5 ms·

> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to

> I've read that doctors now spend as much as 50% of their time documenting their work. Companies such as Epic, which provide the software that hospitals use to build databases of patient data, have been big winners in the new world of hospitals-depending-on-software. But did the doctors become more productive? By almost any measure, they became less productive. I don't think "by almost any measure" is right. I think in a very narrow sense they've become less productive (they see fewer patients), but by your own admission they're building databases of patient data, which you seem to suppose are only useful to the likes of Epic, but obviously Epic has customers--notably healthcare researchers use this data to improve patient care, develop new medicines, and to precisely identify which medicines are likely to help on a particular patient (and which medicines may even harm them!). This is stuff clearly benefits society, and doctors' role in this should be counted as "productive", although we can quibble about the relative value of facilitating healthcare research versus seeing more patients. Note that this isn't meant to vouch for Epic--I work for a company that consumes their data and anyone who has to integrate with them has nothing good to say about the software, but the role it plays is still incredibly important.

VLM 4y ago
Medical decisions are based primarily on financial profit, and patient outcome data is not required to determine which medicines are most profitable. The point of extensive documentation is shielding from the worst of malpractice lawsuits. The legal system is still of the legacy opinion that doctors have a responsibility to their patients as opposed to the more modern understanding of responsibility toward pharma company bottom lines, and all patients legally deserve the 100% successful participation trophy, so a documented decision with only 95% chance of success means insurance payouts about 5% of the time, unless its carefully documented it was all the patients fault or at least the MD could not have known the outcome in advance.
- throwaway894345 4y ago
  > patient outcome data is not required to determine which medicines are most profitable This is blatantly false. Pharma spends tons of money to buy this data for their armies of researchers in order to determine outcomes. There's an entire very lucrative industry (that I work in) which exists to source this data from hospitals and refine it for researchers. If the point of documentation was CYA, then you wouldn't need complicated systems like Epic to standardize the documentation and make it available for electronic processing (you would just have some paralegal pour over the records of the individual patient).
coxmichael 4y ago
Both can be true, and greater systems of medical research and analysis don’t necessarily lead to greater on-the-ground treatment. As you’ve pointed out, access to those information systems is critical. I’d add the distribution of that information as well as the right economic incentives to participate in using that information. I’m not sure we’ve really got any one of those things right. Edit: adding a bit of humanity to the system, as the OP is hinting at, could very much be a part of the fix.
- throwaway894345 4y ago
  > Both can be true Not really. You can't say "doctors have become less productive" without accounting for the value incumbent in the increased documentation effort. > greater systems of medical research and analysis don’t necessarily lead to greater on-the-ground treatment. Maybe not "necessarily", but in practice they do. Perhaps not in every incidence, but broadly the analysis results in better outcomes or else there would be no economic incentive to facilitate medical research ("the incentive is to sell more drugs!" <- insurance companies aren't going to pay for those drugs if they aren't proven to work). > Edit: adding a bit of humanity to the system, as the OP is hinting at, could very much be a part of the fix. That's not how I understand the OP, but I doubt anyone would object to "adding a bit of humanity" (abstractly) to healthcare unless it implies a reduction in empirical rigor.
  - coxmichael 4y ago
    > broadly the analysis results in better outcomes or else there would be no economic incentive to facilitate medical research This is true to a degree, but outcomes for real healthcare rely on much more than research, as you’ve indicated. Documentation is part of that research, of course, and whether they have short-term or long-term effects for researchers’ ability to work out better treatment is relatively lossy. Actual treatment also includes the rest of healthcare (training, hell, even their housing costs), and rules-based or centralised administrative systems backed by insurance don’t necessarily create the right environment for that information to be propagated more widely. People training to be health workers don’t use the frequency or quality of medical research papers to decide whether to become a doctor. I think there’s a view you can take on the information topology here that’s a little odd in how it’s currently set up — documentation for front-line workers and information wealth for researchers feels like it’s relatively polarised.
justinpombrio 4y ago
> notably healthcare researchers use this data to improve patient care, develop new medicines, and to precisely identify which medicines are likely to help on a particular patient (and which medicines may even harm them!) The majority of the notes being written by doctors now is boilerplate. A lot of it is copy-pasted. It's written because of insurance companies (which have incentive to deny claims), because of liability (which gives incentive to leave a lot of notes behind to make it looks like you thought about everything under the sun even if it wasn't applicable), and because of well-meaning but ultimately overly broad laws adding additional requirements even when they don't quite make sense. I'm sure there is a treasure-trove of valuable data in there, especially compared to when it was all hidden away on physical paper. But you could probably reduce the paperwork that doctors do these days by a factor of 4 and not loose anything of value.
- throwaway894345 4y ago
  > But you could probably reduce the paperwork that doctors do these days by a factor of 4 and not loose anything of value. Maybe, but this sounds like some vague hunch based on ???. I very highly doubt the healthcare industry would tolerate doctors wasting ~37.5% of their time (75% of paperwork time is wasteful * 50% of doctors' time spent on paperwork = minimum 37.5% of doctors time wasted). Doctors are expensive, so recouping anywhere near 40% of their time would be a priority. It seems more likely that the paperwork is actually pretty useful (but the utility is not obvious to the lay observer), or at least useful enough that the wasted time isn't significant to the healthcare industry (which is already struggling with margins and personnel).
  - tsol 4y ago
    >I very highly doubt the healthcare industry would tolerate doctors wasting ~37.5% of their time (75% of paperwork time is wasteful * 50% of doctors' time spent on paperwork = minimum 37.5% of doctors time wasted). Doctors are expensive, so recouping anywhere near 40% of their time would be a priority. Doctors are expensive, but malpractice lawsuits are more expensive. Documentation is extremely important for lawsuits. If you get sued because a patient you saw last year later died and they're alleging improper health care(just to use a random example), it's highly dependent on having meticulously documented notes that document every single examination finding and treatment administered. Your memory isn't going to be accurate, and the prosecutor is going to be looking for any errors in documentation they can use.
gort19 4y ago
bumby 4y ago
This is a really good point about how we myopically understand the value stream of a process. Often, steps that we feel are bureaucratic waste provide a lot of value to someone else in the process. With that said, I think most healthcare is correct to take a "patient centric" approach. What the OP seems to be making is a "doctor centric" take and, if one was to be overly cynical (I'm not), your post may skew to the side of a "researcher centric" or "societal centric" approach. Doctors should do what's best for their patient, not necessarily what's best for society, or themselves, or a lawyer, or a research lab. It's easy if you work in one of those tangential areas to take your eye off the ball.
- throwaway894345 4y ago
  I don't think documentation precludes doctors from caring for their patients, but it does limit the number of patients they can handle. This implies that healthcare is more expensive, which maybe seems like a bad thing for patients, but I think it's more of an indicator that we need to find a way as a society to pay for the societal good that is data collection and research--"medicare for all" is one conceivable incarnation.
  - bumby 4y ago
    >but it does limit the number of patients they can handle. Or, by extension, it limits the amount of time with each patient if they have a throughput constraint to stay solvent. Tbf, I’m not sure the data supports the claim that doctors spend less time with patients, but the increase in documentation does seem to correlate with doctor burnout.

