10 ms·

When the Doctor Must Choose Between Her Patients and Her Notes

65 points by xenophonf 11y ago

fixermark 11y ago
I can't help but think there could be two solutions to this problem. 1) A speech-to-text transcripting intelligent system that could automatically make some guesses at the notes the doctor would want to write. Could save them quite a bit of time if it can be tuned for utility 2) (the cheaper short-term solution) An assistant who can focus on taking notes while the doctor focuses on the patient. Unfortunately, (1) is a technologically challenging AI problem and I bet the current medical rules and patient's expectations of being able to 1:1 with their doctor without a third-party listening in probably scuttle (2).
- ploxiln 11y ago
  Speech recognition could help. In fact some doctors already make (very quick) voice-recording notes and have an assistant transcribe them. But... we already have much more advanced technology than we had 30, 20, or even 15 years ago. And the problem has only gotten worse. > “Our notes could be shorter back then,” was his reply. (Insurance, regulations and electronic health records weren’t issues back then.) This quote in passing just assumes everyone is familiar with the fact that "electronic health records" are something that makes things harder. That doesn't make sense, does it? Shouldn't electronic records make things easier? They should. But they don't, due to adverse incentives in the medical system, and in the political organizations which constitute it. My point is, the pressing need is not for more advanced technology. We have the technology, we have had it for years. We just need to somehow reduce the crazyness. Medical software is like enterprise software but worse - it's the crappiest, most expensive software you've ever seen in your life. There are all sorts of reasons for this. It's not chosen by the people who use it, checkbox feature lists are more important than what works, regulations, political deals, "high touch" sales, etc. The result is often "I have to sign in three times, then wait 5 minutes for it to load the patient, and hope it doesn't crash in the middle". It has to be seen to be believed.
- adrianN 11y ago
  There is also option 3: Reduce the amount of paperwork doctors need to do.
- RHSeeger 11y ago
  3) Push back and let supervisors/managers know that treating a patient takes X + Y time, where X is the time with the patient, and Y is the time for admin/non-billable duties for that patient. Admittedly, doing so isn't as easy as it sounds, but this isn't all that much different than developers being told to push back on schedules that don't leave time for (testing, documentation, technical debt payoff, etc)
- djb_hackernews 11y ago
  My SO is a family medicine MD and works at an inner city clinic. When we first started dating she'd mention the need to spend time during the evenings to write notes. As someone that a) wanted more of her time b) wrote software for a living, it surprised me that such a system doesn't already exist. It seems like it could aid in catching errors and also being a helpful assistant of sorts to ensure good notes are being captured and all possibilities are being addressed. From what I've seen, even with newer EHR systems (Epic, Athena), medical technology is about 15 years behind current technology.
  - Spooky23 11y ago
    It's worse than 15 years behind -- it is a step backwards. In ye olden days, they recorded notes on a $50 voice recorder, and had a transcriptionist transcribe notes into a written form that went into records. Now, to make data more standardized, it's a wall of clicks and checkboxes, which require domain expertise. So doctors canned the transcriptionists, replaced them with enterprise IT and hire PAs and NPs to try to bridge the gap. I shake my head every time I go to my doctor. He's a brilliant guy and really good physician, but easily 50% of his time is dedicated to click-monkey bullshit.
danieltillett 11y ago
Whenever I look at the USA medical system I wonder how much longer it can go on for. Ever rising costs combined with an ageing population and a political system that finds it hard to make decisions must end at some point, but when? What percentage of GDP does the healthcare budget have to reach before it breaks?
- dawnbreez 11y ago
  In order to change something, you usually have to break it first.
- creshal 11y ago
  I'm honestly surprised just how much red tape there must be in the US health care system. Even fully socialized systems managed by the civil service get away with less bureaucracy over here in Europe, which is just insane (and the complete opposite of virtually everything else). And the US system is not even significantly more effective for it (if at all), despite being 50-100% more expensive per patient. How did it end up becoming this broken in the first place?
  - 2skep 11y ago
    I think this is a good example where the usual association government run = bureaucratic ; privately run = straightforward breaks down because bureaucracy/non bureaucracy is not a function of the economic model but that of the inherent simplicity of the model. One of the reasons why many soicialised systems of healthcare are 'simpler' is because they have universal coverage which means that the whole process of checking who is eligible to see a doctor, does their plan cover this doctor, did they pay their premium, which treatments they are eligible for, how much of their spending limit they have exhausted do not exist because everyone is eligible and everyone is eligible for everything. It is like going to an all you can eat buffet and wondering why is no one writing down what I am eating :-). I could add more examples to it e.g. If all surgeons are paid a fixed salary there need not exist an infrastructure to count how many stitches they applied this quarter and so on..
    - 11y ago
deleted 11y ago
[deleted]
iambateman 11y ago
