Runaway Burden Physician Paperwork

What’s Ruining Medicine for Physicians: Paperwork and Administrative Burden

Allow me to share some thoughts on this year’s results of the Medical Economics annual physician survey of top challenges they face. Physicians we asked in a poll the following: “What’s ruining medicine for physicians?” This year’s physician top challenge not surprisingly is paperwork and administrative burden. We all have heard and seen published journal articles highlighting the magnitude of physician administrative burden, spending 2 hours or more on administrative paperwork, entering information into and feeding the insatiable appetite of the electronic health record. Health and Human Service’s has recently took note of this growing administrative burden and drafted a strategy that aims to engaged stakeholder discussions on  this administrative burden associated with electronic health record use, titled Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs. (Draft Strategy to Reduce Administrative Burden EHRs). Numerous recommendations to explore abound in the draft strategy which I will touch base upon later in this post.

Getting back to the Medical Economics’ survey Medical Economics Survey), a quote in the article really resonated with me, hopefully it resonates with other CDI professionals as well

·      Kyle Varner, MD, an internist at the Tripler Army Medical Center in Hawaii and author of White Coat Cartels, laments that he spends more time in front of a computer documenting his time with patients than he actually spends with patients. “This is not because I am trying to create a good record of the care—it is because I have to play semantic games so that the hospital gets paid,” he says. 

Unfortunately, this sentiment towards documentation in the health record is deep seated in many hospital institutions as physicians continue to provide the best quality care while facing continually increasing administrative burden associated with the practice of medicine, drowning in a sea of paperwork. How best to address this sentiment and turn the tide on physician’s view of clinical documentation as an afterthought in the practice of medicine? Providing effective, complete, concise and accurate documentation that best serves the role in communicating patient care, describing and telling a complete patient story to the extent other providers can review the medical record and easily and confidently assume patient care where the last treating physician let off. This degree and preciseness of documentation does not require more time and effort on the part of physicians or even more documentation; instead complete and accurate documentation requires just better documentation that reflects the physician’s reporting of the patient care provided and why, the physician’s clinical judgment, medical decision making and thought processes, and where is the physician going in regards to workup and treatment of the patient. Accurate depiction of the care provided requires a reasonable assessment of a patient’s clinical scenario and the initiation of action congruent with the assessment. Inclusion of all clinically relevant diagnoses with appropriate clinical specificity for ICD-10 reporting is a fundamental component that summarizes and best represents the care provided and outcomes achieved.

Today’s CDI Processes- “A Better Approach”

Why does the sentiment of documentation represented in the physician’s thoughts above reflect the notion that CDI programs are basically a hospital initiative benefiting the hospital only, almost thought of as a game for hospitals to play to capture more revenue, resonate with a wide variety of physician types and specialties? Quite simple- the CDI industry, whether you refer to it as clinical documentation improvement or clinical documentation integrity, has not been terribly effective at making a compelling argument and case for enhancing the value and quality of documentation to physicians. Oh yes, physicians are educated about severity of illness reporting, value-based reimbursement methodologies, physician profiling, expected versus observed mortality and clinical acuity represented and captured through documentation of clinical diagnoses with appropriate clinical specificity to capture CCs and MCCs as well as optimal principal diagnoses. We have educated physicians on HCCs, PSIs and HACs, sentinel events and core measures and sepsis criteria. We have taught physicians to consider the diagnoses of sepsis and encephalopathy in the face of patient presenting and exhibiting “change in mental status” in a quest to “optimize the documentation.”  I fully support these elements of CDI and certainly do not downplay their significant importance and role in a concerted effort to achieve documentation integrity and optimal reimbursement for care provided.  On the hand, the CDI profession is overlooking and neglecting a major opportunity to address physician’s valid concern with increasing paperwork and overwhelming administrative burden associated with the practice of medicine. I am convinced that the repetitive transactional retroactive query process as the hallmark of clinical documentation integrity programs is contributing to this administrative burden, especially within CDI programs that utilize the remote CDIS model. The current CDI standard of achieving a 30% query rate for records reviewed, an arbitrary number not rooted in validity yet promoted as the standard by CDI consultants, inarguably adds to physician burnout and administrative burden.

A better more effective approach to CDI to address the administrative burden of the electronic health record is developing and tailoring each hospital’s CDI initiative to meet the individual documentation challenges of the physicians on staff. There appears to be notion that more documentation is better with physician practices of including everything from the kitchen sink within the record. Blow in of previous labs and radiology results from initial hospitalization day, copy and paste and carry forward of notes from previous days, inclusion of all diagnoses whether clinically relevant or not in the assessment every day, inclusion of the same History of Present Illness for every progress note when all that is required is an interval history, completion of a comprehensive exam on a patient who is admitted when the nature of the presenting problem and the physician’s clinical judgment do not necessarily warrant the extent of the exam, are just a few examples where the administrative burden of documentation can be alleviated with physician’s understanding and appreciating the key elements of documentation that must be included for solid communication of patient care. Rather than focusing upon diagnosis reporting only, we must expand our breadth and depth of knowledge in what constitutes the basic standard of clinical documentation, bulk up our ability to review the record, identify documentation insufficiencies AKA poor documentation and work closely with physicians to alleviate the practice of more documentation by promoting, advocating for and achieving robust, concise, consistent and contextually correct physician documentation. A definite principle that can be traced to my high school and college years was that the most enjoyable rewarding classes from a learning and knowledge perspective were in fact those where professors tailored the instruction and training to meet the individuals enrolled in the class. The same principles can be incorporated into the mechanics and operational processes of every CDI program. Transforming a CDI program from a off the shelf me too initiative to one that achieves positive outcomes and truly engages physicians as willing participants requires a balanced physician tailored approach that doesn’t forget the individual physician’s individual documentation challenges and the relevance of effective communication of patient care to the welfare of the patient.

Closing Consideration

I submit to the CDI profession the need to take a real close look at mitigating the physician’s administrative burden of documentation and become a key part of the solution by working with physicians to understand and provide meaningful knowledge sharing on standards of documentation that sufficiently communicate the care provided while driving down noise and clutter in the record. The profession can capitalize upon the opportunity to partner with stakeholders as well as our facility medical staff to encourage adoption of best practices related to documentation requirements. Unless the professions alters underlying processes and techniques of CDI represented by the query process, we are contributing to continued physician administrative burden through the repetitive query process. The query process has done little if anything to improve documentation quality and completeness. All one must do is pick up most records and see for yourself.  The well respected adage of “We have always done it this way” should be an immediate call to action, resting on our laurels is not a viable option for the CDI profession.