Excessive Paperwork Detracts From Patient Care, Professional Mentoring, and Research

The results of a recent American Societyof Clinical Oncology (ASCO) survey of more than 2,500 cancer physicians confirmsthat the level of paperwork required to document patient care has become soexcessive as to undermine the practice of medicine as a whole, and patients inparticular.

Concerned by what he called a "health-care system out ofcontrol," ASCO President Lawrence H. Einhorn, MD, dedicated his presidencyto tackling the issue of excessive documentation as required by Medicare. Foryears, anecdotal evidence has been mounting to suggest that the increasingamount of documentation takes considerable time away from physicians’ othermore important responsibilities. Now, the results of the first study to examinethe scope of the problem confirms that documentation is, in fact, detractingfrom the amount of quality time physicians have to care for their patients andfamily members, conduct important clinical research, and mentor and teach thenext generation of cancer doctors.

Longer Work Day,Less Job Satisfaction

The study, "Impact of Regulatory Burdens on Quality CancerCare," shows that, on average, the amount of time clinical oncologistsspend filling out paperwork and documenting patient care has more thanquadrupled over the past 25 years. Simultaneously, the study found time spentconducting clinical research decreased by half, and time spent teaching medicalresidents also decreased by nearly half. The study reports that the biggestimpact of this "regulatory creep" into medicine is a significantincreasein the number of hours a physician works and a significant decrease in jobsatisfaction.

"People who choose to go into medicine choose thisprofession because they want to help people. Patients have always come first,still come first, and will always come first. However, the Health Care FinancingAdministration (HCFA) and Congress and even the general public do not have atrue sense of what it’s like in a modern-day doctors’ office," said Dr.Einhorn.

Based on data from this study, as well as the results of sitevisits, ASCO is planning to call for reform of Medicare’s documentationrequirements. These requirements, dictated by HCFA, are part of the federalgovernment’s attempt to ferret out fraud and abuse in the Medicare system.Although safeguards are needed to ensure that fraud and abuse are not tolerated,the Society believes the level and degree of documentation now required areexcessive and detrimental to the quality of health care.

Quality of Time WithPatients Decreases

The study found that the amount of time spent with patientsremained relatively stable over the past 25 years, but the quality of that timehas been greatly affected by the need to document information extraneous to thereason for the medical visit. For instance, under the guidelines issued by HCFA,doctors are often forced to conduct unnecessary diagnostic checks (eyes, ears,nose, and throat) and repeat previously asked questions (personal medicalhistory, family medical history, etc) to justify billing the level of servicethat appropriately reflects the actual medical care delivered. Furthermore, eachtime a doctor sees a patient, the visit must be documented in minute detail.Doctors argue that a patient’s diagnosis and treatment, not checklistspublished by the government, should drive documentation.

"As a result of fear of the government’s enforcement ofdocumentation requirements, compliance offices have come into being, creating afull-fledged, costly, cottage industry within the health-care sector," saidDr. Einhorn. "The sole purpose of these compliance offices is to ensurethat should the government conduct an audit of patient records, documentation ofpatient care is completed exactly according to government regulations, andmedical services are coded precisely according to Medicare reimbursementrules." Unfortunately, he commented, most of the people who work incompliance offices do not have the medical training needed to undertake suchefforts.

"This situation is an example of unintendedconsequences," he continued. "HCFA wants to prevent fraud and abuse,so it sets up documentation rules. Health-care institutions want to avoid legalproblems, so they aggressively enforce the rules. Although everyone has goodintentions, the result has made practicing medicine increasinglydifficult."

Dr. Einhorn added, "While the purpose of documentation ispurportedly to save taxpayers money, the true costs of this regulatory burdenare being shouldered by society. Patients are receiving less quality attention,medical residents are not getting the individualized instruction they need, andclinical research is suffering."

ASCO plans to complete additional site visits and will issue acomplete report of the findings along with recommendations for how to improvethe system.