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Tuesday Apr 04, 2017

Sorry, I'm Too Busy for Your Busy Work

A few months ago, I wrote about "hitting the wall" in medicine -- reaching a point of exhaustion and work fatigue that led to depression. Since then, I have found myself having conversations with physicians -- both in and out of family medicine -- about the overwhelming amount of work we are doing.

The point we all focused on wasn't the number of patients we were seeing, but the amount of paperwork associated with those visits. Of course, there's very little actual paper involved because the tedious work is done online, but whoa -- does it feel like a ton of bricks!

A recent study in the Annals of Internal Medicine found that for every hour physicians spend in direct contact with patients, we spend two hours on updating our electronic health records (EHR) system, administrative work and other tasks. And even when we are in the same room with a patient, more than a quarter of that precious time is spent typing or reading our computer screens.

Jay Lee, M.D., M.P.H., past president of the California AFP, was recently the keynote speaker at the Paul Ambrose Health Policy Forum co-hosted by my alma mater, the Marshall University Joan Edwards School of Medicine. He seemed to have read my mind when he said physicians have become "defenders of our inboxes."

During the past month, I struggled to keep my task list, which is like an inbox inside the EHR, below 200 items. These tasks aren't notes from my patient visits. They aren't prescription refills or reports of imaging studies I ordered yesterday. They are busy work.

I don't think any of us went into medicine expecting to punch a time clock (although many of us do) and to work strictly 40 hours per week, walking out the door on a Friday afternoon with no work obligations. We knew there would be charting to do. We expected that labs drawn up on Friday would require follow-up on Saturday. We expected to check every couple of hours for the result of that chest CT we ordered on that longtime smoker whose lungs just didn't sound quite right on Wednesday. And we expected to check on culture results after hours and on the weekend and -- gasp! -- on vacation. But what I don't think any of us saw coming was the onslaught of duplicative work we now do for insurance companies and, increasingly, pharmacies.

I tell myself I'm going to start keeping track of things, like using my phone as a timer to find out how much time I spend waiting on documents to load in the EHR. Or I might keep a log of how many duplicate EKG reports I get from the ER. But I don't actually do these things because I would drown in the results.

So I wish I could tell you how many "papers" I got this week from the pharmacy telling me my patient didn't fill lisinopril, which I stopped because he lost 25 pounds by counting calories and walking and doesn't need a blood pressure pill anymore.

There also were orders for me to sign a patient's "request" for a knee brace that I recognized from that obnoxious TV commercial that targets Medicare patients. The patient is in a nursing home and didn't actually want the brace. He answered his phone six months ago and, after some badgering by the salesperson, said, "Sure, if it is free." Here I am, six months and -- no exaggeration -- roughly 100 orders later, and I'm still repeatedly denying the same recurring order every couple of days.

Sadly, none of this administrative burden affects the patient in a positive way. I spend an inordinate amount of time on my computer -- instead of exercising, cooking or being with my family -- completing tasks that do not benefit patients. They don't even know I'm doing work on their behalf. They don't even know that the pharmacy sent me five faxes in 24 hours to say they filled their medications two days late a month ago.

What bothers me most is that as doctors, we can't assume that the pharmacy and insurance company employees reviewing our records would give us the benefit of the doubt or understand why I would simply close a letter (rather than making a medication change) stating that my patient, who has a diagnosis of heart failure, is also on a selective serotonin reuptake inhibitor, and that can lead to prolonged QT. I know that she has mild diastolic dysfunction and a preserved ejection fraction and that she is on 20mg of Celexa, which helps not only with her depression but also with her chronic back pain, and that it is safer than her taking nonsteroidal anti-inflammatory drugs because she has chronic kidney disease. Instead, I have to pull up her echo and EKG to document her ejection fraction and lack of arrhythmia or prolonged QT and then make a note on the letter to prove I'm doing the right thing.

We are family doctors, and we all want to do the right thing. Repeatedly defending my treatment decisions to insurance companies and pharmacies is a waste of my time. I am increasingly frustrated with the processes in medicine that seem to be based on the false assumption that I have no idea what I am doing. I went to medical school to make medical decisions, not to justify why I am prescribing one dose of fluconazole, and surely not to request a prior authorization on a $3 tube of erythromycin eye ointment for a patient with a 2mm corneal abrasion.

So how do we -- as Dr. Lee said -- defend our inboxes? An Annals of Family Medicine article suggested that part of the problem is that with the advent of EHRs, many tasks that were once handled by staff have been transferred to physicians. In the study, practices asked nurses or medical assistants to filter electronic and paper information, "passing on to the physician only that information which specifically requires a physician's level of expertise." Doing so allowed one practice to decrease physicians' inbox work from 90 minutes to only a few minutes per day.