My wife is a therapist. Her supervisors expect 80% efficiency (billable time) and her treatment to paperwork load is close to 1:1. So literally her only option is to document while also treating. she comes home and tells me that a patient asked for water and that creates a dilemma for her: go get water and lose productivity while treating your patient like a human OR reject their request and keep productivity high and avoid being scolded. The problem is, obviously, good care is therapy AND getting water for your patient. They're humans not numbers. We're forcing medical professionals to only work within the scope of "billable" activities and that ultimately hurts the patient.
- mikeash 11y ago
  Seems like a big part of the problem is that paperwork is part of the process of treating patients, but apparently isn't billed. If it's a necessary part of treatment then it ought to be billed just like the rest, then there's no more conflict.
  - brudgers 11y ago
    Healthcare (in the US) is a mess. Changing billing requirements means changing Medicare, Medicade and the VA...plus all private insurance which saves money when denying reimbursement. Standardization has benefits in the existing system.
    - mikeash 11y ago
      No doubt. Unfortunately this is one of those cases where identifying the root of the problem doesn't necessarily help you solve it.
      - brudgers 11y ago
        For longer than our twenty years of marriage, my beloved has been in healthcare...I of course have not. My gut tells me that standardization of what is and isn't billable solves a bigger problem than described in the above comment. My whole being tells me that changing the definition of billable time won't fix crappy workplaces run by bean counters. And if I had to guess, classifying documentation as treatment is unlikely to improve patient care and outcomes.
Aleman360 11y ago
Girlfriend is an oncology PA. Writing notes are the absolute most dreaded part of her job. She has to spend about 8 hours every weekend catching up on them. The switch to electronic records vastly increased the amount of time to complete notes. Scribes are a good solution. Her brother-in-law is an ED physician and doesn't really have to worry about notes because he has good scribes.
- alistairSH 11y ago
  The switch to electronic records vastly increased the amount of time to complete notes. Is there something inherent in medical notes that typing them should take longer than hand writing them? Or, is the software just awful? (I assume the second, which makes me wonder why nobody is disrupting this area)
  - Aleman360 11y ago
    Both. It's extraordinarily complex. The data entry is highly structured. All the electronic record software I've seen has probably ~100 pages worth of forms, a big subset of which usually need to be filled out for each patient visit. It's not being "disrupted" because it's extremely capital intensive to enter this market. The requirements seem intractable: - Structured data with very high level of granularity. - Patients often don't fit the mold exactly. It's hard to classify something that is going on with a patient; there are 68,000 ICD-10 codes. - Data needs to be interoperable with existing and competing systems. - Every hospital has their processes and documentation practices. As a result, most electronic record software is highly customizable, and a company representative is usually on call or on site to continuously customize it. - Software needs extreme backwards compatibility. You need to be able to read records that are tens of years old. - Need to be able to print everything. - Need to meet regulatory requirements and security audits. Regulatory requirements vary by state and country. - Healthcare institutions are inherently conservative with their technology, and for likely good reason. Plus they don't upgrade equipment very often. If they just spent $1 billion upgrading their entire IT infrastructure, they're not going to consider your startup's solutions for awhile. - Patients don't like it when their provider is focused on a computer or taking notes instead of on them. - Different UI for each provider (e.g., primary care physician vs. pharmacist vs. radiologist) - Need to communicate with a wide variety of medical hardware that doesn't have good standard protocols, and much of which is very old. And on and on...
nradov 11y ago
The requirement for high levels of documentation is largely an attempt by payers (insurers) to prevent fraud, waste, and abuse. In the US most healthcare providers are still paid on a fee for service basis so the more patients they treat in a day the more money they make. There have been many incidents of providers submitting claims for patients who didn't need treatment, or with the wrong billing codes. (Obviously the vast majority of doctors don't do anything unethical or illegal, but still fraud is fairly common.) So payers want to see the notes in order to verify that treatment actually occurred, was medically necessary, and consistent with the terms of the patient's insurance policy. The new Accountable Care Organization (ACO) model has the potential to reduce the documentation requirement. Under that model the insurer shifts the risk to a provider organization which is receives a flat fee per year to care for the patient. So the providers no longer need to submit detailed insurance claims. The secondary reason for requiring detailed clinical documentation is coordinating between all members of a patient's care team. Obviously your primary care physician would like to know what your psychiatrist did and why.
- Aleman360 11y ago
  There is still a requirement for highly structured data entry that is unavoidable. Even if you reduced the other documentation requirements, the "computerized physician order entry" systems (healthcare lingo) still require quite a lot of provider time. You need to be very explicit when entering things like chemotherapy regimens.
  - nradov 11y ago
    Right that's also a factor. Some medical practices have hired scribes to shadow physicians during patient encounters and do the data entry in real time. This is expensive but can end up being cost effective if it allows a highly-paid physician to see more patients per day.
betenoire 11y ago
The article doesn't mention transcribers. I remember in the 80s and 90s, a few of my relatives typed up medical transcriptions as a part-time from home job. Has this fallen out of style? Or is this a result of some legislation perhaps?
