Too much paperwork, too little time for patients

Two staff nurses walk down a corridor outside an almost empty ward at a hospital. PHOTO: ST FILE

A friend was recently hospitalised after a bicycle accident. At one point, a nursing student, together with a more senior nurse, rolled a computer on wheels into the room and asked my friend to rate her pain on a scale of 1 to 10.

She mumbled: "4 to 5." The student put 5 into the computer - and then they left, without further inquiring about, or relieving, my friend's pain.

This is not an anecdote about nurses not doing their jobs; it's an illustration of what our jobs have become in the age of electronic health records.

Computer documentation in healthcare is notoriously inefficient and unwieldy, but an even more serious problem is that it has morphed into more than an account of our work; it has replaced the work itself.

Our charting, rather than our care, is increasingly what we are evaluated on. When my hospital switched to barcode scanning for medication administration, not only were the nurses on my floor rated as "red", "yellow" or "green" based on the percentage of meds we scanned, but also those ratings were prominently displayed on printouts left at the nurses' station.

Or consider "fall assessments", which a nurse uses to determine a patient's risk of falling while in the hospital - a problem that accounts for 11,000 deaths annually. The assessments ask about medication, mobility issues and confusion, to create a "fall risk score", which then generates an appropriate menu of interventions.

A nurse could spend 10 minutes documenting a patient's fall risk, or 10 minutes trying to keep patients from falling. It seems obvious that a computer record of "fall risk" cannot in and of itself prevent falls, but completing those records is considered essential in hospitals. As a result, real fall-prevention efforts - encouraging patients to use the call light, ordering a bedside commode, having an aide do hourly check-ins - get short shrift.

In home hospice, where I now work, the documentation is even more onerous than in the hospital and seems even more disconnected from actual patients. Hospice care is a covered benefit under Medicare, and the United States Centres for Medicare and Medicaid Services maintains rigid standards for documentation. They regularly withhold reimbursement if documentation is deemed incomplete or flawed.

This paperwork might have a good intent - to prevent fraud - but in practice it gives documentary exactitude an outsize importance.

A colleague doing a hospice admission wrote that a dying patient had "liver failure and renal failure" and, in a separate part of her documentation, wrote the conditions in the reverse order: "renal failure and liver failure". From a medical point of view, the order of the two is irrelevant, but her supervisor reprimanded her for the disparity, since it suggested inconsistency. The concern, of course, was that the hospice would not get paid.

Charting a hospice admission usually takes between two and four hours, and requires filling out a seemingly endless number of data fields - some of them defying logic.

I once had an oxygen-dependent centenarian patient in heart failure seeking admission to hospice.

The hospice physician asked for further proof that the patient met the strict standards for hospice admission. It was a weekend and, during the time it took for me to collect that information, the patient died.

The worst, however, are the health risk assessments done for patients in Medicare Advantage, a programme that pays for coverage under certain private insurance plans. These assessments include an exam, an accurate health history, and diagnosis and documentation of the most serious possible version of the patient's illnesses. This is known as diagnosis "capture", and the entire process is colloquially referred to as "upcoding". Because upcoding classifies these patients as higher-risk medically, Medicare increases the reimbursement given to their insurance companies without requiring that their new, more severe diagnoses be treated in any way.

Independent companies exist to do these evaluations and, according to an expose published by the Centre for Public Integrity last year, they cost the government billions of dollars every year.

The importance of accurate medical histories for very ill patients cannot be argued, and records are often surprisingly incomplete, so there is clinical value to this highly lucrative paperwork. But it seems equally inarguable that healthcare reimbursements should in general be tied to actual care given to actual people and not to documentation alone.

Electronic health records present an enticingly clean and clear vision of clinical work, whereas real patients - their histories, their bodies - are messy, confusing and unpredictable. Sadly, all the attention given to our paperwork is taking us further and further away from the difficult truth that meeting the needs of very ill patients occurs in real time with real people, not in the paperwork about them.

We need to streamline our records so that they serve just one master: the patient. We should focus on the most important information in guaranteeing accuracy of diagnosis, efficacy of treatment, continuity of care and patient safety.

Otherwise, the content of our care will be increasingly warped by the demands of our e-record systems - and patients like my poor friend will lie in hospital beds in pain, uncomforted by the knowledge that the electronic record of that pain is satisfyingly and exactingly complete.


•Theresa Brown is a registered nurse and the author of The Shift: One Nurse, 12 Hours, Four Patients' Lives.

Join ST's Telegram channel and get the latest breaking news delivered to you.

A version of this article appeared in the print edition of The Straits Times on December 21, 2015, with the headline Too much paperwork, too little time for patients. Subscribe