative Value Scale," in which doctors had to choose between five levels of care for an office visit or other services. The more complex the care, the higher the level billed, and the more documentation required. This was about the time computerized medical records began, and the tendency for excessive documentation accelerated. In order to get paid by the insurance company, the doctor had to document many things that were trivial and unimportant to the patient's care. In the old days, a patient would see the doctor for a sore throat, and he would write in his records "Sore throat and swollen glands X 3 days. T101.5 Pustular tonsillitis, tender tonsillar nodes. Dx: Strep Throat. Rx: PCN 250mg 4X/d for 10d." Now, that same patient would likely have 2-4 pages of documentation, much of it nonessential. There are now a small armies of "coders" employed by hospitals to check the doctor's notes and make sure, given what was documented by the doctor, that the correct procedure code is applied before the bill gets sent to the insurance company. Note that this is somewhat of a game that we play with insurers: we want to bill a higher code and they want us to bill the lower code. Nothing is worse than having the claim denied or returned for further documentation as payment is delayed even longer.

A related problem is that now the patient's medical record is full of immaterial information, and it might be difficult for the doctor to find what he is looking for. For example, at the Bennington Free Clinic we commonly request previous medical records from other doctors.

We might receive 20-30 pages of medical records and have to sift through these to find the one line that is needed.

It's not just the patients who have noticed that computers can get in the way of their care. Studies have shown that as many as two-thirds of physicians are unhappy with their computer software. An unintended consequence of this unhappiness is the problem of physician burnout, which is defined as emotional exhaustion, depersonalization (looking at the patient as just another case of COPD rather than the person who has COPD), or the doctor's lack of a sense of personal accomplishment. Studies have shown that over 50 percent of doctors have at least one of these symptoms; some would call this an epidemic. Burnout leads to such things as poorer patient care, and there may be difficulty retaining the doctor in the community. One of the strongest predictors of burnout is how much time a doctor spends tied up doing computer documentation.

Both patients and doctors are unhappy with this system, but at this time it is not clear what can be done. The lesson is that patients and doctors should all be understanding of one another. Your doctor is not the problem; the system is the problem.

G. Richard Dundas, MD

Bennington, Jan. 6


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