gherkin0 11y ago
When I saw a dermatologist about a year ago, and he had an assistant in the room whose job seemed to be to update the notes while he was interacting with me. I can see that helping with a lot of specialties, but maybe not psychiatry.
jernfrost 11y ago
I see people here explain all this documentation requirements as a function of it paying private health care. While some of that is true, it is far from the whole explanation. I am a Norwegian we have what you guys call socialised health care. I've been treated in the US and Norway so I can compare. In the US there is a lot more paperwork related to disclaimers, suing, billing, insurance companies etc which we don't have to deal with. However when it it comes to the medical side of things, doctors here also sit and type at their computer while seeing their patient. They are also stressed out trying to make it all add up. Just because there isn't a profit motive doesn't mean there isn't a push to be more efficient from above. There is lots of political pressure from above to save money on health care. The core problem here isn't profit or not. I think the problem in common both in the US and Norway is the measurement and feedback based management. New Public Management or whatever you call it. Both in public sector and private those at the top want to be able to control and improve what is going on below and so they insist on massive amounts of feedback, so they can measure everything about how things are run. Of course they never consider the massiv cost of all this documentation. It is the same in schools here in Norway. Teachers have ended up spending a shitload of time documenting and measuring over the last decades. The paperwork load keeps adding up even though every successive government says they are all about cutting paperwork. IMO opinion the solution to this isn't to go public or private but to change our ideas about how things are managed and run.
- lmm 11y ago
  This has to be answered empirically. No doubt there is value in giving doctors or teachers the freedom to do what they think best - especially the best ones. But there is also a lot of value in standardization, accountability, and ensuring we know what went on. A patient may think they care more about how kind the doctor was, but if better notes make the difference in spotting a rare condition or simply catching a mistake - or, more subtly, enable data analytics that let us spot new correlations and develop improved treatments - then (with a limited amount of doctor's time available) that's a lot more important. What has the overall effect of these paperwork changes been on healthcare outcomes?
  - ThomPete 11y ago
hardwaresofton 11y ago
Uh... Isn't the fix to just stop taking more patients than you can handle comfortably and enjoyably? Maybe that, paired with encouraging more of the younger generation to become doctors (to cover for the patients you feel like you might be abandoning?)? Doctors are extremely valuable workers/members of society, I'm surprised that they don't feel more in-control of the situation (if you want shorter notes, push for it?)... Also, this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either... If my doctor takes notes while I speak to him/her (and it was made clear at least once that I have their attention), that impresses on me that they're doing their job, which is far more important to me than the feeling of being treated like a human for an hour. Also, why not just take micro breaks during billable time to do notes? bill for the 45 minutes, notes for 15 mins, take notes right in front of the person, and let them know what is happening? Maybe this just seems easy to fix to me because I'm an outsider
- lloyd-christmas 11y ago
  > Isn't the fix to just stop taking more patients than you can handle comfortably and enjoyably? And then the hospital starts making less money (losing money), research funding dries up, and we start using mercury to treat syphilis again. I'm only half-kidding. I say hospital because all the laws that have changed in healthcare have driven most doctors out of private practice into hospital positions. since 2004, hospital-employed doctors have gone from 11% to over 60%[1]. One major reason being that with the wave of medical reform, the overhead of running a practice has skyrocketed. "Comfortable and enjoyable" are rarely applicable when you only start paying off your $1m schooling debt at 30. > I'm surprised that they don't feel more in-control of the situation I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes. > this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either... I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer. >Also, why not just take micro breaks during billable time to do notes? My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill. [1] http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/P...
Xyik 11y ago
Maybe doctors should hire someone to help with the paperwork? This seems like a case where scaling horizontally works better than scaling vertically. Like how some tech companies make use of QA departments while others do their own QAs, perhaps some doctors having an assistant on hand could make things more efficient.
Skeletor 11y ago
If this Doctor was using drchrono she wouldn't have this problem.
gabriel34 11y ago
Multitasking has the effect of increasing perceived workload whilst decreasing work throughput and increasing the error rate. Through training it is possible to become efficient in doing two tasks seemingly simultaneously, in this case, anamnesis and note-taking. Nevertheless true multitasking is not proven, and switching occurs instead, the trained person simply responds quicker to certain stimuli. Multitasking might also be the source of frustration and contributing factor to the reported depression. Of course the documentation work can be rationalized and tools can be developed to help this, but there is also room for improvement on the work of the doctors, revealed by the lack of standardization reported in the article.
ALee 11y ago
This article just makes me think of supporting more startups like Augmedix and the future of Augmented Reality will truly be a revolution in healthcare.

