A Modest Proposal: Charting Day
By Jeff Goldsmith, Ph.D.
At 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 http://www.icd10data.com/ICD10CM/Codes/V00-Y99/W50-W64/W56-/W56.21XD). 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 (http://andromeda.rutgers.edu/~jlynch/Texts/modest.html), 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.
Physicians (http://content.healthaffairs.org/content/32/11/1990.full) nurses (http://www.jacksonhealthcare.com/media-room/surveys/nurses-on-non-patient-care-2011.aspx), 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 (http://www.npr.org/blogs/health/2014/04/21/303406306/scribes-are-back-helping-doctors-tackle-electronic-medical-records) 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.