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
Explore this issueOctober 2018
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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.