65 points by xenophonf 11y ago

I can't help but think there could be two solutions to this problem. 1) A speech-to-text transcripting intelligent system that could automatically make some guesses at the notes the doctor would want to write. Could save them quite a bit of time if it can be tuned for utility 2) (the cheaper short-term solution) An assistant who can focus on taking notes while the doctor focuses on the patient. Unfortunately, (1) is a technologically challenging AI problem and I bet the current medical rules and patient's expectations of being able to 1:1 with their doctor without a third-party listening in probably scuttle (2).

ploxiln 11y ago
Speech recognition could help. In fact some doctors already make (very quick) voice-recording notes and have an assistant transcribe them. But... we already have much more advanced technology than we had 30, 20, or even 15 years ago. And the problem has only gotten worse. > “Our notes could be shorter back then,” was his reply. (Insurance, regulations and electronic health records weren’t issues back then.) This quote in passing just assumes everyone is familiar with the fact that "electronic health records" are something that makes things harder. That doesn't make sense, does it? Shouldn't electronic records make things easier? They should. But they don't, due to adverse incentives in the medical system, and in the political organizations which constitute it. My point is, the pressing need is not for more advanced technology. We have the technology, we have had it for years. We just need to somehow reduce the crazyness. Medical software is like enterprise software but worse - it's the crappiest, most expensive software you've ever seen in your life. There are all sorts of reasons for this. It's not chosen by the people who use it, checkbox feature lists are more important than what works, regulations, political deals, "high touch" sales, etc. The result is often "I have to sign in three times, then wait 5 minutes for it to load the patient, and hope it doesn't crash in the middle". It has to be seen to be believed.
adrianN 11y ago
There is also option 3: Reduce the amount of paperwork doctors need to do.
RHSeeger 11y ago
3) Push back and let supervisors/managers know that treating a patient takes X + Y time, where X is the time with the patient, and Y is the time for admin/non-billable duties for that patient. Admittedly, doing so isn't as easy as it sounds, but this isn't all that much different than developers being told to push back on schedules that don't leave time for (testing, documentation, technical debt payoff, etc)
djb_hackernews 11y ago
My SO is a family medicine MD and works at an inner city clinic. When we first started dating she'd mention the need to spend time during the evenings to write notes. As someone that a) wanted more of her time b) wrote software for a living, it surprised me that such a system doesn't already exist. It seems like it could aid in catching errors and also being a helpful assistant of sorts to ensure good notes are being captured and all possibilities are being addressed. From what I've seen, even with newer EHR systems (Epic, Athena), medical technology is about 15 years behind current technology.
- Spooky23 11y ago
  It's worse than 15 years behind -- it is a step backwards. In ye olden days, they recorded notes on a $50 voice recorder, and had a transcriptionist transcribe notes into a written form that went into records. Now, to make data more standardized, it's a wall of clicks and checkboxes, which require domain expertise. So doctors canned the transcriptionists, replaced them with enterprise IT and hire PAs and NPs to try to bridge the gap. I shake my head every time I go to my doctor. He's a brilliant guy and really good physician, but easily 50% of his time is dedicated to click-monkey bullshit.

