The Rising Cost of Documentation

There was an interesting study published last month in the Journal of General Internal Medicine. It looked at how interns — medical residents in their first year of post-graduate training (PGY-1) – spend their time. It broke down daily activities into direct patient care, indirect patient care, educational actives, and miscellaneous. The last time a study like this was done was prior to 2003. Here’s a pretty good commentary about the study and the source of the graph below.

The findings are interesting and troubling.

  • Indirect patient care – 64 percent 
    • Computer use, mostly documentation – 40 percent
    • Communication with other providers – 20 percent
  • Education – 15 percent
  • Direct patient care – 12 percent

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Way down on that list at 12 percent is direct primary care. That is the time that an intern spends examining and interacting with the patient. There are a lot of good reasons why direct patient care is a small fraction of the time an intern spends every day. Interns are still learning medicine, so education — both informal and formal — is necessary. So is communicating with other providers, especially specialists and consultants, as medicine, science, and treatment get more complicated.

But the most troubling finding is that interns spend conservatively three times as much time documenting as they do interacting and examining patients. If you spend any time with a resident or an intern, or a practicing physician for that matter, you have pretty good anecdotal evidence that this is the case. Many of my resident friends use words like "drowning" and "overwhelmed" all the time, but almost always one the reason for that descriptor is charting. This new study pegs a number to these activities. The relative differences in activities are a very bad trend for doctors, for patients, and for our health system.

Previous studies have found that interns spent 20 percent of their time on direct patient care. Today that portion of the day has dropped by 40 percent. I don’t have the numbers on documentation from earlier studies, but I bet it has seen the inverse and has grown by numbers close to 40 percent. Another sign of a bad trend.

The troubling part has very little to do with medical education. Intern year and residency are meant to prepare physicians for practice, and an increasingly large part of practice is documentation. So in a sense, this study shows that graduate medical education is in touch with the practice of medicine. It’s preparing interns and residents to be real-life physicians, with all the good and bad that comes with that.

It’s ironic  that many young physicians want to be employed after training. The thinking is that the management and administrative requirements of medicine are too much of a burden and detract from patient care. Many younger and still-in-training docs are afraid of being off on their own because there would be too much other stuff to do. That’s the perception, anyway. This study helps quantify that all physicians, whether employed or independent, still have lots of other non-direct patient care stuff to do.

Why should we care? As people who influence, create, and distribute tools and services for clinical documentation and communications, we should be aware of the practical implications of the tools we create and distribute. Spending three times more time documenting a patient encounter than seeing, collaborating, diagnosing, and treating is not something to be proud of.

It’s National Health IT Week. A big part of HIT involves tools for clinical documentation. We should be critical of the practical effects of HIT on users — both providers and patients — while we celebrate the success of increased EMR adoption by providers.

We should examine how we can make HIT better. Not just to meet Meaningful Use, but to improve care and play a positive role as our health system evolves. HIT should be a tool that helps clinicians, not one that eats up an increasingly large part of their day.

There’s an quote from William Osler, who is considered the father of modern medicine. It goes something like this: "Listen to the patient, he is telling you the diagnosis." We shouldn’t be moving away from this. Digital data, apps, and services in healthcare hold the potential to better both population and individual health, but you can’t do it without clinicians working directly with patients, gathering the relevant information, and helping educate and engage patients.


Travis Good is an MD/MBA involved with health IT startups. More about me.

  • Gregory Park

    Great read Travis!

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