Physician trainees get this. Fewer now choose specialties that used to attract some of the best and brightest graduates. Those who do pursue these medical specialties either choose practices that pay a fixed salary, or they make mid-career changes to better meet their financial needs. Other medical specialists who also perform procedures, such as cardiologists, neurologists and gastroenterologists, often choose to emphasize their procedural services rather than care for complex, long-term patients. These workforce distortions then translate into access problems that affect patients with complex chronic diseases disproportionately.
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Explore This IssueOctober 2018
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Electronic medical records (EMRs) did not cause this shift from value to volume record keeping, but they have enabled it. Physicians initially wrestled with volume requirements using paper records, either handwritten or dictated. EMRs were first sold to medical practices to save storage space and facilitate more rapid electronic communication of essential information among providers and payers. And through no accident, it was also linked to electronic scheduling and billing software to simplify documentation. Then it evolved further, from documentation that mirrored the logic and formatting of previous records to auto-filled standard templates and checklists.
This is when the train flew off the tracks. Such boilerplate records may have saved time and transcription costs, but they also enabled including more information, relevant or not, while obscuring critical thinking and clarity. And the healthcare businesses can’t play the volume game without them.
More recently, more and more physicians copy and paste text from their own and others’ prior records into current visit notes. Any other physician reviewing this work product knows the amount of information copied and pasted could not possibly have been reviewed or collected during the current encounter, as is represented, and that its purpose is volume. This practice is a red flag for billing fraud, and payers are increasingly disallowing it. Predictably, however, physicians will devise other work-arounds to maximize volume as long as this is what they get paid to do. The promise of EMRs improving communication across providers at the system level also remains unrealized because of sheer volume, let alone impossibly low signal-to-noise ratio.
The professional and personal impacts of volume-based documentation on physicians are profound. The shift to volume-based record keeping in EMRs not only adds 1.5 hours of work per day for today’s physicians, it has fundamentally changed how they spend this time. Only 30% is spent providing care, while 45% is spent documenting it, and 25% is spent on other administrative activities, such as coding reviews and specialty recertification requirements.8