My message to healthcare leaders and managers

Our job – though many of us actually see it more as a calling than a job – is to care for patients. 

Documentation is a process whose primary purpose is to support the patient care process. Coding, billing, population management, Meaningful Use and many other processes may be important to an institution but are of little or no use (and provide little or no benefit) to the individual patient. These things will not go away. Nor should they, as they serve legitimate purposes.  But they should be done in a way that they do not interfere with, or distract from, the primary purpose of a health care institution: caring for patients. 

The typical medical institution has long since lost its way. The machinery for coding and billing is just one small manifestation of this.

I liken what has happened to most health care organizations to the difference between a local baker and a national business that makes and distributes bread products.  The baker is intimately familiar with her ingredients, the bread making process, the product, and the needs of her customers. She will also need to be aware of the cost of her ingredients, the price of her bread compared to others on the market, and other commercial pieces involved in selling her bread, but on a day-to-day basis, making bread that smells, tastes good, and serves the needs of her customers is the thing that is most important and most real to her. 

Now imagine that her business thrives, the volume of bread she sells grows, and it becomes a big national industry.  To maintain a big and complex industry requires that there are individual people working at individual pieces of bread making: some put flour into big vats, others purchase yeast, still others drive trucks and deliver product to stores. They may be very focused on the quality of their individual role, but they have no connection to the bread in the customer’s kitchen. Efforts by individuals in this complex system to maximize the quality and efficiency of their piece may, in fact, be detrimental to the efficiency of the process as a whole, or even degrade the quality of the bread. Worse, the people who own and run the organization and make all the decisions have quite probably never baked bread. Their expertise is in areas like business, finance, risk management or human resources. Their awareness and goals are entirely focused on maintaining the business and its processes. They simply assume that the bread exists and meets adequate standards - as defined by the business.  The bigger the industry, the greater the chasm between the decision makers and the actual product. 

This is what has happened in medicine. Institutional policy and operational decisions are made by people who have no experience in or expertise with actual patient care. People like me are expected to be little MacGyvers, using and repurposing broken clinical and non-clinical tools in an attempt to provide quality care in an environment that too often sees medical care as an almost accidental byproduct rather than as the prime purpose.

This is a cultural and systems problem. The individual department heads, managers, and mid-level leadership don’t own this and my frustration is not directed at them. The process of health care should be to (1) make sure patients get quality care and that systems are set up that support this; and (2) do this in a way that *also* captures appropriate documentation and reporting for billing and audit.

Instead, most organizations evolve huge complex and inflexible machinery that is so focused on the billing and audit process that it impedes care, and actual interest in care or quality is appallingly absent in the planning and management process.

Here is a simple and real-world example: recently the social history and risk factor forms in the EHR were changed in order to capture MU data better, with no regard for the fact that the changes hid important clinical information and made the clinical work flow harder. This happened with no warning or training; clinicians came in and the forms had been changed the night before. There was no clinical input in the process. Contrast this with the coming ICD-10 roll out, where there are two mandatory live training sessions and two online training modules (total commitment of 6 hours) in order to make sure billing goes smoothly.

The priorities of health care institutions are broken.  When we clinicians work really hard and do a bang-up job with a complex patients DESPITE systems that make it very difficult to do so, it really rubs us the wrong way when we cannot get traction or resources for concerns about the actual care process.

If health care institutions ever start spending time and energy helping us improve our ability to provide good care, then we might be more willing to join your committees, go to your meetings, read your memos, and spend more time and energy on billing and administrative processes. At the moment, to paraphrase a famous movie, we frankly don’t give a damn. It isn’t worth it to us, and we’re too tired after struggling all day with unnecessary friction and absurd barriers to good patient care.

As I said, our job is to care for patients. Your job is to ensure we have the tools and support to do our job.  We are doing our job. It’s time for you to step up to the plate and do yours. 

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