A Modest Proposal: Charting Day

flying cadeuciiAt the end of March, Congress decreed a year-long postponement of the implementation of ICD-10, a remarkably detailed and arcane new coding scheme providers would have been required to use in order to get paid by any payer in the US (“bitten by orca” is but one of the sixty thousand new codes ).

The year postponement gives caregivers and managers a little more time to prepare for a further unwelcome increase in the complexity of their non-patient care activities.

In the spirit of Jonathan Swift, who famously proposed in 1729 that the Irish sell their children as a food crop to solve the country’s chronic poverty problem , I have a suggestion about how to cope with the steady rise in complexity of the medical revenue cycle.

Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.

Physiciansnurses, and others involved in patient care already spend at least a day a week of their time on this process now, but it is interspersed within the patient care workflow, constantly distracting clinicians and interrupting patient interaction.

Hospitals are solving this problem with a medieval remedy:  scribes who follow physicians around and enter the required coding and “quality” information into the patient’s electronic record on tablets.   Healthcare might be the only industry in economic history to see a decline in worker productivity as it automated.

If we simply devoted an entire day to nothing but charting, documentation and other billing and administrative tasks, physicians’ offices could send their receptionists and supporting cast home, and spend their entire time on Fridays getting their bills out. Scribes would not be needed.

Physicians and nurses could spend 100% of their time Monday thru Thursdays with patients – listening, analyzing, educating and advising- the things they to add value in the first place.  Patients would appreciate having the caregivers’ full attention, and have more time to spend asking questions and fully understanding what they need to do to be healthy. They would simply have to time their visits to fit within the narrower access window.

This solution would introduce certain logistical complexities.  For example, how would caregivers remember what to record hours or days later about individual patients?  Simple solution:  issue them those Star Trek-looking Bluetooth earpieces connected to their smart phones.  They could simply mutter continuously into the earpieces without breaking eye contact with patients.

Caregivers could snap a photo of the patient at the beginning of the encounter, and an app could synchronize the patient photo to the stream of muttering, providing the information necessary for the care giver to fill out their electronic charts on Fridays.

But what about all those patients in the hospital?  Simple.  Send them home and ask them to come back on Monday.   Hospitals are spooky places on weekends where not much happens anyway, and most physicians are “virtual” on weekends in any case.  Hospitals could save a ton of money on reduced call pay.  Some patients won’t come back.  If patients are really sick, they can come back on Mondays to resume treatment.

For people in the ICUs too sick to send home, simply put them in medically induced comas to slow them down, and they can be managed remotely with virtual ICU software, with care administered by a skeleton crew of ICU nurses.  Emergency rooms can simply ask people to wait a little longer than they normally wait, and provide them tablets to amuse themselves on Facebook or play Candy Crush.

Time flies when you’re in cyberspace.

It may be that a single day might not suffice, in which case “charting day” could begin on Thursday afternoon, and patient care could resume again on Monday.   To make sure patients get the caregiver’s full attention Monday thru Thursday, you could print on the backs of their lab coats in big red letters, “If you can read this, text the following number and this visit will be free!”

That will assure that physicians and nurses don’t turn their backs on patients, as they do today, to get a jump start on their charting.

Since healthcare is an irony-free zone, one can expect a lot of misunderstanding about this proposal.   But at some point, we need to sort out the two key missions of healthcare:  caregiving and feeding the chart.  A brighter line between these two demands on clinician time-one shrinking and the other growing- might help clarify what we expect from our dedicated but overburdened healthcare workforce.

Jeff Goldsmith is president of Health Futures Inc, which specializes in corporate strategic planning and forecasting future health care trends.

14 replies »

  1. Hi every one, here every one is sharing these know-how, thus
    it’s good to read this web site, and I used to pay a visit this blog all the time.

  2. Has anyone attempted this in a pilot program of some sort? It would be interesting to see the results. I wonder about the batching aspect of this. Lean management suggests that batching is inherently wasteful and results in variety of defects. More and more provider organizations seem to be adapting a flow model which enables clinicians to chart in flow with all work done at end of the day and no need (or minimal need) for physicians to lug work home.

  3. Jeff, I appreciate that you are helping us overcome the ban against irony.

    I agree with your vision that we need systems that help clinicians more efficiently and effectively care for patients. We have a long way to go.

