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Physicians as pencil pushers

/ 09:03 AM April 22, 2019

Recently, the Philippine Health Insurance Corp. rolled out a new requirement, the Claim Form 4, for medical claims, with an eye to better assessment of the quality of care provided to PhilHealth members. Dr. Roy Ferrer, acting president and CEO, has described elsewhere how improvements in the system, with the addition of the CF4, are meant to streamline the processing of claims.

If social media is anything to go by, physician response to this development has been mixed. This is no criticism against the CF4, but it does highlight, and is an addition to, physicians’ frustration with a workday where a significant percentage of the time is already taken up by paperwork — redundant, copious paperwork.

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The burden of paperwork has been plaguing healthcare for a while; a memorable 2015 Washington Post article on “Why doctors quit” posits that paperwork has turned us from learned healers to glorified clerical secretaries.

A commonly shared article among physician groups recently is a report that physicians spend over two-thirds of their time doing paperwork, supported by a small-scale 2016 study in the Annals of Internal Medicine. It noted that for every hour spent seeing patients, a physician spent nearly two more on clerical tasks.

It’s estimated that the fraction of time spent filling out papers, both manually and through electronic health records systems, has doubled in the decade preceding the study, both because hospitals are increasingly aware of the need for accessible, correct and permanent documentation, and because healthcare is increasingly dependent on medical insurance.

The burden falls mostly on doctors themselves, since other members of the healthcare team might not be trained or held accountable for the documentation. Allied health professionals have their own burden of paperwork as well, and most of the documentation needed for insurance claims and in hospital records are mandated for physicians themselves to fill out.

As a result, paperwork has been called the “hidden killer” in the healthcare system, and has been reported by the 2018 Medical Economics’ Physician Report as the biggest problem plaguing primary healthcare in the United States. It reduces the share of time devoted to actual patient care, and increases physician burnout.

The filling out and completion of forms are incentivized — or rather, incomplete forms are penalized in some systems, which may suspend physician or trainee pay when electronic health records go unaccomplished. Sadly, as one social media user pointed out, computers make all notes legible, but we have systems that create notes that aren’t worth reading, as physicians struggle and hurry to complete their forms in order to make time for all other tasks as well as personal time.

This is not to say that indirect care spent reviewing or encoding patient records is without its benefits. Time spent reviewing images, labs and primary data comprises patient care as well, and is an avenue for learning.

It is also still a physician’s duty to assist patients with healthcare expenses, and these days that happens within our capacity as data-gatherer and data-encoder.

The Hippocratic oath reminds us of this promise: “I will remember that I do not treat a fever chart or cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.”

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However, we can still do more for both our physicians and for the patients under their care. Some systems abroad make use of remote scribes and medical transcriptionists, who are trained to either edit dictated reports or even to take notes remotely while a physician sees a patient or performs a procedure. We’re a long way away from having the infrastructure to take on these innovations. But we can still take steps to streamline health provider paperwork, to simplify or shorten forms, or reduce redundancy. Here’s hoping we can reverse the trend toward less paper, and hopefully better healthcare.

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