danieltillett 11y ago

Whenever I look at the USA medical system I wonder how much longer it can go on for. Ever rising costs combined with an ageing population and a political system that finds it hard to make decisions must end at some point, but when? What percentage of GDP does the healthcare budget have to reach before it breaks?

dawnbreez 11y ago
In order to change something, you usually have to break it first.
creshal 11y ago
I'm honestly surprised just how much red tape there must be in the US health care system. Even fully socialized systems managed by the civil service get away with less bureaucracy over here in Europe, which is just insane (and the complete opposite of virtually everything else). And the US system is not even significantly more effective for it (if at all), despite being 50-100% more expensive per patient. How did it end up becoming this broken in the first place?
- 2skep 11y ago
  I think this is a good example where the usual association government run = bureaucratic ; privately run = straightforward breaks down because bureaucracy/non bureaucracy is not a function of the economic model but that of the inherent simplicity of the model. One of the reasons why many soicialised systems of healthcare are 'simpler' is because they have universal coverage which means that the whole process of checking who is eligible to see a doctor, does their plan cover this doctor, did they pay their premium, which treatments they are eligible for, how much of their spending limit they have exhausted do not exist because everyone is eligible and everyone is eligible for everything. It is like going to an all you can eat buffet and wondering why is no one writing down what I am eating :-). I could add more examples to it e.g. If all surgeons are paid a fixed salary there need not exist an infrastructure to count how many stitches they applied this quarter and so on..
  - 11y ago

deleted 11y ago

[deleted]

iambateman 11y ago

My wife is a therapist. Her supervisors expect 80% efficiency (billable time) and her treatment to paperwork load is close to 1:1. So literally her only option is to document while also treating. she comes home and tells me that a patient asked for water and that creates a dilemma for her: go get water and lose productivity while treating your patient like a human OR reject their request and keep productivity high and avoid being scolded. The problem is, obviously, good care is therapy AND getting water for your patient. They're humans not numbers. We're forcing medical professionals to only work within the scope of "billable" activities and that ultimately hurts the patient.

mikeash 11y ago
Seems like a big part of the problem is that paperwork is part of the process of treating patients, but apparently isn't billed. If it's a necessary part of treatment then it ought to be billed just like the rest, then there's no more conflict.
- brudgers 11y ago
  Healthcare (in the US) is a mess. Changing billing requirements means changing Medicare, Medicade and the VA...plus all private insurance which saves money when denying reimbursement. Standardization has benefits in the existing system.
  - mikeash 11y ago
    No doubt. Unfortunately this is one of those cases where identifying the root of the problem doesn't necessarily help you solve it.
    - brudgers 11y ago
      For longer than our twenty years of marriage, my beloved has been in healthcare...I of course have not. My gut tells me that standardization of what is and isn't billable solves a bigger problem than described in the above comment. My whole being tells me that changing the definition of billable time won't fix crappy workplaces run by bean counters. And if I had to guess, classifying documentation as treatment is unlikely to improve patient care and outcomes.

