A recent study reveals that for every hour doctors spend caring for patients, they spend almost two hours documenting the care they gave those patients in the EHR.

Patients complain because medical staff spend more time focused on the medical record than on medical care, staring at computers instead of engaging in direct care.

Doctor, remember when you first began your medical studies? Hours upon hours spent studying pathophysiology, pharmacology, anatomy, histology, embryology, biochemistry, and more? All the classroom work, leading to the transition to the clinical education necessary for becoming a physician? And of course, that favorite of all courses, “Paperwork for Physicians?” You don’t recall it? I cannot either. That is too bad.

Many professions require proper documentation of the work done. Medicine is not different in this respect. For years, handwritten charts documented the care and progress of patients. Some practices transcribed the hastily scrawled notes using typewriters; these notes were typically brief, and to the point. Physicians did not spend time waxing eloquent while discussing facts considered irrelevant.

Financial pressures came to bear, requiring more documentation to justify higher pay.  The office visit was associated with tiered payment scale – more complex visits were logically paid at a higher rate. How could the paymasters know a visit was worth a higher payment? There are codes designating a higher level visit, and there evolved checklists intended to guide the coordination of the billing and the supporting documentation. A certain amount of time was associated with a certain level of care, and in that time, a certain number of systems must be examined and that exam documented to justify the time and expense. 

Consider the perverse implication of this system. A doctor performs some incredible feat swiftly and effectively. A life is saved; a disease cured. Yet the reward is tied not so much to the performance, but to the documentation of the feat. Many physicians actually settle, even now, for lower pay, performing some calculus based on time spent documenting care versus rendering care, choosing to care more and write less – or, have more life, but get paid less. Insurance companies will never object to this!

The endless documentation requirements are the flaw in the system that fuel this system still. The goal was, and remains, to render excellent care. Extensive documentation has become the hallmark of better care.  Voluminous charts were superficially seen as indicative of better care, but appearances can be deceiving. Some practices realized that forms and templates could ease the burden. As these gained traction, early medical record software sought to bridge the gap, simplifying and streamlining record-keeping and generating the records so desired by payors and providers alike.

Everyone associated with the medical profession dreamed of a well-organized system of recording information that could easily communicate vital data between providers, improving care. No more time wasted reviewing hastily scrawled and often illegible medical records, with no need to replicate examinations or duplicate tests.

The promise of the early medical record software was somewhat hollow. Systems had steep learning curves, often requiring more time to complete even the simplest of patient encounters. Later systems made some progress, but often the difference was purely cosmetic. Records were more attractive – they looked better, they were consistently organized, so they must be better, right? With each iteration of the systems, the most noticeable improvements were often cosmetic. This cosmetic improvement was crucial – to the lay public, records that looked better were accepted as better, just as complex surgical procedures were often judged by the external scar rather than on the quality of the internal work.

These more attractive, consistent, well organized records were much easier for paymasters, such as insurance companies and, of course, Medicare and Medicaid, to analyze. There is no doubt that the consistency and simplicity of these records could and did simplify the communication of vital information, which is a measure of the success of any such system. 

Information is double-edged. As electronic records became ever more sophisticated, more information was captured. An encounter that once was documented in a paragraph or two soon became immortalized over two or three pages. One week spent in a hospital could generate hundreds and hundreds of pages of medical records – or more. Charts are often more difficult to review due to the enormous amount of information. Vital nuggets of information are sometimes overlooked.

No change is perfect. Yet in a time when we seek to improve care, one unfortunate fact remains: Doctors spend more time documenting the care they render than they spend rendering care.

That is the sad conclusion of a recent study published in the Annals of Internal Medicine. The researchers found that for every hour spent in direct patient care, almost two hours was spent documenting care during the clinic day. That unfortunate ratio does not include after-hours time spent on the same tasks. Even more disturbing is the way time is spent in the examination room. While slightly over half the direct contact time is spent in a “face-to-face” manner, over a third is spent on the electronic health record.

Too often we hear complaints from patients who are upset because their doctor seems to be staring at the computer rather than listening to their complaints or examining them. Doctors,  nurses, and other medical staff likewise dislike the time spent pushing paper, even in the electronic form. This sad state of affairs is unlikely to change in the near future, but practitioners should aspire to maximize patient contact and minimize time spent massaging the EHR.