The AAFP has been putting pressure on the administration to help reduce the seemingly endless paperwork family physicians face. Meanwhile, it would be helpful to hear from my colleagues who have found ways to manage this overload. So for those of you who have cracked the code on survival in an EHR world, please share your secrets in the comments below.

Kimberly Becher, M.D., practices at a rural federally qualified health center in Clay County, W.Va.


My clinic staff does 'triage' my task list. This has cut down on my busywork time significantly. I also use a voice recognition dictation system for documentation. It turns out, I can talk faster than I can type. These two changes have pulled me back from 'the wall.'

Posted by Jessica Richmond on April 04, 2017 at 03:06 PM CDT #

I'm with you, sister.

Some of the stuff you are mentioning I simply delete or close with no further notation. I feel no obligation to let the pharmacy know why I'm prescribing a certain combination of medications or that I am aware that a patient hasn't refilled their statin. There don't seem to be any rules that I have to respond to those requests, and I'm comfortable with my decision-making and can defend it if/when I need to.

It seems like the pharmacies near you have gone insane though. I don't know why they would send so many repeats of things - that's bizarre.

As for the other total nonsense - I'm hoping to hear some good responses here as well.....

Posted by Kristen Goodell on April 05, 2017 at 09:57 PM CDT #

I tell all of my patients that I do not respond to anything that does not come directly from them and even then I require an office visit to do so. When they come in for a visit I take care of all refills etc so they do not have to come in again soon after.

This way, virtually all of the sort of correspondence mentioned above goes right in the the trash. My staff trashes most of it before I ever see it.

I require an office visit for all refills so I deal with very few refill requests. I give patients enough refills to get them to their next routine follow up so they do not complain.

I do not do prior authorizations on generic medications so I do not deal with man PAs either.

I dictate lab notes via Dragon. It is okay, not great.

I do not do workman's comp or DOT physicals or disability evaluations.

It is sad that most of my coping mechanisms listed above include what "I do not do" because I used to to do most of them. But that is the sad state of medicine these days.

And even with all of the above adaptations I still find the use of the EHR (any of them) to be frustrating, slow, inefficient, buggy and often times dangerous. Every physician in this nation needs to boycott, rise up, sit down or whatever we need to do to demand of our EHR vendors, the government or our employers to make a meaningful change to our EHRs. They will be our legacy of shame as we look back on these times.

Posted by George T. Barron, MD on April 06, 2017 at 07:41 AM CDT #

Physicians need to understand that EHRs have NOTHING to do with providing better patient care. They are about monitoring and controlling physician behavior, a necessary tool in the corporate take-over of the medical system. Margarlit Gur-Arie, one of the most perceptive commentators on HIT, has said "They (those promoting EHRs) are aiming at changing medicine from a personal service to a mass produced electronic commodity delivered by low wage workers."

The performance of the AAFP in this has been both heart-breaking and deeply, deeply shameful. They have enthusiastically aided and abetted every step of this de-professionalization of the family physician - we are now data entry clerks who provide free labor to increase the profits of others.

Can our leadership really be a clueless about the consequences of their actions as they seem?

Posted by R Stuart on April 06, 2017 at 11:18 AM CDT #

I am a physician involved with a number of clinics using EHR systems. They are an abomination. Cumbersome, slow, unreliable. Only a bureaucrat with a stake in controlling medicine would think these beneficial Moreover, rather than developing organically in response to demand they have features mandated by government. Insurance companies the government and pharmacy interactions have become increasingly burdensome to work with. Dr. Becher and others have the right idea. Refills associated only with a visit; triaging paperwork. And, frankly increased resistance to the bureaucratization of medicine. Is the government really capable of managing medicine? Well, look at the VA, the Indian health Service; Medicare, Medicaid, Obamacare; Amtrak; the Post Office and the Department of Motor Vehicles. Which of these is solvent, meeting expectations; and a pleasure to deal with? Or which ones are over staffed with middle management, inefficient; losing money and providing poor service. Put the government in charge of sand and in six weeks we would see sand shortages; more paperwork and increased cost.

Ill see indigent patients on my terms, thank you, cheaply efficiently, and quickly. When politicians run the country effectively Ill listen to what they have to say. Otherwise I have yet to see one who knows as much about my business as I do.

Posted by Mark W. Fowler on April 10, 2017 at 11:02 AM CDT #

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