Paperwork
There is a story, probably apocryphal (those are the best) that an international delivery company had trucks that required the driver, at each delivery, to turn on the light in the back of the delivery van, since they had been told to turn the light off in between stops to save money. Each delivery, find the switch, turn the light on; after finding the package, find the switch again and turn the light off. As the story goes, one senior executive, looking for ways to save money, timed how long it took each driver to find the switch and turn the light on, then to do the same and turn the light off. He then multiplied that number of seconds by the rate the delivery driver was paid (not a large amount). He then worked out how much that translated into when you took into account every driver in their fleet, every package, every year. As the story goes, it was cheaper to just leave the light on than to pay the drivers to toggle the switch.
If the volume of repetition is high enough, any task, no matter how brief, can add up to a waste of time.
Doctors have been talking a lot recently about “Administrative Burden,” a term that is unclear outside of the business. Paperwork is more colloquial, but it does not convey the depth of the problem. Doctors receive information in a clinical context in two main ways; electronically and paper (yes, still paper, yes, in some cases actual faxes).
A brief explanation of the electronics. Doctors interact with a number of electronic systems in order to take care of patients. They usually have an app they use primarily to do their business (the app that is supposed to replace paper charts in offices). For Family Doctors, that app is called an Electronic Medical Record, or EMR. There are other systems that the doctor will need to use as well to get information about you; hospital, laboratory, radiology. Depending on the degree of integration, the number of steps they need to perform how they get the information about you varies from just annoying to WTF!
Perhaps an example. You are seeing a Family Doctor for back pain you have noticed since you shovelled the driveway snow this past weekend. You were a construction worker before you retired and back pain is something you have had before, just not like this. The good news is it doesn’t go down your leg and it seems to respond to heat and rest. The Doctor decides to order some x-rays on your back, some blood work in case the x-rays show it is not wear and tear from the work you did, and some physio to augment the relief you are getting from the heat.
Time was, there was only one bloodwork requisition; you wrote the patient information on it and what blood work you wanted done. Same thing for x-rays, one requisition, write down what x-ray you wanted done and why. If physio needs a note, it was brief and descriptive.
Today, I would turn to my EMR to order these tests. In the EMR I use, there are over twenty different requisitions for blood work, depending on what you need ordered. If I fill in the wrong requisition, it will be returned with nothing done. One of the twenty forms has seventy-seven options from which to choose; to choose an option, one must click the tiny check box next to the name of the test. Not near the box or in the territory of the box, in the box. It is very exacting work, this choosing. Imagine trying to eat a plate of rice, one grain of rice at a time, using chopsticks. It can be done, yet few choose so to do. There are sixteen x-ray forms to choose from, depending on what you need (they have lots of check boxes too). Depending on where you decide to go for physio, they too may have a form, specific to their office, that is the only way they will allow access to their care. That form may be in your EMR, it may not, it may be paper.
All of this is in addition to recording the encounter; your complaints, physical findings, assessment and plan. If I had planned to send you to a specialist, there would have been a form for that, not just a generic form though. Where one form was used for all referrals, now there is a different form for each speciality. Some specialists have their own individual forms, and will not see the patients until their form is filled in. Keeping track of all this is a job in itself.
That’s one patient, one complaint, one visit.
At some point, the results are going to come back, in dribs and drabs. Most of them will come back electronically into the EMR as “tasks”. For these purposes, think of tasks like email; everyday, they come into your inbox for you to peruse. Unlike email, most of the tasks won’t be easily recognizable spam that you can just delete without opening. Each task will be about a patient of yours. Each must be opened, its contents evaluated. This might require opening the patient’s electronic chart to remind you of the context of this result. Why was it ordered, what does this result tell you about what’s going on with this patient, what needs to be done as a consequence of this result.
A Family Doctor may receive a hundred such tasks about their patients … a day. Let’s replicate the delivery exec’s experiment. Say it takes three minutes (just three minutes) to review each task and that you have a hundred tasks to review. That’s three hundred minutes. That’s six hours. Over and above the time spent seeing patients that day. After clinic. In your “free time.”
Every day, because tomorrow there will be another hundred tasks waiting to be addressed.
Then there’s the paper.
I measured two weeks worth of paper received by a community based Family Doctor. Seven centimeters/three inches tall. It all has to be reviewed, reconciled with the patient of record, actions arising completed. In addition to the tasks. In addition to recording the patient visit.
Doctors report that they spend two hours a day on paperwork, over and above the time they spend with patients. A time and motion study out of the Excited States, where they actually followed doctors around and recorded what they do, had the number at two to three hours a day during the week, eight to twelve hours a weekend.
Do you know what you call a weekend where you work twelve hours? Work!
The Canadian Medical Association reports that 18.5 million hours are spent each year by doctors doing paperwork. That’s 55.6 million patient visits per year not available. Instead of seeing you, they are doing paperwork.
The next time you wonder why you need to wait three or four weeks to get an appointment with a family doctor and you asking yourself what they are doing, now you know. If you don’t have a family doctor and wonder why, now you know what the ones in the business are doing instead of being able to take on new patients and why doctors are shying away from Family Medicine to do other things.