Aleman360 11y ago

Girlfriend is an oncology PA. Writing notes are the absolute most dreaded part of her job. She has to spend about 8 hours every weekend catching up on them. The switch to electronic records vastly increased the amount of time to complete notes. Scribes are a good solution. Her brother-in-law is an ED physician and doesn't really have to worry about notes because he has good scribes.

alistairSH 11y ago
The switch to electronic records vastly increased the amount of time to complete notes. Is there something inherent in medical notes that typing them should take longer than hand writing them? Or, is the software just awful? (I assume the second, which makes me wonder why nobody is disrupting this area)
- Aleman360 11y ago
  Both. It's extraordinarily complex. The data entry is highly structured. All the electronic record software I've seen has probably ~100 pages worth of forms, a big subset of which usually need to be filled out for each patient visit. It's not being "disrupted" because it's extremely capital intensive to enter this market. The requirements seem intractable: - Structured data with very high level of granularity. - Patients often don't fit the mold exactly. It's hard to classify something that is going on with a patient; there are 68,000 ICD-10 codes. - Data needs to be interoperable with existing and competing systems. - Every hospital has their processes and documentation practices. As a result, most electronic record software is highly customizable, and a company representative is usually on call or on site to continuously customize it. - Software needs extreme backwards compatibility. You need to be able to read records that are tens of years old. - Need to be able to print everything. - Need to meet regulatory requirements and security audits. Regulatory requirements vary by state and country. - Healthcare institutions are inherently conservative with their technology, and for likely good reason. Plus they don't upgrade equipment very often. If they just spent $1 billion upgrading their entire IT infrastructure, they're not going to consider your startup's solutions for awhile. - Patients don't like it when their provider is focused on a computer or taking notes instead of on them. - Different UI for each provider (e.g., primary care physician vs. pharmacist vs. radiologist) - Need to communicate with a wide variety of medical hardware that doesn't have good standard protocols, and much of which is very old. And on and on...

nradov 11y ago

The requirement for high levels of documentation is largely an attempt by payers (insurers) to prevent fraud, waste, and abuse. In the US most healthcare providers are still paid on a fee for service basis so the more patients they treat in a day the more money they make. There have been many incidents of providers submitting claims for patients who didn't need treatment, or with the wrong billing codes. (Obviously the vast majority of doctors don't do anything unethical or illegal, but still fraud is fairly common.) So payers want to see the notes in order to verify that treatment actually occurred, was medically necessary, and consistent with the terms of the patient's insurance policy. The new Accountable Care Organization (ACO) model has the potential to reduce the documentation requirement. Under that model the insurer shifts the risk to a provider organization which is receives a flat fee per year to care for the patient. So the providers no longer need to submit detailed insurance claims. The secondary reason for requiring detailed clinical documentation is coordinating between all members of a patient's care team. Obviously your primary care physician would like to know what your psychiatrist did and why.

Aleman360 11y ago
There is still a requirement for highly structured data entry that is unavoidable. Even if you reduced the other documentation requirements, the "computerized physician order entry" systems (healthcare lingo) still require quite a lot of provider time. You need to be very explicit when entering things like chemotherapy regimens.
- nradov 11y ago
  Right that's also a factor. Some medical practices have hired scribes to shadow physicians during patient encounters and do the data entry in real time. This is expensive but can end up being cost effective if it allows a highly-paid physician to see more patients per day.

betenoire 11y ago

The article doesn't mention transcribers. I remember in the 80s and 90s, a few of my relatives typed up medical transcriptions as a part-time from home job. Has this fallen out of style? Or is this a result of some legislation perhaps?

gherkin0 11y ago

When I saw a dermatologist about a year ago, and he had an assistant in the room whose job seemed to be to update the notes while he was interacting with me. I can see that helping with a lot of specialties, but maybe not psychiatry.

jernfrost 11y ago

I see people here explain all this documentation requirements as a function of it paying private health care. While some of that is true, it is far from the whole explanation. I am a Norwegian we have what you guys call socialised health care. I've been treated in the US and Norway so I can compare. In the US there is a lot more paperwork related to disclaimers, suing, billing, insurance companies etc which we don't have to deal with. However when it it comes to the medical side of things, doctors here also sit and type at their computer while seeing their patient. They are also stressed out trying to make it all add up. Just because there isn't a profit motive doesn't mean there isn't a push to be more efficient from above. There is lots of political pressure from above to save money on health care. The core problem here isn't profit or not. I think the problem in common both in the US and Norway is the measurement and feedback based management. New Public Management or whatever you call it. Both in public sector and private those at the top want to be able to control and improve what is going on below and so they insist on massive amounts of feedback, so they can measure everything about how things are run. Of course they never consider the massiv cost of all this documentation. It is the same in schools here in Norway. Teachers have ended up spending a shitload of time documenting and measuring over the last decades. The paperwork load keeps adding up even though every successive government says they are all about cutting paperwork. IMO opinion the solution to this isn't to go public or private but to change our ideas about how things are managed and run.

