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

The results of a recent American Society of Clinical Oncology (ASCO) survey of more than 2,500 cancer physicians confirms that the level of paperwork required to document patient care has become so excessive as to undermine the practice of medicine as a whole, and patients in particular.

Concerned by what he called a "health-care system out of control," ASCO President Lawrence H. Einhorn, MD, dedicated his presidency to tackling the issue of excessive documentation as required by Medicare. For years, anecdotal evidence has been mounting to suggest that the increasing amount of documentation takes considerable time away from physicians’ other more important responsibilities. Now, the results of the first study to examine the scope of the problem confirms that documentation is, in fact, detracting from the amount of quality time physicians have to care for their patients and family members, conduct important clinical research, and mentor and teach the next generation of cancer doctors.

Longer Work Day, Less Job Satisfaction

The study, "Impact of Regulatory Burdens on Quality Cancer Care," shows that, on average, the amount of time clinical oncologists spend filling out paperwork and documenting patient care has more than quadrupled over the past 25 years. Simultaneously, the study found time spent conducting clinical research decreased by half, and time spent teaching medical residents also decreased by nearly half. The study reports that the biggest impact of this "regulatory creep" into medicine is a significant increase in the number of hours a physician works and a significant decrease in job satisfaction.

"People who choose to go into medicine choose this profession because they want to help people. Patients have always come first, still come first, and will always come first. However, the Health Care Financing Administration (HCFA) and Congress and even the general public do not have a true 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 site visits, ASCO is planning to call for reform of Medicare’s documentation requirements. These requirements, dictated by HCFA, are part of the federal government’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 are excessive and detrimental to the quality of health care.

Quality of Time With Patients Decreases

The study found that the amount of time spent with patients remained relatively stable over the past 25 years, but the quality of that time has been greatly affected by the need to document information extraneous to the reason 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 medical history, family medical history, etc) to justify billing the level of service that appropriately reflects the actual medical care delivered. Furthermore, each time a doctor sees a patient, the visit must be documented in minute detail. Doctors argue that a patient’s diagnosis and treatment, not checklists published by the government, should drive documentation.

"As a result of fear of the government’s enforcement of documentation requirements, compliance offices have come into being, creating a full-fledged, costly, cottage industry within the health-care sector," said Dr. Einhorn. "The sole purpose of these compliance offices is to ensure that should the government conduct an audit of patient records, documentation of patient care is completed exactly according to government regulations, and medical services are coded precisely according to Medicare reimbursement rules." Unfortunately, he commented, most of the people who work in compliance offices do not have the medical training needed to undertake such efforts.

"This situation is an example of unintended consequences," he continued. "HCFA wants to prevent fraud and abuse, so it sets up documentation rules. Health-care institutions want to avoid legal problems, so they aggressively enforce the rules. Although everyone has good intentions, the result has made practicing medicine increasingly difficult."

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

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