Paperwork and Physicians: Medical Documentation in the Information Age

BY MIMI CHUNG

As in many professions, the constant presence of paperwork is an annoyance, but in the medical field, it serves an important and obvious purpose – namely, to protect patients from malpractice and record medical history. Nurses and physicians must keep accurate note of clinical documentation, such as tests, patients’ conditions, and other essential information. Such a straightforward process, however, has paradoxically grown more complicated and bloated in an attempt to make medical records more streamlined.

Medical documentation has been a frustration for physicians for years. A 2002 survey by Powerhouse Cooper, a consulting and research organization, found that documentation made up a significant portion of a physician’s time in clinic, often cutting deeply into patient care time. The most striking results came from some of the most important specialties: the emergency care department reported an hour’s worth of paperwork for every hour spent with a patient. In other words, half of the work time was spent not on caring for the injured or sick, but instead was lost finishing reams of paperwork. Surgery and inpatient acute care fared slightly better, with thirty-six minutes of documentation for every hour of patient care, while skilled nursing care only had thirty minutes.

In other words, half of the work time was spent not on caring for the injured or sick, but instead was lost finishing reams of paperwork.

Over a decade after these problems were identified, after years of technological innovation, and after a large number of new regulations, physicians still find that paperwork impedes their actual job. The most significant current challenge is the introduction and adoption of electronic medical records (EMR) and electronic health records (EHR), a move meant to simplify the process and increase transparency. This move has many potential benefits, yet the actual implementation of the program has been hindered by a slow acceptance in the medical field and a host of legal, ethical, and financial questions.

EMR and EHR can potentially solve extremely salient issues that still plague the healthcare system. Documents can be edited simultaneously by multiple people, providing instant updates on a patient’s health without having to fax or email information. Copying relevant information and disseminating it becomes a trivial concern. Timestamps and alerts can increase accountability for physicians, since the EMR and EHR would provide legal evidence of misconduct or neglect.

However, the implementation of these records have provided an ethical and legal minefield, since technology advances much faster than the court can resolve problems. A key question is liability issues involved with EMR and EHR alert systems. EMR and EHR include alerts for doctors, which are popups warning them of potential health consequences based on certain medications or surgery arrangements. Alerts can range from allergic reaction information to NPO assignments. This alert system provides a check for busy doctors, but worries about alert fatigue have brought this potential benefit into question. Because a large number of the risks pinpointed by the system are fairly negligible, physicians can miss some of the more important alerts, which could provoke substantial problems for physicians.

However, the implementation of these records have provided an ethical and legal minefield, since technology advances much faster than the court can resolve problems.

Further, the sheer volume of information, both provided to and provided by physicians and nurses, has drawn criticism, especially from those working against the clock to find specific information. The ease of copy-paste both benefits physicians while hindering the ease of finding pertinent diagnoses. “Information overload,” a common phrase in today’s oversaturated Digital Age, hides information under all the other data within an electronic file – and if the nurse or doctor can’t find what they are looking for, they face consequences since the information was, technically, right there.

Although 33% of doctors who have implemented EMR said that the system has improved quality of care, according to a survey by the Physicians Foundation in 2012, physicians have voiced frustrations with the system as well. One pointed out that EMR “simply do not work for certain specialties,” such as dermatology, and requested that mandatory adoption be postponed.

Another doctor claimed that the “benefits of an EMR are overstated” since it “do[es] not seem to have been designed with any significant physician input,” resulting in “poor” outcomes. More harshly, some physicians have said the system is “a scam” because increasing the amount of required note taking has led to a decrease in time spent with patients. 34% of those who have not yet implemented EMR have stated that the cost of introducing the system has been the most prevalent concern.

Perhaps the most concerning is the question of privacy. Digitizing medical records increases the risk of privacy breaches, as cases of healthcare hacking has increased exponentially – about one in three Americans have had their records compromised, with criminal attacks on healthcare records increasing 125% since 2010. Medical identity theft is much more serious than financial identity theft: with someone’s complete medical record, hackers can fabricate an entire person, including ordering prescriptions and filing false tax returns. Hospitals and private physicians struggle to provide adequate security for this data due to high costs and lack of innovation.

About one in three Americans have had their records compromised, with criminal attacks on healthcare records increasing 125% since 2010. 

Though EMR and EHR have brought a significant benefit to certain specialities, much more research and development must be done to provide the American people with the best care – and allow doctors to focus on their patients, not their paperwork.

 

 

Sources

Patients or Paperwork? The Regulatory Burden Facing American Hospitals. Chicago: American Hospital Association. 2008. PDF file. http://www.aha.org/content/00-10/FinalPaperworkReport.pdf.

AHIMA. “Integrity of the Healthcare Record: Best Practices for EHR Documentation.” Journal of AHIMA 84, no.8 (August 2013): 58-62. http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050286.hcsp?dDocName=bok1_050286

Rouse, Margarent. “Clinical Documentation (healthcare).” SearchHealthIT. http://searchhealthit.techtarget.com/definition/clinical-documentation-healthcare.

Sittig, Dean F., and Hardeep Singh. “Legal, Ethical, and Financial Dilemmas in Electronic Health Record Adoption and Use.” Pediatrics 127, no. 4 (2011): e1042–e1047. PMC. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065078/

Gechlik, Gary. “Electronic Medical Records: Current and Future Challenges.” ABA Health 6, no. 3 (November 2009): n.p. http://www.americanbar.org/newsletter/publications/aba_health_esource_home/Gechlik.html

A Survey of America’s Physicians: Practice Patterns and Perspectives. Physicians Foundation. 2012. PDF file. http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf

Costello, Tom. “Hacking of Health Care Records Skyrockets.” NBC, 13 Feb. 2016. http://www.nbcnews.com/news/us-news/hacking-health-care-records-skyrockets-n517686.

Weisbaum, Herb. “Health Industry Can’t Protect Your Records from Hackers: Report.” NBC, 7 May 2015.  http://www.nbcnews.com/tech/security/health-industry-cant-protect-your-records-hackers-report-n355401

Documentation in Health Care (Practice Portal). Rockville: American Speech-Language-Hearing Association. 2016. http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935365&section=Key_Issues#Legal_and_Ethical_Issues

Frellick, Marcia. “Note Bloat Disrupts Utility of Electronic Health Records.” Medscape, 16 March 2016. http://www.medscape.com/viewarticle/860459

Weir, Charlene R., and Jonathan R. Nebeker. “Critical Issues in an Electronic Documentation System.” AMIA Annual Symposium Proceedings 2007 (2007): 786–790.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2655797/

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