Monday, 2 February 2015

PAPERWORK: the enemy of the Good.

The sweetest joy, the wildest woe is love. What the world really needs is more love and less paperwork.
Pearl Bailey

SO, HERE WE ARE, 2015.

I have 40,726 emails in my in-box of which 1,982 are marked as ‘unread’. I say ‘marked as unread’ because I have read them, and acted on them (I believe) but I have flagged them as unread to remind me to go back and think about them some more. In reality the likelihood that I will reread 1,982 emails and refine the action taken on at least some of them is remote to say the least. If I were to do that, by the time I finished I would have accumulated 1,982 new emails that would need to be dealt with de novo.

A British MP, desperately seeking re-election this year and trying to impress his constituents, when interviewed for a newspaper article said that each night when he got home after a long day at work, he personally answered over 400 emails. I strongly doubt that is possible, unless the MP in question suffers from Fatal Familial Insomnia. FFI is code for ‘seriously can’t sleep’. It manifests itself in hallucinations, delirium, and confusional states like that of dementia. This might explain the behaviour of more politicians than just this one. The average survival span for patients diagnosed with FFI after the onset of symptoms is 18 months. Having this condition would certainly take the worry out of contesting the next election.

Surgeon Pauline Chen, writing a piece in the New York Times claims that as much as one third of a doctor’s work day hours are spent on paperwork. How many hours does that leave for seeing patients? Only six if it is nine hour day but more likely eight or nine given the hours doctors work.

Perhaps even more worrying, however is the amount of time paperwork robs Residents of what Residents are supposed to be doing: learning through educational activities and learning by doing.

Electronic medical records and other eMed applications will change all that, right? Sadly no. Not only has the paperless office not cut down on paperwork, it has increased it and confounded it.
Increased – we exchange a staggering 10,000 times more communications than we did pre eWorld (and we print out a hell of a lot of them, despite the plea we see at the end of emails begging us not to). And that is not just because there are more of us.

Confounded – cutting and pasting was virtually impossible pre eWorld, now it is rampant in the professions with law leading the way and medicine catching up. The cutting and pasting of notes by over (paper) worked doctors is a worrying trend. A dear surgical friend of mine who was a trailblazer in eHealth told me, with great prescience in the early eDays, that the claims of a paperless office were about likely as would be claims of a paperless toilet.

Dr Chen writes: ‘Residents may rely on notes written by other doctors instead of talking to the patients themselves. These other notes may have also been pieced together from previous notes rather than from actual interactions with the patient. As a list, a paragraph or whole sections get pasted into progressively more documents, important information, like a reaction to a certain treatment, can be lost in the transfer. Clinicians who rely mostly on computer notes for their information are at risk of inadvertently choosing the wrong therapeutic course of action for a patient.

So much for patient safety! eHealth becomes ‘eUnhealthy’.

So what can be done? Suggestions include outsourcing some of the paperwork requirements away from doctors, to support staff. This takes money. But wait, isn’t employing support staff to do paperwork at $50 per hour better than having doctors do it at $100 per hour? And, if a doc cannot see all the patients in A and E in the allotted time because of paperwork an extra doc may be put on to clear the waiting area.

Surely I should be able to put this into some type of numeric. Let me try………..

100 patients seen for 30 minutes each by one Doc at $100 an hour = $5,000


100 patients’ notes written up at 10 minutes each by one Doc at $100 an hour = $1,667


The 33 patients not seen while the Doc was writing up her notes which had to be seen by another Doc at $100 an hour = $1,650


33 patients notes written up at 10 minutes each by Doc 2 at $100 an hour = $550

TOTAL $8,867


133 patients seen by a Doc for 30 minutes each at $100 an hour = $6,650


Support staff writing up notes for 133 patients for 10 minutes each at $50 an hour = $1,100

TOTAL $7,750

An add to that the fact that in the second scenario seeing the patients and note writing are taking place concurrently rather than serially so the total time taken to see 133 patients is less by about 20% which makes the patients happier and everyone can switch off the lights and go home early, thereby saving even more money.

I have simplified this for the purposes of illustration realising full well it is more complex than this. But it suggests a modus operandi that could be massaged into place with some lateral thinking and number crunching.

The other perhaps less measurable effect of paperwork on doctors, and even more so, Residents, is how demoralising paperwork can be.

I accept that Doctors need to know how to record what they see and the treatments they recommend, but today’s paperwork is way more than this. I call it ‘defensive’ paperwork. It is a bit like defensive prescribing (of medications and tests). Let’s prescribe the medication or order the test, however remote the likelihood that we are treating something you have or trying to find something you might have, in case you have it and I get sued for not finding it. All this defensive prescribing and defensive ordering of tests has to be entered in the record………..more paperwork!

Maybe there should be an agreed ‘likelihood percentage’ below which Docs are indemnified against not prescribing/ordering and against not mentioning it in the course of providing ‘informed consent’.
The incidence of hospital acquired infection is around 6% to 10% in developed countries and docs will tell you when you go for surgery that it is a risk with a likelihood of about 10% (to be on the safe side). That is fair enough even though the surgeons I have worked with tell me no patient has decided not to go for surgery because of the risk of contracting HAI. So, could 10% be the threshold above which docs should warn of the risks, order the tests, prescribe the medication and below which they can’t be sued if the risk materialises? What do you think?

That’s it from me for now. Perhaps just a few ideas to stimulate your grey matter as we launch into 2015.

NOW, back to my 1,982 unread emails……Oh Crikey!! While I have been busy writing this BLOG for you that 1,982 is now 2,246 !!


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