lmm 11y ago
This has to be answered empirically. No doubt there is value in giving doctors or teachers the freedom to do what they think best - especially the best ones. But there is also a lot of value in standardization, accountability, and ensuring we know what went on. A patient may think they care more about how kind the doctor was, but if better notes make the difference in spotting a rare condition or simply catching a mistake - or, more subtly, enable data analytics that let us spot new correlations and develop improved treatments - then (with a limited amount of doctor's time available) that's a lot more important. What has the overall effect of these paperwork changes been on healthcare outcomes?
- ThomPete 11y ago

hardwaresofton 11y ago

Uh... Isn't the fix to just stop taking more patients than you can handle comfortably and enjoyably? Maybe that, paired with encouraging more of the younger generation to become doctors (to cover for the patients you feel like you might be abandoning?)? Doctors are extremely valuable workers/members of society, I'm surprised that they don't feel more in-control of the situation (if you want shorter notes, push for it?)... Also, this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either... If my doctor takes notes while I speak to him/her (and it was made clear at least once that I have their attention), that impresses on me that they're doing their job, which is far more important to me than the feeling of being treated like a human for an hour. Also, why not just take micro breaks during billable time to do notes? bill for the 45 minutes, notes for 15 mins, take notes right in front of the person, and let them know what is happening? Maybe this just seems easy to fix to me because I'm an outsider

lloyd-christmas 11y ago
> Isn't the fix to just stop taking more patients than you can handle comfortably and enjoyably? And then the hospital starts making less money (losing money), research funding dries up, and we start using mercury to treat syphilis again. I'm only half-kidding. I say hospital because all the laws that have changed in healthcare have driven most doctors out of private practice into hospital positions. since 2004, hospital-employed doctors have gone from 11% to over 60%[1]. One major reason being that with the wave of medical reform, the overhead of running a practice has skyrocketed. "Comfortable and enjoyable" are rarely applicable when you only start paying off your $1m schooling debt at 30. > I'm surprised that they don't feel more in-control of the situation I'm not sure what else to say other than "They aren't". These are laws, not administrative suggestions. Hospitals expect/need the same output regardless of the laws the government changes. > this assumption that constant note taking makes someone feel like they're not being treated as human isn't completely convincing either... I have a life-long condition. I don't care when my doctor is typing because I've had it my whole life, it's nothing more than maintenance, and I'll see them again in 6 months. Imagine being told you have 6 months to live from someone half-sitting behind a computer. >Also, why not just take micro breaks during billable time to do notes? My father doesn't eat lunch, using that time to catch up on notes. For as long as I remember, has left for work at 5am and gotten home at 8pm. He spends his Saturdays and Sundays working. And again, hospital employees don't get to choose how many hours they bill. [1] http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/Pdf/mha2012survpreview.pdf http://www.merritthawkins.com/uploadedFiles/MerrittHawkins/P...

Xyik 11y ago

Maybe doctors should hire someone to help with the paperwork? This seems like a case where scaling horizontally works better than scaling vertically. Like how some tech companies make use of QA departments while others do their own QAs, perhaps some doctors having an assistant on hand could make things more efficient.

Skeletor 11y ago

If this Doctor was using drchrono she wouldn't have this problem.

gabriel34 11y ago

Multitasking has the effect of increasing perceived workload whilst decreasing work throughput and increasing the error rate. Through training it is possible to become efficient in doing two tasks seemingly simultaneously, in this case, anamnesis and note-taking. Nevertheless true multitasking is not proven, and switching occurs instead, the trained person simply responds quicker to certain stimuli. Multitasking might also be the source of frustration and contributing factor to the reported depression. Of course the documentation work can be rationalized and tools can be developed to help this, but there is also room for improvement on the work of the doctors, revealed by the lack of standardization reported in the article.

ALee 11y ago

This article just makes me think of supporting more startups like Augmedix and the future of Augmented Reality will truly be a revolution in healthcare.