The road to hell is paved with good intentions
According to a 2016 study on physician activities in the clinic setting, "ambulatory care in the United States has been subject to dramatic pressures in the past decade to cut costs, meet regulations, and transition to electronic health records (EHRs)." EHRs have been heralded as both time savers and space savers, eliminating the need for bulky paper records and enabling physicians and their staff to more effectively identify and follow a patient's treatment.

But there are two sides to every story and offsets to these benefits became evident almost as soon as EHRs were introduced. Among the unintended consequences associated with EHRs, researchers have noted the following:

• increased time required to document care
• impaired communications with patients
• physician career dissatisfaction and burnout

Moreover, these unintended consequences are related. As the authors note, "Time spent in meaningful interactions with patients and the ability to provide high quality care are powerful drivers of physician career satisfaction." Computer charting and other administrative tasks, on the other hand, correlate with physician burnout and attrition. Other recent studies have highlighted the "gap between expectations and outcomes" with EHRs.

Time-savers or time-takers?
The study, "Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties," appeared in the Dec. 6, 2016, issue of Annals of Internal Medicine. To better understand how physicians' time is allocated in the clinic setting, researchers tracked 57 U.S. doctors, including 15 orthopaedic surgeons from four different practices in Illinois, New Hampshire, Virginia, and Washington. Most practices had an EHR system and almost half (46 percent) used documentation support (dictation and scribe services). The "Work Observation Method by Activity Timing (WOMBAT)" technique was used to divide physician duties during the workday into one of 12 mutually exclusive task categories.

The study reported that physicians spent 27 percent of their office day on direct face time with patients. But they spent almost half (49.2 percent) of that office day on EHRs and other desk work. Even when physicians were in the examination room with patients, only about half (52.9 percent) of the time was spent talking with patients, while another 37 percent was spent on EHRs and other desk work.

After the office day ended, the study reported that these physicians spent up to 2 hours of their personal time every night "catching up" on additional clerical work. Physicians who were on call for the practice spent an additional 2.2 hours of time (ostensibly not including any operating room or emergency department time), during which they used EHRs 69 percent of the time.

Taxonomy of administrative work
In January, the Board of Regents of the American College of Physicians (ACP) approved a position paper drafted by its Medical Practice and Quality Committee. This paper, an extension of their 2015 "Patients Before Paperwork" initiative, appeared in the March 28, 2017, Annals of Internal Medicine.

The report begins by trying to classify administrative tasks. A number of previous physician workflow studies, for example, did not consider charting times, although EHR technologies have added considerably to the time spent in these activities. The ACP also notes that these tasks may differ from payer to payer and "appear one month without notice, then reappear modified or changed the next; and often result from not using documentation that already exists in the medical record."

To create a systematic approach to reducing these burdens, the authors created a framework or taxonomy based on the following questions:

1. Where did the task come from?
2. What is the task's intent?
3. What is the task's effect?
4. How can this task be approached in a more focused and cohesive way?

Although some administrative tasks are generated by the physician or practice itself, most are externally imposed by public and private payers; governments and policymakers; private certification, accreditation, and recognition organizations; vendors and suppliers; healthcare consumers; and other clinician practices and healthcare provider organizations.

For example, the ACP notes the burdens resulting from evaluation and management (E&M) guidelines. These guidelines are regulated and maintained by the Centers for Medicare & Medicaid Services (CMS), in conjunction with other federal agencies, and are used by all public and private payers. Clinicians must follow these guidelines to receive reimbursement; noncompliance may result in billing fraud, potential fines, restriction from participation in Medicare and Medicaid, and even criminal penalties.

Since their introduction, however, these rules have been implemented in ways that are difficult to understand and use. Determining the "level of service" to code and bill for is complex and time-consuming. My own large, hospital-based practice has a team of coding specialists to correlate documentation and billing records. The time cost is massive.

The ACP points out a frustration likely to be common among orthopaedic surgeons, the "tedious and confusing" paperwork associated with durable medical equipment (DME) prescriptions. They note that aggressive direct-to-consumer marketing has not helped. For me, adding a signature to every page takes much longer on an EHR. Can we legally designate this task to someone else? Apparently, it all depends and is not always clear.

The ACP reports that, just as the sources of administrative tasks vary, so do their intentions. They classify these intentions into five main categories, based on the following questions:

• Is the intent to provide and pay for products and service?
• Does it ensure high-quality, high-value, safe, and effective provision of products and services?
• Does it reduce excess and inappropriate costs and prevents or identifies fraud and abuse in the healthcare system?
• Does it ensure financial security and potential profitability for the stakeholder?
• Does it lack a clear intent?

Certainly, it is reasonable to want to avoid fraud and ensure that the money spent delivers value. The question is: How well do the systems created achieve the intended results? The ACP argues that "the complexity of the U.S. health care payment system leads to significant waste, overuse or inappropriate use of services, and intentional or unintentional fraud or abuse."

Findings and impact
The ACP report contained findings consistent with an analysis of the 2008 Health Tracking Physician Survey published in 2014. At that time, physicians and their staff spent 3 to 5 hours per week on billing and insurance-related (BIR) activities, with some estimates as high as 8.7 hours per week. The related cost effects of BIR time were found to be approximately 12 percent to 14 percent of revenue, or about $68,000 to $85,000 per year per full-time equivalent physician.

Quality measurement and reporting activities required up to 15.1 hours per physician per week, of which 2.6 hours were direct physician time. Often underreported are the impacts of software glitches, system upgrades, and other "down time" on physician productivity. The ACP reports that changes in the healthcare landscape since 2008 have increased the burden of quality measurement and reporting.

According to study author Stephanie Woolhandler, MD, MPH: "American doctors are drowning in paperwork. Our study almost certainly understates physicians' current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant. And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work."

In an interview with Kaiser Health News, Christine A. Sinsky, MD, vice president of professional satisfaction at the American Medical Association, noted that increasing documentation burdens could be linked to rising physician burnout rates. Athenahealth President and CEO Jonathan Bush corroborated this sentiment, writing that "The more our country spends on traditional EHR software, the more time providers must spend on them, the more dissatisfied they become, the more frustrated patients feel, and the more expensive health care gets. This is a shared problem with more than enough culpability to go around.

"Vendors like my company," he added, "have been required to develop EHRs that satisfy government regulations rather than the needs of providers and patients."

Eeric Truumees, MD, is editor-in-chief of AAOS Now.

References:

1. Woolhandler S, Himmelstein DU. Int J Health Serv 2014;44(4):635-642 Administrative work consumes one-sixth of U.S. physicians' working hours and lowers their career satisfaction.
2. Sinsky C, Colligan L, Li L, et al: Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Ann Intern Med 2016;165(11):753-760.