  4. Spend some time in a hospital and watch how much time doctors and nurse spend “charting” versus actually seeing and touching the patient. Everybody is busy “buffing the chart” (reference to the House of God by S. Shem) The electronic medical record has just made this problem worse.

  5. “Beginning when ICD-10 is implemented, there should be no patient care whatsoever on Fridays, permitting nurses and physicians to spend the entire day catching up on their charting and documentation, and other administrative activities.”

    Think of charting / coding as “lossy compression,” i.e., condensing your evaluation of a patient’s condition (and treatment plan) a la .jpeg. Only worse. Putting off finishing the notes as is proposed here will indisputably increase the irretrievable “data loss.”

    I can’t imagine researchers in RCTs doing this. But, then, that’s “science.”

    Change the payment paradigm.

  6. Wrong enemy. Marilyn is a nurse. She took care of patients once upon a time. She’s now just a soldier. She takes her orders from a bunch of politicians, about whom the less said the better. The “brains” behind this so-called “quality” movement are a bunch of academics, policy entrepreneurs, reformers, health insurance types and assorted consultants.

    They are filling a vacuum left by “organized” medicine and nursing practice that failed to take ownership over the appalling variation in clinical practice, and resultant sloppy care. Now, in a fit of overreaction, this policy elite have drowned front line practitioners in a tsunami of meaningless box-checking. They have captured the electronic record and are using it to reshape medical practice in a completely senseless and wasteful way. Like all reformers, they meant well. . ..

  7. “Isn’t the administrative side of healthcare complicated enough already?”

    Of course, Marilyn “Shit For Brains” Tavenner would strongly disagree with you.

  8. Doesn’t ICD-9 already have about 14K-15K codes and, if so, doesn’t that make it roughly equivalent to the ICD-10 systems used in other countries? Isn’t the administrative side of healthcare complicated enough already?

  9. Does any such platform exist?

    If we could build the system you envision–which has noble goals and I would like to see–the costs to transform would likely be large. So large in fact, the kludge of ICD10 might be the more economical route. Short term. Longer term, we need a bigger boat with the idealized goals you articulated so well above.

    The issue of data collection and study for population health purposes also will require enough depth to accomplish triple aim ends–probably an amalgamation of ICD10 and risk-based data. I think you need a bit of both.


  10. I’m going to defer to Pappy below on the international context. The issue that worries me is the incremental increase in administrative burden on an already overburdened clinical workforce, and distracting them from caring for us. Every health insurer seems to have its own rules, and there has been a huge increase in federal data gathering with PQRS, meaningful use, etc.

    On ICD-10, my biggest problem is that the coding scheme is completely out of phase with where nearly everyone in the policy community thinks healthcare payment is headed. If we’re going to phase out fee-for-service, incident based payments in favor of population health/capitation, why on earth would we burden caregivers with microscopic-level characterization of the presenting diagnosis??? And if we’re moving from “visits” to real-time monitoring of health, how does ICD 10 help us, exactly?

    We want to be managing risks, not “complaints”. So what we ought to be coding is the state of those risks- the underlying morbidity, which is layered and constantly changing, and how it is manifesting itself in the patient at presentation. Not sure how you do this exactly, but you cannot manage what you do not accurately characterize.

    Orca bites?? That’s for the emergency room. What the care system ought to be managing is metabolic syndrome and its grisly manifestations, neurological degeneration, addiction, congestive heart failure, etc.

  11. ICD-10 is individualized by each country using it. Most of them have about 15k codes, less than 20% of what the USA version contains. We have made our ICD-10 by far the most complicated and user-unfriendly to be found anywhere.

    No other country uses CPT and MU, the major sources of EMR dysfunctionality in this country.

  12. Jeff
    Serious question.

    The rest of the world uses ICD10, presumably without scribes. They also collect data competently and their systems, other problems aside, function.

    Aside from the logistical shift from ICD9–granted a major headache–why do we (I use the plural here) characterize ourselves as outliers?


  13. A fabulous idea Jeff.

    It’s rather sad that these measures that are supposed to “help” patient care do nothing of the sort, and only frustrate providers. What’s also sad is that the reason so many doctors are fed up is because they try to use their regular day to do patient care, and spend what should be their free time doing these extra unneeded tasks to prove they are good doctors.