VLM 4y ago

Medical decisions are based primarily on financial profit, and patient outcome data is not required to determine which medicines are most profitable. The point of extensive documentation is shielding from the worst of malpractice lawsuits. The legal system is still of the legacy opinion that doctors have a responsibility to their patients as opposed to the more modern understanding of responsibility toward pharma company bottom lines, and all patients legally deserve the 100% successful participation trophy, so a documented decision with only 95% chance of success means insurance payouts about 5% of the time, unless its carefully documented it was all the patients fault or at least the MD could not have known the outcome in advance.

throwaway894345 4y ago
> patient outcome data is not required to determine which medicines are most profitable This is blatantly false. Pharma spends tons of money to buy this data for their armies of researchers in order to determine outcomes. There's an entire very lucrative industry (that I work in) which exists to source this data from hospitals and refine it for researchers. If the point of documentation was CYA, then you wouldn't need complicated systems like Epic to standardize the documentation and make it available for electronic processing (you would just have some paralegal pour over the records of the individual patient).

coxmichael 4y ago

Both can be true, and greater systems of medical research and analysis don’t necessarily lead to greater on-the-ground treatment. As you’ve pointed out, access to those information systems is critical. I’d add the distribution of that information as well as the right economic incentives to participate in using that information. I’m not sure we’ve really got any one of those things right. Edit: adding a bit of humanity to the system, as the OP is hinting at, could very much be a part of the fix.

