In reflecting on a recent hospital stay, Alan Spiro observes “For those of you worried about depersonalization of medical and nursing care I want to reassure you. The commitment to caring for the computer is front and center.” He goes on to say “The nurse and the doctor are diligent in paying attention to the computer, frequently touching the computer to show concern, and feeding it frequently.”
While Dr. Spiro employs gentle irony and humor to make his point, the problem is serious and vast. My colleague Alan Schwartz and I have spent over a decade listening to doctors talk to patients during the medical encounter. In one study we employed actors as unannounced standardized patients (USPs) to conduct 400 visits to physicians who thought, at the time of the encounter, that they were seeing a real patient. In another, over 600 real patients carried concealed recorders into their visits for our analysis. More recently we’ve invited Veterans to carry concealed audio recorders into their appointments, so that we can collect data on missed opportunities to provide optimal care, and then feed that information back to participating doctors. Our team has listened to over a thousand of those. Often it’s painful to hear how the demands of the computer consume a visit.
Nearly everyone — including clerks, nurses and pharmacists (and we collect audio recordings of all of them) — is meeting a data entry expectation. For physicians in the outpatient setting it’s typically E&M coding. How distracted and preoccupied are providers? One of the things we do when we send in USPs is we instruct them to drop little bombs during the visit that should get any conscious clinician’s attention. For instance, a patient with diabetes who comes in with repeated episodes of near fainting, says “you know doctor, sometimes I take 12 of the long acting insulin and 24 of the short acting one and sometimes I think I do it the other way around. It all probably evens out.” In the best case scenario, the physician looks up from the keyboard and says something like “That sounds like a problem. Can you tell me more about the challenges you are having taking your medications as directed?” Such a response is rare. More often, the physician’s focus is on what to put in the EHR when their patient can’t feed them the data they need. We’ll hear: “So, it’s probably 24 of the long acting and 12 of the short acting. Right? That’s the usual way it’s prescribed. That’s what I’ll put here…” The significance of the patient’s confusion as a problem that needs to be addressed directly gets lost.
Remarkably, quite a few physicians do an impressive job of multi-tasking. They attempt to simultaneously follow the patient’s lead, while interjecting questions to meet the documentation requirements for billing purposes. So, while trying to follow up on a comment by a patient that “boy, it’s been tough since I lost my job” they are running through a mindless checklist about possible headaches, constipation, itchiness etc… But even these doctors often make a Faustian bargain: while they take a rational approach to conducting a physical exam, they chart things they didn’t do. Most typically, they record a normal “review of systems” and head-to-toe physical exam without completing either. Interestingly, this phenomenon, which has been called “the ethical problem of false positives” (others just call it fraud), pre-dates widespread use of the EHR. What that 2002 USP study on false positives does not pre-date is Evaluation and Management Coding, established by Congress in 1995 as a pre-requisite to bill for reimbursement.
The admonition that “if you didn’t document it, you didn’t do it” profoundly changed healthcare over a 20 year period. Doctors and nurses, and other providers, are judged based on the thoroughness of their record keeping. So much is riding on it: First, there’s billing. If you didn’t document enough, you can’t bill at a particular expected level. Second, if you didn’t document it, you could get sued and lose in court. And third, documentation is regarded as a measure of quality during peer review. Health care providers are frequently nagged about documentation issues. It can define their worth.
It’s human nature that if you are judged on something (and your paycheck is riding on it) you are going to make that your focus. So the focus of health care is making the medical record look terrific or, at least, complete. It doesn’t look terrific a lot of the time because of all the copying and pasting, and a lot of what’s in it turns out to be fabricated….but it certainly looks like everyone’s keeping busy.
What if we assessed care delivery based on actually observing it now and then? Our work, and that of others who employ unannounced SPs, suggests it is readily feasible and is eye opening. It provides a window into the challenges providers face, the trade-offs they make, and consequences both for care delivery and documentation of care delivery. In fact, if we started observing care directly (think mystery shopper program, but with rigorous standardization) we could liberate health care professionals to just do the right thing (aware that some of their patients are collecting data on their performance), document what’s clinically important, and direct their attention to the patient before them.