throwaway894345 4y ago
> Both can be true Not really. You can't say "doctors have become less productive" without accounting for the value incumbent in the increased documentation effort. > greater systems of medical research and analysis don’t necessarily lead to greater on-the-ground treatment. Maybe not "necessarily", but in practice they do. Perhaps not in every incidence, but broadly the analysis results in better outcomes or else there would be no economic incentive to facilitate medical research ("the incentive is to sell more drugs!" <- insurance companies aren't going to pay for those drugs if they aren't proven to work). > Edit: adding a bit of humanity to the system, as the OP is hinting at, could very much be a part of the fix. That's not how I understand the OP, but I doubt anyone would object to "adding a bit of humanity" (abstractly) to healthcare unless it implies a reduction in empirical rigor.
- coxmichael 4y ago
  > broadly the analysis results in better outcomes or else there would be no economic incentive to facilitate medical research This is true to a degree, but outcomes for real healthcare rely on much more than research, as you’ve indicated. Documentation is part of that research, of course, and whether they have short-term or long-term effects for researchers’ ability to work out better treatment is relatively lossy. Actual treatment also includes the rest of healthcare (training, hell, even their housing costs), and rules-based or centralised administrative systems backed by insurance don’t necessarily create the right environment for that information to be propagated more widely. People training to be health workers don’t use the frequency or quality of medical research papers to decide whether to become a doctor. I think there’s a view you can take on the information topology here that’s a little odd in how it’s currently set up — documentation for front-line workers and information wealth for researchers feels like it’s relatively polarised.

justinpombrio 4y ago

> notably healthcare researchers use this data to improve patient care, develop new medicines, and to precisely identify which medicines are likely to help on a particular patient (and which medicines may even harm them!) The majority of the notes being written by doctors now is boilerplate. A lot of it is copy-pasted. It's written because of insurance companies (which have incentive to deny claims), because of liability (which gives incentive to leave a lot of notes behind to make it looks like you thought about everything under the sun even if it wasn't applicable), and because of well-meaning but ultimately overly broad laws adding additional requirements even when they don't quite make sense. I'm sure there is a treasure-trove of valuable data in there, especially compared to when it was all hidden away on physical paper. But you could probably reduce the paperwork that doctors do these days by a factor of 4 and not loose anything of value.

throwaway894345 4y ago
> But you could probably reduce the paperwork that doctors do these days by a factor of 4 and not loose anything of value. Maybe, but this sounds like some vague hunch based on ???. I very highly doubt the healthcare industry would tolerate doctors wasting ~37.5% of their time (75% of paperwork time is wasteful * 50% of doctors' time spent on paperwork = minimum 37.5% of doctors time wasted). Doctors are expensive, so recouping anywhere near 40% of their time would be a priority. It seems more likely that the paperwork is actually pretty useful (but the utility is not obvious to the lay observer), or at least useful enough that the wasted time isn't significant to the healthcare industry (which is already struggling with margins and personnel).
- tsol 4y ago
  >I very highly doubt the healthcare industry would tolerate doctors wasting ~37.5% of their time (75% of paperwork time is wasteful * 50% of doctors' time spent on paperwork = minimum 37.5% of doctors time wasted). Doctors are expensive, so recouping anywhere near 40% of their time would be a priority. Doctors are expensive, but malpractice lawsuits are more expensive. Documentation is extremely important for lawsuits. If you get sued because a patient you saw last year later died and they're alleging improper health care(just to use a random example), it's highly dependent on having meticulously documented notes that document every single examination finding and treatment administered. Your memory isn't going to be accurate, and the prosecutor is going to be looking for any errors in documentation they can use.

gort19 4y ago

bumby 4y ago

This is a really good point about how we myopically understand the value stream of a process. Often, steps that we feel are bureaucratic waste provide a lot of value to someone else in the process. With that said, I think most healthcare is correct to take a "patient centric" approach. What the OP seems to be making is a "doctor centric" take and, if one was to be overly cynical (I'm not), your post may skew to the side of a "researcher centric" or "societal centric" approach. Doctors should do what's best for their patient, not necessarily what's best for society, or themselves, or a lawyer, or a research lab. It's easy if you work in one of those tangential areas to take your eye off the ball.

throwaway894345 4y ago
I don't think documentation precludes doctors from caring for their patients, but it does limit the number of patients they can handle. This implies that healthcare is more expensive, which maybe seems like a bad thing for patients, but I think it's more of an indicator that we need to find a way as a society to pay for the societal good that is data collection and research--"medicare for all" is one conceivable incarnation.
- bumby 4y ago
  >but it does limit the number of patients they can handle. Or, by extension, it limits the amount of time with each patient if they have a throughput constraint to stay solvent. Tbf, I’m not sure the data supports the claim that doctors spend less time with patients, but the increase in documentation does seem to correlate with doctor burnout.